Uncu Modified Remnant-Supported Laparoscopic Double-Layer Peritoneal Pull-Down Vaginoplasty
The technique involves vaginal and laparoscopic approaches. After laparoscopic set-up and visualization of the pelvis, the vaginal approach begins with the vaginal introitus’s transverse incision. After careful dissection between the bladder and rectum through the Douglas pouch, peritoneal entry is applied by laparoscopic dissection. Later than, opened canal through the peritoneum was vaginally gradually dilated with sterilized acrylic molds. After the largest mold is replaced, No.1 Vicryl sutures are laparoscopically placed through the peritoneum’s anterior, posterior, left, and right sides. All four sutures are pulled down through the vagina to stitch the lower edges of the parietal peritoneum to the vaginal opening. To form the vaginal cuff, firstly uterine remnant is divided into two parts by bipolar energy, then starting from one remnant parietal peritoneum is cut by scissors through the bladder peritoneum and through to the other remnant. After dividing the other remnant into two parts, the posterior parietal peritoneum is cut through the rectum and the other remnant. The peritoneal flap is mobilized and stripped of the underlying tissue by sharp dissection with scissors and traction– counter-traction. The prepared peritoneal flap is lied over the vaginal mold and stitched with a purse-string suture using 2/0 Vicryl. A second peritoneal layer is created using the lower edge of the in situ parietal peritoneum. A second purse-string suture was placed. The second suture is passed through the lateral halves of the divided rudimentary horns as well as the medial halves sitting on the neovaginal vault. This connection is made to provide further support to the vaginal dome.
Following double-layer closure of the vaginal vault, lower edges of the peritoneum, which is pulled down at the beginning of the surgery, are stitched to the introitus mucosa at 4 points: anterior, posterior, and two edges. The largest mold is placed into the neovagina at the end of the operation. After the last laparoscopic view of the pelvis, the operation is completed. (Figure-1)