Objective

To describe the surgical technique of laparoscopically assisted uterovaginal/vestibular anastomosis in patients with cervical atresia associated with partial or complete absence of the vagina.

Design

Surgical video article. Local institutional review board approval and written permission from the patients were obtained.

Setting

Tertiary referral center.

Patient(s)

The surgical video presents surgical correction in 3 different patients with cervical agenesis. The first patient, aged 14 years, had a normoconformed uterus and total absence of the vagina. The second patient, aged 12 years, demonstrated a left unicornuate uterus and partial absence of the vagina. The third patient, aged 13 years, displayed a right unicornuate uterus and total absence of the vagina.

Intervention(s)

Laparoscopic time and perineal time. During laparoscopy, the entire abdominopelvic cavity was assessed to evaluate the uterine morphology and size to exclude anomalies such as hematometra. The adnexa and adhesions were evaluated and any endometrial flare-ups were treated appropriately. A laparoscopic ultrasound probe was used to evaluate the size and location of the endometrial cavity. In cases with total absence of vaginas, an H-shaped incision in the hymenal dimple allowed a larger area of available tissue for the anastomosis. A tunnel was then created by blunt finger dissection between the bladder and rectum. Simultaneously, the uterus was pushed caudally by an assistant while the operator grasped it from below using an internal probe. A circular myometrial incision at the uterine caudal body allowed to reach the endometrial cavity and open it. The edges of the uterine cavity were then anastomized with the edges of the hymenal incision. In cases with partial absence of vaginas, the creation of the tunnel between the vagina and rectum was not necessary and the open uterus was anastomosed with the margins of the vaginal dome, engraved on the guide of a metal dilator. All patients received broad-spectrum antibiotics (i.e., cephalosporins of the last available generation) on the day before surgery and on the day of surgery.

Main Outcome Measure(s)

Intraoperative anatomic and ultrasound data, neovaginal length, and recovery of menstrual function 180 days after surgery.

Result(s)

The surgical procedure was successful in all cases. No major complications were recorded, and in particular, no bladder or rectal injuries occurred. No stenosis of the neocervix was recorded. The main hospital stay of the patients was 3.5 ± 1.5 days. In each case, the neovagina developed gradually over time after surgery because of the upward traction action exerted by the uterus through its natural ligament apparatus (cardinal ligaments and ovarian vessels). This fact eliminated the requirement for the use of a mold after surgery. At the 15-week follow-up, vaginoscopy was performed, with mucus observed at the site of uterovaginal anastomosis in all cases. None of the patients developed infection after surgery because of the avoidance of molds or pessaries and the natural mucus production. Six months after surgery, the length of the neovagina was >4 cm in all 3 cases.

Conclusion(s)

Laparoscopic-assisted uterovaginal/vestibular anastomosis may be considered the treatment of choice for patients with cervical atresia associated with partial or complete absence of the vagina.

中文翻译：

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与阴道部分或完全缺如相关的宫颈闭锁的保守手术修复

客观的

描述在伴有阴道部分或完全缺如的宫颈闭锁患者中腹腔镜辅助子宫阴道/前庭吻合术的手术技术。

设计

手术视频文章。获得了当地机构审查委员会的批准和患者的书面许可。

环境

三级转诊中心。

病人）

手术视频展示了 3 名不同的颈椎发育不全患者的手术矫正。第一位患者，14 岁，子宫正常，阴道完全缺失。第二名患者，12 岁，左侧单角子宫，阴道部分缺失。第三名患者，13 岁，显示右侧单角子宫且完全没有阴道。

干预措施

腹腔镜时间和会阴时间。在腹腔镜检查期间，对整个腹盆腔进行了评估，以评估子宫形态和大小，以排除异常情况，例如血肿。评估附件和粘连，并适当处理任何子宫内膜发作。使用腹腔镜超声探头评估子宫内膜腔的大小和位置。在完全没有阴道的情况下，处女膜凹陷处的 H 形切口允许更大面积的可用组织用于吻合。然后通过在膀胱和直肠之间用钝指切开来创建隧道。同时，子宫被助手向尾部推动，而操作者使用内部探针从下方抓住它。子宫尾部的圆形子宫肌层切口允许到达子宫内膜腔并将其打开。然后将子宫腔的边缘与处女膜切口的边缘吻合。在阴道部分缺失的情况下，不需要在阴道和直肠之间建立隧道，开放的子宫与阴道穹顶的边缘吻合，阴道穹顶刻在金属扩张器的导向器上。所有患者在手术前一天和手术当天接受了广谱抗生素（即最后一代头孢菌素）。

主要观察指标）

术中解剖和超声数据、新阴道长度和术后 180 天月经功能的恢复。

结果）

手术过程在所有情况下都是成功的。没有记录到重大并发症，特别是没有发生膀胱或直肠损伤。没有记录到新宫颈狭窄。患者的主要住院时间为 3.5 ± 1.5 天。在每种情况下，由于子宫通过其天然韧带装置（主韧带和卵巢血管）施加的向上牵引作用，新阴道在手术后随时间逐渐形成。这一事实消除了手术后使用模具的要求。在 15 周的随访中，进行了阴道镜检查，在所有病例的子宫阴道吻合处均观察到粘液。由于避免了霉菌或子宫托以及天然粘液的产生，因此没有患者在手术后发生感染。手术后六个月，

结论

腹腔镜辅助子宫阴道/前庭吻合术可被认为是与阴道部分或完全缺如相关的宫颈闭锁患者的治疗选择。