Surgical Science, 2011, 2, 422-426
doi:10.4236/ss.2011.28092 Published Online October 2011 (http://www.SciRP.org/journal/ss)
Applicability of Sigmoid Colon Graft for Vaginal
Replacement (Colovaginoplasty) at Young Age
Mohamed A. Baky Fahmy1, Hanaa Abdel Hamid M. Al Abeissy1, Mohamed M. Abdalla2
1Al Azher University, Cairo, Egypt
2Al Galaa Teaching Hospital, Cairo, Egypt
Received June 9, 2011; revised A ugust 13, 2011; accepted August 25, 2011
Abstract
Objective: to evaluate the applicability, feasibility, complications, short and long term results of vagino-
plasty by using sigmoid colon graft with stapler assistance for resuming colonic continuity in children with
absent vagina. Patients and Methods: records of 15 patients 8 of them had Androgen Insensitivity Syn-
drome, 4 had congenital vaginal atresia, and 3 had Congenital Adrenal Hyperplasia, underwent sigmoid graft
vaginal reconstruction with the aid of circular stapler during the period from 2005 to 2010 were reviewed
retrospectively. Results: a neovagina was constructed in those patients who aged from 3 to 9 years (mean 4
years), where sigmoid colon was used in all patients. Hospital stay ranged from 5 to 12 days (mean 7), op-
erative time ranged from 60 min to 120 min (mean 75 min). All patients were followed up 6 monthly in the
first year and then yearly, complications occurred in 4 patients: introital stenosis in 2, and another 2 cases
had minor wound infection. The need for neovaginal dilation was indicated in 5 out of 15 patients. There was
no complications related to bowel anastomosis, no mortality in this group and the cosmetic results were ex-
cellent in all cases. Conclusion: sigmoid colovaginoplasty appears to be applicable for remedy of vaginal
atresia at any age. It is associated with a less complication rate, the long term results is satisfactory and it
seems a better technique, especially in girls who doesn’t expect sexual activity shortly after surgery.
Keywords: Vaginal Replacement, Vaginal Atresia, Stapler, Neovagina, Colovaginoplasty and Sigmoid Graft
1. Introduction
Surgical management of girls with congenital absent
vagina continues to be a major technical problem due to
a prospective functional and psychological effect of the
outcome. The majority of cases of absent vagina result
from abnormality results from congenital adrenal hyper-
trophy, müllerian duct failure, androgen insensitivity
syndrome and gonadal dysgenesis [1]. Co nst ruction of an
artificial vagina had undergone a long evolution from
conservative to various surgical methods since 1938
when Frank proposed a nonsurgical approach using
various instruments and saddle-like devices that exerted
pressure on the vaginal vestibule [2]. This method re-
placed the technique proposed by Baldwin in 1904 [3],
whereby the vagina was reconstructed using an isolated
segment of small intestine, Pratt in 1961 proposed the
use of sigmoid colon in vaginal reconstruction [4]. With
the same purpose in mind cecum had been used, others
proposed a dermatome-collected cutaneous graft, mu-
cous membrane flap harvested from the bladder, and
peritoneal fragment advanced from the Douglas pouch.
Vaginal reconstruction was also performed with skin
island flaps created in the perineal and inguinal region
[7]. It is widely accepted that staplers use for resuming
bowel anastomosis is effective in reducing operating
time and potential complications related to their use spe-
cially in the pediatric population [8]. In this study the
sigmo id graft used fo r vaginal reconstruction winning the
advantage of surgical stapler to reduce the time of re-
suming bowel continuity and to minimize the complica-
tion rate related to bowel anastomosis and the whole
procedure.
2. Patients and Method
During a period of 5 years, from 2005 to 2010 a total of
15 patients had an indication for vaginal replacement due
to different pathology was reviewed.
Abdominal ultrasound, chromosomal analysis and hor-

M. A. B. FAHMY ET AL.423
monal assay were performed preoperatively for all pa-
tients, Magnetic Resonance Imaging (MRI) and ascend-
ing cystourtherogram done for 10 patients to assess the
associated anomalies and the status of the existing geni-
tal organs. Patients with AIS (8 patients) underwent go-
nadectomy before vaginoplasty and patients who had
CAH (3 patients) underwent clitoral surgery either along
the vaginoplasty, or latter on (Figures 1 and 2).
3. Technique
The surgical procedure for creating a sigmoid colon ne-
ovagina was done basically according to the principles
described by Graziano et al. [9] with some modifications
mainly in establishing bowel continuity by stapler. Pa-
tients were admitted to the hospital 2 days before the
surgery for mechanical and antibiotic bowel preparation.
Through a small abdominal Pfannenstiel incision or an
existing abdominal scar, the descending and sigmoid
colon were mobilized. The mesentery was examined to
Figure 1. A case of adrenoge nital hyperplasia.
Figure 2. A case of androgen insensitivity syndrome.
identify vascularisation and to evaluate the length of the
sigmoid loop which will be used for vaginal construction.
A 10 cm to 12 cm segment of the sigmoid colon con-
taining at least 2 sigmoid arteries was isolated on its
vascular pedicle for transposition to the perineum, and
the mesenteric defect was closed.
Depending on the individual patient’s vascular anat-
omy, either an iso-peristaltic or anti-peristaltic orienta-
tion was used. The proximal end of the sigmoid segment
was closed with interrupted absorbable sutures and fixed
to the vestigial remnants of the Mullerian ducts or to the
uterosacral ligaments. The continuity of the colon was
restored by an appropriate size (from 21 mm to 28 mm)
curved disposable intraluminal gastrointestinal anasto-
mosis (GIA) stapler, and we preferred the Curved De-
tachable Head (CDH) type (By Ethicon Endo—Surgery,
one of Johnson & Johnson Company) where the handle
introduced from the anus, with minimal anal dilation to
join the head of stapler at the proximal bowel (Figure 3).
We performed the abdominal procedures first, and af-
ter the preparation of the sigmoid loop, the upper side of
the rectovesical space was opened and enlarged to con-
tain the distal end of the sigmoid loop, in cases of vagi-
nal atresia a surgical plane was created between the ure-
thra, bladder and rectum by sharp dissection, but in GAH
cases the sigmoid graft connec ted to the vaginal remnant.
The mobilized sigmoid loop was brought down to the
perineal canal without tension to create a colon-perineal
anastomosis with interrupted absorbable sutures. To
prevent early retraction, the lateral portions of the sig-
moid neovagina were also fixed to the levator ani mus-
cles with interrupted absorbable sutures. Finally, the ne-
ovagina was packed with Povidone-iodine soaked gauze,
which was removed 24 hours after surgery, and an in-
dwelling Foley’s catheter was left in place for 2 to 3 days.
At discharge fro m the hospital pa tients were instr ucted to
irrigate the neovagina daily for 3 weeks and weekly there-
Figure 3. Curved disposable intraluminal GIA stapler for
bowel.

M. A. B. FAHMY ET AL. 424
after with Povidone-iodine solution. Calibration of the
neovagina done 2 weeks after discharge and during the
follow up visits, and if there is any need for dilatation it
is scheduled two weekly under local anesthetic. All pa-
tients had been followed up from 6 months to 4 years in
six months intervals for the first year and then yearly.
4. Results
A total of 15 girls aged from aged from 1 to 8 years
(mean 3), 8 of them had Androgen Insensitivity Syn-
drome (AIS), 4 had congenital vaginal atresia, and 3 had
CAH (Figures 4 and 5).
Operative time ranged from 60 min to 120 min (mean
75). Hospital stay ranged from 5 to 12 days means 7 days.
All patients were followed up from 6 month to 4 years
(mean 2 years), and calibration done 2 weeks after dis-
charge and during the follow up visits, by an appropriate
size Hegar’s dilators, the need for neovaginal dilation
was evaluated and it was indicated in only 5 out of 15
patients for 4 sessions in 5 and for 6 sessions in 3 pa-
tients with local anesthetic. Excessive mucous discharge
observed in 6 patients (older one) but it abstained gradu-
ally with the neovaginal wash by Povidone-iodine solu-
tion.
Complications occ urred in 4 patients, introital ste nosis
in 2 patients, one of them lost during the follow up due to
Figure 4. Age distribution at su rgery.
Figure 5. Cases distri b utio n.
some social pro blems b ut came back into s ight with ti ght
stenosis which necessitates redo of the introital wound,
and 2 cases had minor wound infection which managed
conservatively without any surgical intervention and
without sequels. There was no complications related to
bowel anastomosis, and there is no mortality in this
group of patients. All patients had functional adequate
patency and lubricant neovagina, with good patient sat-
isfaction and the vagina had good appearing introits,
mucus production decreased 3 to 4 month after the op-
eration (Figure 6).
As the tradition in our society that the girls had no
sexual activity outside marriage, so it seems difficult to
assess the sexual function of the reconstructed vagina,
which dictates a further follow up to evaluate the sexual
activity and functional effectiveness of the neovagina
latter on.
5. Discussion
Vaginal reconstruction may be indicated in cases of
Mayer-Rokitansky-Kuster-Hauser Syndrome [5], where
the vagina is congenitally absent, intersex and for other
cases of Androgen insensitivity Syndrome. Reconstruct-
ing the vagina in the children and young adults may be a
great technical challenge. Patients were more likely to
present after puberty with primary amenorrhea or failure
of intercourse, but recently the gender assignment to a
neonate with ambiguous genitalia became crucial [7].
Most investigators, however, suggest timing for surgery
from the newborn to 3-year-old period. Reasons for this
early intervention include better compliance with dila-
tions, lessening of the parents concerns regarding their
“anomalou s” child, and the assu mption that the child later
in life does not remember early interventions [6-7].
Numerous surgical and non-surgical methods have
been proposed to create a vaginal tunnel, the aim of any
Figure 6. Postoperative.

M. A. B. FAHMY ET AL.425
method is to provide a canal of adequate length, which is
lined with mucous membrane, characterised by a low
tendency to stenosis and comfortable during sexual ac-
tivity. Although used as a first-line of treatment for dec-
ades, skin grafts and dilation techniques are associated
with a high incidence of shrinkage, lack of lubrication
and dyspareunia [10].
Intestinal transplant methods to create a functioning
neovagina were advocated more than 100 years ago; the
advantages of these methods include adequate vaginal
length, natural lubrication, early intercourse and a low
rate of shrinkage [3]. Most segments of the intestinal
tract have been used to create a neovagina, but the sig-
moid colon is particularly useful because it is anatomi-
cally close to t he perineum, it is s ufficiently lon g and the
mobility of its vascular pedicle allows it to be brought
into the perineum [11].
Also the bowel vaginoplasty utilizing sigmoid colon
offers some advantages over skin grafts because of dis-
tensibility and sel f lubricating pro perty with no tendency
for neovagina stenosis, but it has the drawbacks of a
laparotomy with visible scars, possibility of bowel leak-
age/obstruction and problem of mucous secretion [12].
Also the sigmoid segments of the colon could be liable
for inflammatory bowel disease [13], primary adenocar-
cinoma has been reported, so vaginoscopy should be
used for any case of postoperative bleeding, pain, or
suspected mass .There have been reports of mucosal
prolapse, as well as of stenosis [14].
The Vecchietti technique [15] and its laparoscopic
varia nt re quir es a va gina l d i mple o f 3 - 4 c m, a long t ime
and rigorous cooperation by the patients to achieve ac-
ceptable results [15].
In the last decades, due to the progress in anesthesia,
antibiotic use and the reduction of risks associated with
colorectal anastomosis, the sigmoid graft technique has
became the first-line choice for the treatment of vaginal
agenesis in both children and adults [16]. A sigmoid ne-
ovagina is cosmetically pleasing, offers natural lubrica-
tion and during creation can be anchored to prevent
prolapse.
A collective analysis of 202 patients from 7 recent se-
ries of bowel neovaginoplasty found a complication rate
of 35% and a re-operation rate of 4%. These rates of
complications are not comparable to those reported for
skin gr aft vaginoplasties [1 0].
In this study we used the sigmoid graft as a preferable
procedure in 15 patients aged from1 to 8 years (mean 3
years), a historical cohort study of those consecutive pa-
tients who underwent neovagina reconstruction were
presented.
A dedicated database was reviewed for the etiology of
vaginal malformation, surgical complications and post-
operative follow-up, where Androgen Insensitivity Syn-
drome (AIS) was the common cause of vaginal atresia (8
pati ents), 4 had congenital vaginal atresi a (Figure 5).
In this small series the introduction of surgical stapler
for resuming the bowel continuity enabled to shorten the
time of surgery (60 min to 120 min, mean 75), to reduce
the hospital sta y which ranged from 5 to 12 days means 7
days, and we claim that it is al so li mits the complications
of bowel anastomosis to nil.
But other complications encountered in 4 patients, in-
troital stenosis in 2 patients, one of them had a tight
stenosis which necessitates redo of the introital wound,
and 2 cases had minor postoperative wound infection
which managed conservatively with local wash and sys-
temic antibiotic for 5 days without any surgical interven -
tion and without sequels. There were no long term com-
plications or impediment related to bowel anastomosis,
and there is no mortality in this group of patients. All
patients had functional adequate patency and lubricant
neovagina, with good patient satisfaction and the vagina
had fine appearing introits and mucus production de-
creased 3 to 4 month after the operation.
6. Conclusions
Vagina could be reconstructed with better success rate
and low complication rate by using sigmoid colon, it
does not require moulds, dilatation, lubricant, and the
vagina gro ws with t he child and could be used in differ -
ent diagnosed vaginal atresia, especially in girls who
doesn’t expect sexual activity shortly after surgery. The
use of stapler to reestablish the bowel continuity seems
to minimize the time of the technique and decline the
rate of complications related to bowel anastomosis. The
long-term satisfaction with the sigmoid neovagina for
intercourse, especially in girls had their vagina con-
structed before puberty, still requires long-term evalua-
tion.
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Appendix
Abbreviation
Androgen Insensitivity Syndrome (AIS), Congenital Ad-
renal Hyperplasia (CAH), Gastrointestinal Anastomosis
(GIA), Curved Detachable Head (CDH).