腹腔镜下回肠代阴道成形术式探讨

On surgical techniques of laparoscopic ileal vaginoplasty

目的探讨腹腔镜下带血管蒂回肠代阴道成形术的临床应用效果。方法回顾性分析45例腹腔镜下带血管蒂回肠代阴道成形术患者的临床资料,其中先天性无阴道33例,男性假两性畸形1例,男性易性癖11例。结果45例手术均获得成功,手术时间90～313min,平均155min,人工阴道壁生长良好,接近女性阴道的形态和生理功能。术后10天内阴道排液较多(>200ml/d),3个月后阴道排液量<100ml/d。术后3个月随访,6例男性易性癖者(截取回肠20～22cm)人工阴道排液量较其余39例(截取回肠13～18cm)多,前者应用卫生巾8～10片/d,后者应用卫生护垫3～5片/d。共有15例佩带阴道模具达6个月以上,人工阴道扩张良好;有性生活者35例,均满意。手术并发症1例,为全腹腔镜下手术后不完全肠梗阻,经腹腔镜梗阻段肠管切除、回肠端端吻合术治愈。结论腹腔镜下带血管蒂回肠代阴道成形术是目前较理想的阴道成形方法。截取回肠段15cm左右足以满足患者对性生活的要求,过长会增加人工阴道排液量,从而增加患者的不便。

Objective To study the clinical effectiveness of laparoscopic ileal colpopoiesis using a long vascularized pedicled flap. Methods We reviewed clinical data of 45 cases of laparoscopic vaginoplasty using a vascularized pedicled ileal flap. There were 33 cases of congenital absence of vagina, 1 case of male pseudohermaphroditism, and 11 cases of male-to-female transsexual. Results The ileal colpopoiesis was preformed successfully in all the 45 cases. The operation time was 90 - 313 min （mean, 155 min）. The artificial vaginas had excellent cosmetic results, including adequate vaginal length, good lubrication, and appearance and physical functions similar to natural vagina. There was plenty of vaginal discharge （ 〉 200 ml/d） following the first 10 days after operation, and the discharge was gradually reduced in 3 postoperative months （ 〈 100 ml/d）. At follow-up observation at 3 postoperative months, the vaginal discharge was more in 6 cases of male-to-female transsexual （with 20 - 22 cm ileum isolated） than the rest 39 cases （with 13 - 18 cm ileum isolated）. About 8 - 10 pieces of sanitary napkins were used each day in the male-to-female transsexuals, while only 3 - 5 pieces of sanitary pads were required each day in the other patients. A vaginal mould was employed for more than 6 months in 15 cases, achieving a good dilatation of the artificial vagina. Thirty-five patients with sexual intercourse reported satisfactory results. One patient experienced an incomplete intestinal obstruction, and was cured by a second operation of laparoscopic ileectomy and end-to-end anastomosis. Conclusions Laparoscopic vaginoplasty using a vascularized pedicled ileal flap is a feasible, safe, and ideal method. An ileal flap isolated for about 15 cm in length is enough to meet patient＇s sexual requirements. Excessively prolonged flap will lead to increased amount of vaginal discharge, thus putting patients to inconvenience.