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Extensive  necrosis  in  african   post-partum  fistulae  :

 

Substituting  a sigmoïdal  graft  for  the  lost  vagina

Personal  technique

 

 

SIGMOIDO-VAGINOPLASTY      Operation  steps

 

The operation requires both abdominal and perineal accesses and is best done by two surgeons working simultaneously.

The basic technique comes from the Schmid operation for creating a replacement duct in vaginal agenesis.

( See : Encyclopédie Médico-Chirurgicale, Techniques Chirurgicales, Urologie, Gynécologie )

 

Replacing the vagina by a sigmoïdal graft is appropriate for the extensive damages ( left ) ,  the complete colpocleisis ( right )  or  the  agenesis.

ABDOMINAL  STEPS

 

   

Length of the gut segment : 15 to 20 cm.  It shall be turned upside down, i.e. antiperistaltically ; therefore the lower section is not performed in the deep pelvis but confortably high enough to ensure a normal vaginal length after closure. For the same reason the upper gut section is performed rather high on the sigmoïd segment, this graft end  being pulled downwards through the Douglas cul-de-sac along the right side of the rectum to become the new vulvar outlet.  Reconnection of the gut.          The graft must be tightly anchored to the uterus or to any steady local structure in order to prevent its prolapse.

 

PERINEAL  STEPS

 

The sigmoïdal end of the graft is pulled down to make the vulvar outlet.

A tube is left in the uterine cervix for the epithelization period.

Prolapse following  inadequate anchoring of the graft.

 

If necessary the access to the deep vagina is widenend by episiotomy. Vaginal remnants are removed up to the cervix except the vulvar outlet region.  ( Just a few scissors bites  are necessary  since  in the majority of cases  almost the whole vagina has disappeared ). The cervix is hardly guessed among fibrous tissues ; a small vaginal collar may be preserved to be used for anchoring the graft.

The Douglas cul-de-sac is opened. The fistular bladder, urethra, rectum and anal canal are sutured, superposing plane upon plane, as far as it is possible.

The cervix is controlled by a thread. The sigmoïdal graft is pulled through the vesico-rectal space to the vulva and possibly recut to its best shape. The graft is firmly anchored to the uterus ( that step is best done by the abdominal surgeon, if any ) A small hole is made in the graft wall in front of the cervix. The lip is sutured around the cervix and a tube is left in place in the uterine cavity for the epithelizing time, what intends hopefully to make a stabilized way for insemination and menstruation.

The shaft of the graft should be fixed very cautiously to the walls of the vesico-rectal space, keeping in mind the necessity of a good blood supply.

To ensure the adhesivity of the external peritoneal epithelium to the environment, the lumen of the graft is moderately padded with gauze. The padding is left in place for at least one week and renewed in the meanwhile if necessary.

In cases when the recto-vaginal wall is surviving, a posterior strip of graft may be removed to adjust its shape on demand and the new border be sutured to the edges of the remaining recto-vaginal safe area.  Doing so does not endanger the graft blood supply because the mesocolic vascular border is actually shorter than the opposite and applies automatically to the anterior wall, while the longer side applies by itself to the posterior wall. Likeness of shape and blood supply between vagina and the sigmoïd segment is a happy matter of fact.

 

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