Chapter 7
Laparoscopic rectosigmoid colpopoiesis:
does it benefit our transsexual patients?
S.M. Maas, Q.A.J. Eijsbouts, J.J. Hage, M.A. Cuesta
Plast Reconstr Surg 1999;103:518-24
Abstract
When inversion of the combined penile and scrotal skin flaps for vaginoplasty in male-to-female transsexuals has not led to functional results, rectosigmoid colpopoiesis offers an immediate solution to a complicated and difficult problem. However, open colpopoiesis involves major surgery and it may be associated with substantial extended morbitity and hospitalization, short-term and long-term unfavorable results and extensive scarring of the abdomen. To reduce this associated morbidity we employ a laparoscopically assisted approach, and a total laparoscopic rectosigmoid colpopoiesis. This procedure has been performed safely in the series presented herein, with no apparent compromise in the adequacy of the dissections. We conclude that our patients benefitted from this procedure and advocate considering a total or partial laparoscopic approach whenever secondary rectosigmoid colpopoiesis is indicated in male-to-female transsexuals.
Rectosigmoid colpopoiesis for male-to-female transsexualism has been associated with substantial short-term and long-term morbidity and, in general, compares unfavorable to penile and scrotal skin inversion vaginoplasty [1, 2]. One of the origins of the short-term morbidity and complications is the laparotomy performed to harvest the rectosigmoid transplant. Such open colocolpopoiesis results in extended inactivity of the bowel and hospitalization and additional scarring of the abdomen. This is true even though we routinely harvested the transplant through a small, modified Pfannenstiel incision [3]. In our quest to further reduce the complication rate of rectosigmoid colpopoiesis, the video-directed laparoscopy assisted isolation of the rectosigmoid segment was introduced in our clinic in 1995 [4]. Laparoscopically assisted surgery is gaining widespread acceptance as scarring and invasiveness can be minimized and, hence, laparoscopic appendectomies, cholecystectomies and groin hernia repairs have become commonplace [5-7]. In comparison with many of the ablative procedures laparoscopic bowel resection requires advanced technical expertise on the part of the surgeon and, consequently, spread has been less rapid than in some other areas. Ohashi et al. [8] reported favorable results of total laparoscopic primary rectosigmoid colpopoiesis in three female patients suffering from vaginal defects corresponding to Rokitansky-Kuster-Hauser syndrome. With the increasing experience in laparoscopically assisted bowel resection in our hospital [9], the indication range has been expanded to include total laparoscopic isolation and transplantation of the rectosigmoid segment used for secondary colpopoiesis in transsexuals [10]. In this article, our experience with such minimally invasive colocolpopoiesis is evaluated to find out whether it is of benefit to our patients.
Methods
All candidates for vaginoplasty are admitted to the hospital 2 days preoperatively to start a residue-free liquid diet and bowel preparation [11]. Estrogen treatment has, then, been interrupted for at least 3 weeks because in males, such treatment is associated with an increased incidence of thromboembolic events [12]. Preoperatively, 1500 mg cefataxin (Zinacef) and 500 mg metronidazole are administered intravenously and a nasogastric tube and urinary catheter are passed as soon as the patient is anaesthetized. A sufficiently deep general anaesthesie with corresponding extensive muscle relaxation is used throughout the procedure to prevent increase of abdominal pressure and subsequent subsiding of the abdominal cavity [6].The abdominal and perineal approaches are performed simultaneously with the patients in supine position. The patient is placed in the Lloyd Davis position with the legs spread but flat to provide unlimited access to the neovagina cavity and anal canal while, at the same time, avoiding interference with the insertion and handling of the laparoscopic instruments (Fig. 1) [10]. As soon as carbon dioxide pneumo-peritoneum is established through a Veress needle [7], the small umbilical incision is used to insert a 0-degree laparoscope (Karl Storz, Tuttlingen, Germany) through a 10-mm cannula. Under direct vision and video-laparoscopic control, two more 10-mm cannulas are inserted bilaterally at the level of the umbilicus and one 12-mm cannula in the right lower quadrant (Fig. 1). The first assistant manipulates an endoscopic clamp inserted through the left upper-lateral cannula, and the laparoscope [7].
The surgeon and second assistant work through the right upper lateral, and right lower lateral cannulas. After mobilization of the lower part of the descending colon and sigmoid down to the proximal rectum, a segment of the rectosigmoid is selected for transplantation on its vascular pedicle: one of the sigmoid arteries and its concomitant veins (Fig. 2).
Fig. 2. (Above, left) For rectosigmoid colpopoiesis, a 20-cm segment of the rectosigmoid is selected for transplantation on its vascular pedicle, the sigmoid artery and veins. (Above, center) For total laparoscopic rectosigmoid colpopoiesis a gasless abdominal elevation is used to allow for the stapler’s anvil to be introduced in the proximal part of the remaining colon through an incision of the peritoneum at the top of the neovaginal canal. (Above, right)The anvil is left sutured inside the proximal colonic part while the stapler’s shaft is retracted out of the neovaginal canal and passed transanally up to the level of the staple line of the distal rectal stump. The central spike of the stapler’s shaft is advanced through the stump of the rectum adjacent to the transverse staple line. (Below, left) After reconnection of the anvil to the stapler’s spike, the instrument is closed and ‘fired’ to give a circular anastomosis. (Below, center) The rectosigmoid transplant is reversed to allow for its considerable oral length to reach the perineum through the peritoneal insicion and neovaginal canal without subjecting the mesenteric neurovascular pedicle to undue tension and subsequent necrosis.
Distal, aboral dissection of the rectosigmoid is performed at the level of the peritoneal fold using a laparoscopic stapler device (EndoGIA 60 linea, USSC, Norwalk, Conn.) [7]. The proximal oral level of dissection is chosen, allowing for a segment of 20 cm in length.
The mesocolon is divided using scissors with simultaneous electrocautery or an ultrasonically powered instrument (LCS 15, UltraCision, Smithfield, R.I.), and in such a fashion as to ensure preservation of both the superior rectal artery for the rectal stump and the vascular pedicle for the transplant [3]. Proximally, a 1-0 vicryl suture is tied around the sigmoid colon (Fig. 2, above, left). At this stage of the operation the laparoscopically assisted procedures were converted to a modified open laparotomy by use of a small modified Pfannenstiel incision (Fig. 3). Through this incision, the oral transsection of the rectosigmoid was performed and bowel continuity was restored immediately by extra abdominal end-to-end anastomosis using a curved intraluminal stapler (Proximate CDH 33, Johnson & Johnson, Arlington, Texas). After presentation of the pedicled rectosigmoid transplant through a peritoneal incision, all abdominal incisions were closed over one Abdovac drain (Astra, Rijswijk, The Netherlands). Currently, gasless abdominal elevation is created at this stage to allow for a total laparoscopic procedure. For this, the laparoscope is moved to the right upper lateral cannula and the umbilical cannula is replaced by the Airlift Balloon Jr. retractor device (Origin Medsystems, Menlo Park, Calif.). This retractor is raised by an electrically powered mechanical arm (Laparolift, Origin Medsystems) secured on the side rail of the operating table adjacent to the left shoulder. The Airlift system allows for the laparoscope to be reintroduced through the umbilicus incision and without the use of a cannula (Fig. 4). Because the perineal surgical team has meanwhile completed dissection up to the peritoneum of a competent neovaginal cavity reaching the peritoneum, the curved intraluminal stapler can be introduced intra-abdominally through this canal after opening the peritoneum (Figs. 2, above, center).
After partial division of the sigmoid proximally to the 1-0 Vicryl suture at the aboral side, the anvil of this stapler device is inserted into the descending colon, after which transsection of the colon is completed. Subsequently, a 2-0 Vicryl pursestring suture is placed at the opening of the proximal remaining part of the colon and tied around the shaft of the anvil (Fig. 5) [13]. Leaving the anvil inside this proximal colonic part, the shaft of the stapling device is retracted out of the neovaginal canal and passed transanally up to the level of the staple line of the distal rectal stump. The central spike of the stapler’s shaft is advanced through the stump of the rectum adjacent to the transverse staple line (Figs. 2, above, right and 6).
The shaft of the anvil is grasped and reconnected to this spike (Fig. 2, below left). The instrument is closed and ‘fired’ to give a circular anastomosis. The stapler is removed transanally and inspected for two complete ‘doughnuts’ of tissue around its shaft [10]. The bowel lumen is filled with methylene-blue coloured water to check for possible leakage [13]. The rectosigmoid transplant is, then, reversed to allow for its considerable oral length to reach the perineum through the peritoneal insicion and neovaginal canal without subjecting the mesenteric neurovascular pedicle to undue tension and subsequent necrosis (Fig. 2, below, center) [3]. The oral edge of the rectosigmoid transplant is sutured to the remains of the penile skin inversion vaginoplasty in an exaggerated interdigital fashion to prevent introital stenosis [3]. Optionally, a cylindical Heyer-Schulte inflatable vaginal dilator (Rofil Medical International, Breda, The Netherlands) may be left as an introital stent [14]. Postoperatively, antibiotic prophylaxis is continued for 24 hours. The nasogastric tube is kept for gastric decompression until bowel activity can be auscultated. Together with oral feeding, lactulose intake is started to keep the stool soft. The Foley catheter is removed as soon as the patient is mobile again, and patients are prescribed 960 mg cotrimoxazole, twice daily, for 5 days.
Case Reports
Case 1
In 1995, a 50-year-old male-to-female transsexual consulted us because of a shallow and narrow neovagina resulting from a skin inversion vaginoplasty performed elsewhere, 21 years previously. To increase the diameter and depth of the neovagina corrective surgery using local skin flaps was performed. This procedure was complicated by formation of a urethrovaginal fistula and stenosis of the vaginal top. Therefore, a laparoscopically assisted rectosigmoid colpoiesis as described above was accomplished in September of 1995 after informed consent was obtained for this procedure and the possibility of conversion to conventional laparotomy. The urethrovaginal fistula was closed using part of the vaginal skin. This procedure required a total of 4 hours, in which the perineal blood loss amounted to approximately 500 ml.
Postoperatively, pain medication (naproxen 500 mg, three times daily) was required for two days only. Bowel function returned on the fourth postoperative day and the patient tolerated a liquid diet on the fifth day. On the sixth postoperative day, the abdominal drain was removed after a total production of 500 ml. The patient tolerated a regular diet on the ninth day but she was discharged from the hospital on the eleventh postoperative day as a precaution because this was our first laparoscopically assisted rectosigmoid colpoiesis. At 2.5 years of follow-up, she continues to do well without bowel dysfunction (Fig. 7). Sexual intercourse is possible and satisfactory to both the patient and her partner. So far, none of the previously reported unfavorable long-term results have been encountered in this case [2].
Case 2
A 32-year-old male-to-female transsexual consulted the Amsterdam gender team because of obliteration of the neovagina. She had undergone penile and scrotal skin inversion vaginoplasty elsewhere, three years previously. In October 1995, laparoscopically assisted rectosigmoid colpopoiesis was performed. The total operative time was 3.15 h, again with minimal abdominal blood loss. Postoperatively, the patient required pain medication for two days. Bowel function returned on the second postoperative day, and the patient was started on a liquid diet on the third day. On the fifth postoperative day a regular diet was tolerated and the abdominal drain was withdrawn after a total production of 360 ml. She was dismissed on the seventh day after surgery. She continues to do well with both normal bowel function, and satisfactory neovaginal function. Two years after RSC she was admitted to the hospital for surgical correction of the vestibular cosmesis and sculpturing of a neoclitoris.
Case 3
In 1985, a penile skin inversion vaginoplasty was performed in a then 24-year-old male-to female transsexual. As was expected at the time, the neovagina turned out too shallow and too narrow due to the limited amount of penile and scrotal skin. The patient agreed to a total laparoscopic rectosigmoid colpopoiesis, which was performed as described above, in November 1997. The total surgical procedure required 4 hours, with an abdominal blood loss of only 10 ml. On the first postoperative day the abdominal drain could be removed as its production was approximately 10 ml. The patient did well and experienced minimal postoperative bowel dysfunction or pain. She required pain medication (naproxen 500 ma, three times daily) during the first postoperative day only. Although she requested something to drink on the first postoperative day while active bowel sounds could already be auscultated, we did not dare feed her until the second postoperative day. By the third day, she was taking a regular diet, and the patient was discharged on the seventh postoperative day after removal of a 70 cc inflatable introital stent.
She has done well now 4 months postoperatively and reports satisfactory sexual intercourse. Scarring of the abdomen is minimal (Fig. 8) and, sofar, no complications such as painful junctional neuromas or scars, disturbing neovaginal contractions, or vaginal diversion colitis have been encountered.
Discussion
In cases where primary penile and scrotal skin inversion vaginoplasty has become impossible or has not led to functional results, RSC offers an immediate solution to a complicated and difficult problem [3]. The alternative Abbe-McIndoe split skin graft vaginoplasty often does not provide favorable results in the scarred area encountered following complications of skin flap inversion surgery [15]. Because thicker skin grafts show less tendency to shrink, a full thickness skin graft harvested by (mini-) abdominoplasty may be applied and such abdominoplastic vaginoplasty has been proven to provide a good alternative when rectosigmoid colpopoiesis is not favored or even contra-indicated in secondary cases [15]. Its main disadvantage is the resulting 30-cm scar in the lower abdominal region. Apart from comparable lower abdominal scarring, the invasiveness of the conventional laparotomic rectosigmoid colpopoiesis is the main disadvantage of such an open procedure [8]. Laparoscopic cholecystectomies and hernia repairs have taught us that much of the morbidity following an abdominal operation is related to the incision and [16] hence, we should strive for minimal scarring. Techniques for laparoscopically assisted bowel resection have up until recently been limited to laparoscopic mobilization and delivery of the bowel to a separate small abdominal incision followed by extracorporal resections and reanastomosis [5].
Applying the current total laparoscopic approach all of the steps are performed laparoscopically, retrieving the resection specimen through the anus [9]. The impetus for employing a laparoscopic technique are the many proposed benefits of laparoscopic rectal procedures as compared with conventional laparotomy procedures [16, 17]. These techniques allow for less blood loss and less fluid loss from decreased peritoneal exposure to the environment. Moreover, the details of abdominal and pelvic anatomy are more clearly visible and the length of the bowel transplant can be equal to that achieved with conventional surgery [5]. Also, there is less manipulation of the small bowel, which is possibly why gastrointestinal function returns sooner. Postoperatively, there is less incisional and musculoskeletal pain and decreased analgesic requirements, with a resultant earlier mobilization and discharge of the patient. Possible long-term benefits include decreased incidence of ventral hernia and small bowel obstruction secondary to adhesions as well as improved cosmesis [5, 13, 16-18].
For a laparoscopic rectosigmoid colpopoiesis, the perineal reconstructive team is dependent on a well-experienced abdominal team of nurses and surgeons performing the laparoscopic part. Because the anvil of the stapler device has to be introduced through a peritoneal incision annihilating the pneumoperitoneum whilst the colonic reanastomosis has still to be performed, the total laparoscopic variant can only be possible with gasless intra-abdominal exposure. Applying the gasless technique there is no risk of leaking ports but a constant view of the operative area is guaranteed even after the peritoneum has been opened. Such a combination of total laparoscopic and gasless techniques requires skilled surgical and assisting hands. The most difficult task is said to no longer rest with the scrub nurse but with the circulating nurse who has to operate the insufflator and retractor device, the light source, and video camera and recorder [6]. The learning curve for newcomers and new procedures alike, applies to laparoscopy as it does to any new surgical procedure. Introduction and disconnection of the stapler’s anvil and application of the internal pursestring suture around it represent some of the difficult skills and should be practiced beforehand [13]. If critical intraoperative situations arise, there is no disgrace in changing the procedure to a laparotomy, and indeed this suggests an appropriate sense of responsibility. Such an open minded approach helps avoiding complications [6]. It has not been necessary to convert to a conventional laparotomy, although we will not hesitate to do so if the circumstances so require [4]. Our patients enjoyed the same benefits as derived from other laparoscopic procedures [17]. Patients in this series had less postoperative pain, shorter ileus, and were discharged on average 7 days sooner than our patients undergoing open procedures [3]. At 4 months to 2.5 years of follow-up, all patients continue to do well with both normal bowel function, and satisfactory neovaginal function. Scarring of the abdomen is minimal. Like Ohashi et al. [8] reporting on his series of female patients suffering from vaginal aplasia and agenesis, we found the outcome of laparoscopic secondary rectosigmoid colpopoiesis to be favorable in male-to-female transsexuals.
Conclusions
Since laparoscopic-assisted and total laparoscopic techniques did not compromise the extent of rectosigmoid mobilisation while the short-term and long-term associated morbidity was less than in conventional open techniques, we conclude that our patients benefitted from this procedure. These positive results in this initial series lead us to recommend this technique as one of the salvage procedures to additional patients that have unfavorable results of a skin inversion vaginoplasty. We advocate considering a total laparoscopic approach whenever rectosigmoid colpopoiesis is indicated, provided a surgical team well skilled in laparoscopic procedures is available.
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