McIndoe Vaginoplasty for Neovagina The McIndoe Vaginoplasty is indicated in patients with congenital absence of the vagina, in patients whose vagina must be removed, and in patients with severe stenosis following irradiation therapy. A split-thickness skin graft has traditionally been utilized with this operation, but we have changed to a full-thickness skin graft over an expandable foam rubber mold placed in the canal between the bladder and rectum. The use of the full-thickness skin graft reduces the postoperative contraction previously noted with the split-thickness skin graft requiring long-term utilization of a vaginal form, which is undesirable if unnecessary. Recently, it has been shown that a full-thickness skin graft takes as well as a split-thickness graft. Compared with a split-thickness skin graft, a full-thickness graft allows sufficient penetration of the transudate nutrients from the bed of the graft that are necessary for nutrition during the first 72 hours until microcapillary ingrowth has been completed. Full-thickness grafts do not have the same degree of contraction as the split-thickness grafts. Physiologic Changes. One of the unique physiologic changes is the selection of thickness desired for the split-thickness skin graft. The split-thickness graft of 1/12,000ths of an inch has traditionally been used because it is thin enough to allow penetration of the transudate nutrients from the bed of the graft that are necessary for nutrition during the first 72 hours until microcapillary ingrowth has been completed. A splint-thickness graft of 1/12,000ths of an inch is, however, associated with extensive contraction in the postoperative period unless a vaginal form is worn for many months. Currently, there has been greater utilization of thicker and thicker split-thickness skin grafts until lately, full-thickness skin grafts have been utilized. Initially, it was thought that the blood supply to these full-thickness skin grafts would be insufficient and there would be excessive amounts of necrosis. The copious blood supply of the pelvis has demonstrated, however, that the full-thickness skin graft will survive. Thus with excellent survival of a full-thickness skin graft the patient is spared long-term vaginal form dilatation. Points of Caution. Careful dissection between the bladder and rectum is necessary to avoid cystotomy and enterotomy. Meticulous hemostasis is essential for the graft to adhere to the vaginal walls. The skin grafts should be of uniform size and predominately of full-thickness. The air-powered dermatome is preferred over the Reese or the electrical dermatome because it gives a uniform specimen of consistent thickness. The full-thickness grafts can be taken by the hand technique with a standard scalpel. We now prefer to take these from the skin covering the inguinal ligaments bilaterally. If there is tension on the suture line closing these donor site wounds, the new SureClosure skin-stretching system can be used to adequately close the wound. This has the advantage of leaving the patient with a cosmetic scar over the inguinal ligament versus a large scar over the buttocks or legs. The vaginal mold should be soft and flexible. Foam rubber confined to a rubber condom has produced a soft vaginal mold that expands against the graft in a gentle manner without producing points of pressure. Excessive pressure could produce necrosis with possible vesicovaginal or rectovaginal fistula formation. The vaginal form should be left in place for a minimum of 10 days. The form should then be removed, and the skin graft donor site should be inspected. One of the most important criteria for this operation is the surgeons conviction that the patient is mature enough to wear the vaginal form for at least 6 months, unless she is engaging in regular sexual intercourse. Failure to wear the vaginal form, especially with the split-thickness skin graft, is the major cause of failure in this operation. This generally occurs in adolescent girls who do not understand the importance of keeping the vaginal form in place even if it is inconvenient or uncomfortable. Technique A sagittal section through the pelvis demonstrates congenital absence of the vagina. The site of dissection will be in the areolar tissue between the bladder and rectum. The space is exaggerated here for illustration. The dissection should continue cephalad to 1-2 cm before the level of the peritoneum. Deeper dissection may allow the development of an enterocele. In this view of the introitus in congenital absence of the vagina, a slight indentation or dimple may exist where the urogenital sinus in the fetus failed to invaginate and fuse with the Mllerian duct to develop a normal vagina. A second cause of absence of the vagina is surgical removal for oncologic reasons. The air-powered dermatome is preferred because of the uniform thickness and size of the graft produced. The setting on the air-powered dermatome can be adjusted to 18/1,000ths or 24/1,000ths of an inch. STSG identifies the split-thickness skin graft. Two proposed paddle-shaped full-thickness skin grafts over the inguinal ligaments from the anterior superior iliac spine to the pubic tubercles are depicted. These paddles should be approximately 10 cm in length and 6 cm in width. Harvesting of the full-thickness skin graft is performed with the standard scalpel after marking the shape of the paddle in ink on the skin. The full-thickness skin grafts (FTSG) are placed in a graft pan and moistened with saline. The same is true for the split-thickness skin graft (STSG) if that is preferred to the full-thickness skin graft. After harvesting the full-thickness skin graft from the inguinal ligaments, if closure of the wound is on tension, the new SureClosure skin-stretching system can be utilized as shown. The stabilization needles are inserted in the subcutaneous space parallel to the line of the incision. Two, 4, or 6 of these can be utilized as necessary. Usually, no more than 2 are required. The skin-stretching device is anchored into the needle, and the ratchet on the skin-stretching device is activated until the skin is stretched to close the incision. Presently, a subcuticular suture of 3-0 delayed synthetic absorbable suture is utilized to close the wound. A block of ordinary foam rubber, such as that used in the upholstery industry, is sterilized by gas autoclaving. The shape of the proposed vaginal form is outlined with brilliant green solution. The split-thickness skin graft is removed from the adhesive tape of the dermatome and placed in a sterile pan filled with saline solution. Ordinary contraceptive condoms that have been sterilized by gas autoclaving are used. Generally, two condoms are used to ensure against leakage of fluid into the foam rubber form. The foam rubber block is held in one hand and, with curved Mayo scissors, is shaped into the desired vaginal form. The condom is slipped over the foam rubber vaginal form. The condom can be removed partially or completely if the size of the vaginal form needs to be adjusted in diameter or length. When the size of the vaginal form is satisfactory, the end of the condom is tied with a 2-0 synthetic monofilament permanent suture. The vaginal form is laid on the epidermal side of the split-thickness skin graft. The split-thickness skin graft is folded over the vaginal form and sutured along its seam with interrupted 4-0 synthetic absorbable suture. Excess graft is trimmed away. The full-thickness, paddle-shaped skin grafts are placed over a foam rubber condom, and the margins are sutured together with synthetic absorbable suture. The dimple in the introital area is identified. The labia are retracted with Allis clamps, and a transverse incision is made in the epithelium. Blunt dissection with the fingers opens the space between the bladder and rectum. Once the correct plane is reached, i.e., below the pubovesical cervical fascia under the bladder and superior to the perirectal fascia over the rectum, gentle blunt dissection is all that is needed to create an adequate cavity. A sagittal section shows the dissection carried approximately 2 cm from the peritoneum. This will reduce the incidence of enterocele in these patients. Meticulous hemostasis should be maintained throughout the cavity. The skin-covered form is inserted into the cavity. A sagittal view of the pelvis shows the skin-covered form inserted into the new vaginal canal. To hold the form in place for 12 days, the labia are sutured in the midline with interrupted 0 nylon sutures without tension. After the foam rubber vaginal form has been removed on the 12th postoperative day, the new vagina should be thoroughly inspected and irrigated with normal saline solution. A permanent vaginal form made of soft rubber or silicone should be fitted and inserted. Care should be taken that the new vaginal form does not protrude beyond the introitus. Protrusion will erode the introital area and cause pain, discouraging the patient from continuing to use the form.

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Vagina and Urethra

Anterior Repair and Kelly Plication

Site Specific Posterior Repair

Sacrospinous Ligament Suspension of the Vagina

Vaginal Repair of Enterocele

Vaginal Evisceration

Excision of Transverse Vaginal Septum

Correction of Double-Barreled Vagina

Incision and Drainage of Pelvic Abscess via the Vaginal Route

Sacral Colpoplexy

Le Fort Operation

Vesicovaginal Fistula Repair

Transposition of Island Skin Flap for Repair of Vesicovaginal Fistula

McIndoe Vaginoplasty for Neovagina

Rectovaginal Fistula Repair

Reconstruction of the Urethra

Marsupialization of a Suburethral Diverticulum by the Spence Operation

Suburethral Diverticulum via the Double-Breasted Closure Technique

Urethrovaginal Fistula Repair via the Double-Breasted Closure Technique

Goebell-Stoeckel Fascia Lata Sling Operation for Urinary Incontinence

Transection of Goebell-Stoeckel Fascia Strap

Rectovaginal Fistula Repair via Musset-Poitout-Noble Perineotomy

Sigmoid Neovagina

Watkins Interposition Operation

McIndoe Vaginoplasty for Neovagina

The McIndoe Vaginoplasty is indicated in patients with congenital absence of the vagina, in patients whose vagina must be removed, and in patients with severe stenosis following irradiation therapy. A split-thickness skin graft has traditionally been utilized with this operation, but we have changed to a full-thickness skin graft over an expandable foam rubber mold placed in the canal between the bladder and rectum. The use of the full-thickness skin graft reduces the postoperative contraction previously noted with the split-thickness skin graft requiring long-term utilization of a vaginal form, which is undesirable if unnecessary. Recently, it has been shown that a full-thickness skin graft takes as well as a split-thickness graft. Compared with a split-thickness skin graft, a full-thickness graft allows sufficient penetration of the transudate nutrients from the bed of the graft that are necessary for nutrition during the first 72 hours until microcapillary ingrowth has been completed. Full-thickness grafts do not have the same degree of contraction as the split-thickness grafts.

Physiologic Changes. One of the unique physiologic changes is the selection of thickness desired for the split-thickness skin graft. The split-thickness graft of 1/12,000ths of an inch has traditionally been used because it is thin enough to allow penetration of the transudate nutrients from the bed of the graft that are necessary for nutrition during the first 72 hours until microcapillary ingrowth has been completed. A split-thickness graft of 1/12,000ths of an inch is, however, associated with extensive contraction in the postoperative period unless a vaginal form is worn for many months. Currently, there has been greater utilization of thicker and thicker split-thickness skin grafts until lately, full-thickness skin grafts have been utilized. Initially, it was thought that the blood supply to these full-thickness skin grafts would be insufficient and there would be excessive amounts of necrosis. The copious blood supply of the pelvis has demonstrated, however, that the full-thickness skin graft will survive. Thus with excellent survival of a full-thickness skin graft the patient is spared long-term vaginal form dilatation.

Points of Caution. Careful dissection between the bladder and rectum is necessary to avoid cystotomy and enterotomy. Meticulous hemostasis is essential for the graft to adhere to the vaginal walls.
The skin grafts should be of uniform size and predominately of full-thickness. The air-powered dermatome is preferred over the Reese or the electrical dermatome because it gives a uniform specimen of consistent thickness. The full-thickness grafts can be taken by the hand technique with a standard scalpel. We now prefer to take these from the skin covering the inguinal ligaments bilaterally. If there is tension on the suture line closing these donor site wounds, the new SureClosure skin-stretching system can be used to adequately close the wound. This has the advantage of leaving the patient with a cosmetic scar over the inguinal ligament versus a large scar over the buttocks or legs.

The vaginal mold should be soft and flexible. Foam rubber confined to a rubber condom has produced a soft vaginal mold that expands against the graft in a gentle manner without producing points of pressure. Excessive pressure could produce necrosis with possible vesicovaginal or rectovaginal fistula formation.

The vaginal form should be left in place for a minimum of 10 days. The form should then be removed, and the skin graft donor site should be inspected.

One of the most important criteria for this operation is the surgeon's conviction that the patient is mature enough to wear the vaginal form for at least 6 months, unless she is engaging in regular sexual intercourse. Failure to wear the vaginal form, especially with the split-thickness skin graft, is the major cause of failure in this operation. This generally occurs in adolescent girls who do not understand the importance of keeping the vaginal form in place even if it is inconvenient or uncomfortable.

Technique

A sagittal section through the pelvis demonstrates congenital absence of the vagina. The site of dissection will be in the areolar tissue between the bladder and rectum. The space is exaggerated here for illustration. The dissection should continue cephalad to 1-2 cm before the level of the peritoneum. Deeper dissection may allow the development of an enterocele.

In this view of the introitus in congenital absence of the vagina, a slight indentation or dimple may exist where the urogenital sinus in the fetus failed to invaginate and fuse with the Mullerian duct to develop a normal vagina.

A second cause of absence of the vagina is surgical removal for oncologic reasons.

The air-powered dermatome is preferred because of the uniform thickness and size of the graft produced. The setting on the air-powered dermatome can be adjusted to 18/1,000ths or 24/1,000ths of an inch. STSG identifies the split-thickness skin graft.

Two proposed paddle-shaped full-thickness skin grafts over the inguinal ligaments from the anterior superior iliac spine to the pubic tubercles are depicted. These paddles should be approximately 10 cm in length and 6 cm in width.

Harvesting of the full-thickness skin graft is performed with the standard scalpel after marking the shape of the paddle in ink on the skin.

The full-thickness skin grafts (FTSG) are placed in a graft pan and moistened with saline. The same is true for the split-thickness skin graft (STSG) if that is preferred to the full-thickness skin graft.

After harvesting the full-thickness skin graft from the inguinal ligaments, if closure of the wound is on tension, the new SureClosure skin-stretching system can be utilized as shown. The stabilization needles are inserted in the subcutaneous space parallel to the line of the incision. Two, 4, or 6 of these can be utilized as necessary. Usually, no more than 2 are required. The skin-stretching device is anchored into the needle, and the ratchet on the skin-stretching device is activated until the skin is stretched to close the incision. Presently, a subcuticular suture of 3-0 delayed synthetic absorbable suture is utilized to close the wound.

A block of ordinary foam rubber, such as that used in the upholstery industry, is sterilized by gas autoclaving. The shape of the proposed vaginal form is outlined with brilliant green solution. The split-thickness skin graft is removed from the adhesive tape of the dermatome and placed in a sterile pan filled with saline solution. Ordinary contraceptive condoms that have been sterilized by gas autoclaving are used. Generally, two condoms are used to ensure against leakage of fluid into the foam rubber form.

The foam rubber block is held in one hand and, with curved Mayo scissors, is shaped into the desired vaginal form.

The condom is slipped over the foam rubber vaginal form. The condom can be removed partially or completely if the size of the vaginal form needs to be adjusted in diameter or length. When the size of the vaginal form is satisfactory, the end of the condom is tied with a 2-0 synthetic monofilament permanent suture.

The vaginal form is laid on the epidermal side of the split-thickness skin graft. The split-thickness skin graft is folded over the vaginal form and sutured along its seam with interrupted 4-0 synthetic absorbable suture. Excess graft is trimmed away.

The full-thickness, paddle-shaped skin grafts are placed over a foam rubber condom, and the margins are sutured together with synthetic absorbable suture.

The dimple in the introital area is identified. The labia are retracted with Allis clamps, and a transverse incision is made in the epithelium.

Blunt dissection with the fingers opens the space between the bladder and rectum. Once the correct plane is reached, i.e., below the pubovesical cervical fascia under the bladder and superior to the perirectal fascia over the rectum, gentle blunt dissection is all that is needed to create an adequate cavity.

A sagittal section shows the dissection carried approximately 2 cm from the peritoneum. This will reduce the incidence of enterocele in these patients.

Meticulous hemostasis should be maintained throughout the cavity.

The skin-covered form is inserted into the cavity.

A sagittal view of the pelvis shows the skin-covered form inserted into the new vaginal canal.

To hold the form in place for 12 days, the labia are sutured in the midline with interrupted 0 nylon sutures without tension.

After the foam rubber vaginal form has been removed on the 12th postoperative day, the new vagina should be thoroughly inspected and irrigated with normal saline solution. A permanent vaginal form made of soft rubber or silicone should be fitted and inserted. Care should be taken that the new vaginal form does not protrude beyond the introitus. Protrusion will erode the introital area and cause pain, discouraging the patient from continuing to use the form.