Pedicled Peritoneal Flap Vaginoplasty in Male-to-Female Gender Affirmation Surgery: A Case Report

Abstract

Peritoneal vaginoplasty has been used for the reconstruction of vaginas in females born with congenital vaginal agenesis (eg, Mayer-Rokitansky-Küster-Hauser [MRKH] syndrome).1 Traditionally, the eponymic “Davydov” procedure uses a sliding peritoneal flap pull-down into the vaginal cavity.2 Recently, a series of laparoscopic vaginoplasty techniques using a single peritoneal flap in MRKH syndrome patients has been reported.3 The advantages of using the peritoneum for vaginal reconstruction include its abundant availability, proximity to the vagina, mucosal-type surface, and self-lubrication.4 In male-to-female (MtF) gender affirmation surgery, penile skin inversion (PSI) vaginoplasty remains the standard surgical technique. Intestinal vaginoplasty or nongenital grafting is often used for secondary deepening procedures. Some authors reported successful use of the Davydov procedure for augmenting neovaginal length in a postsurgical transgender woman (TGW).5,6 Peritoneal vaginoplasty has become an exciting procedure for TGW who are unable to undergo (or have failed) PSI.4 Although the pedicled peritoneal flap can achieve a deeper neovaginal cavity than the original pull-through procedure, there are no reports of its use in primary vaginoplasty in TGW. We present the case of a transgender woman with penoscrotal hypoplasia who underwent primary peritoneal vaginoplasty for her gender incongruence. CASE REPORT A 25-year-old transgender woman was referred to our clinic for gender affirmation surgery. Her history regarding sex transition included 10-year feminizing hormone therapy and breast augmentation. She had 2 referrals from psychiatrists and had passed all criteria for MtF genital surgery.7 From physical examination, her penile and scrotal skin was insufficient to create a neovagina with the patient’s desired functional depth. The patient did not want to have any bowel resection but agreed to undergo an abdominal procedure. To obtain a vaginal depth more than that obtained by the Davydov pull-through procedure, we decided to proceed with peritoneal vaginoplasty using a pedicled peritoneal flap based on the deep inferior epigastric vessels. The operative procedures are described below. Indocyanine green angiography was used to demonstrate the flap perfusion intraoperatively.8,9 The study was exempted from review by the institutional review board of Chulalongkorn University, and informed consent was obtained from the patient. Operative Procedures The operation was a team effort performed by the senior general surgeon (S.U.), an expert in advanced laparoscopy, and the plastic surgeon (P.S.), an expert in MtF vaginoplasty. The procedures were divided into 3 steps: laparoscopic, groin, and perineal. Total operative time was 8 hours, the estimated blood loss was 250 mL; no blood transfusion was needed along the operation. The Laparoscopic Step This step included 2 parts: first, dissection of the preperitoneal space, and second, the intraabdominal peritoneal flap harvesting. The operation began with making an umbilical incision and dissecting the preperitoneal space on the left-sided abdominal wall, using a balloon dissector. After completing the dissection, the preperitoneal space was insufflated with CO2 to a pressure of 12 mm Hg, and the 2 other trocars were then placed on the left subcostal and suprapubic areas. The left deep inferior epigastric artery (DIEA) was identified using video laparoscopy. The peritoneal branches of the DIEA were preserved, whereas the musculocutaneous perforators to the rectus abdominis muscle were ligated and divided (Fig. 1). The peritoneum was opened cranially, and the intraperitoneal cavity was entered. The incision was continued in a horizontal direction along the superior border of the created preperitoneal space, establishing the pneumoperitoneum.FIGURE 1: Identification of musculocutaneous and peritoneal branches of the left DIEA via laparoscopy.From the inside of the abdominal cavity, the peritoneal