[Abstract] Objective To explore the possibility of laparoscopically assisted interception of ileal segment with vascular tip transfer to reconstruct the vagina and to provide a new method of vaginoplasty for clinical practice. Methods Using laparoscopic guidance and ultrasonic knife, we completed mesenteric separation, ileal segment interception, intestinal end anastomosis, and ileal segment pull-down transfer to form a vagina through a small incision. Results: Since February 2002, laparoscopic assisted interception of ileal segment with vascular tip was successfully performed for 69 patients who needed vaginal reconstruction. Conclusion Laparoscopic ileal transfer is a new and ideal method for vaginoplasty because it avoids the donor scar of dissection and previous procedures and relieves the great psychological stress of these patients. Key words] Vaginoplasty; laparoscopy; ileum Vaginoplasty consists of two parts, one is the formation of a cavity between the bladder and rectum; the other is the repair of the epithelial lining of the cavity wall. There are many methods of lining repair, such as relying on the natural growth of epithelial tissue into the cavity, using intestinal loops, peritoneum, and skin flaps as the cavity wall, and implanting amniotic membrane and skin pieces as the lining, each with its own advantages and disadvantages. Among them, with the increasing maturity of abdominal gastrointestinal anastomosis techniques, the results of intestinal tube in place of vagina are usually considered more satisfactory. Since February 2002, we have successfully performed laparoscopic-assisted interception of ileal transfer vaginoplasty with vascular tissues in 69 patients requiring vaginal reconstruction. 1. Data and methods 1.1. Clinical data There were 69 cases in this group, aged 18-40 years, including 36 cases of congenital absence of vagina in women, 9 cases of pseudohermaphroditism in men, 1 case of pseudohermaphroditism in women (3 cases failed after inguinal flap reconstruction, 3 cases had unsatisfactory results of vaginoplasty by mold pressure, and 1 case combined with congenital left renal prolapse), 23 cases of transsexualism (male → female) (5 cases had failed after scrotal flap reconstruction), and 23 cases of vaginoplasty (male → female). (5 of them failed after scrotal flap vaginal reconstruction). 1.2. The surgical method was to improve the fluid diet, oral intestinal antibiotics and laxatives 1 day before surgery, clean enema in the evening, and gastrointestinal decompression tube was placed in the morning of the operation. Under general anesthesia with intubation, the abdominal and perineal groups were operated simultaneously. To avoid mutual interference between the two groups, patients were placed in the left lower limb abducted and right lower limb bladder truncated position. 1.2.1. Abdominal group: artificial CO2 pneumoperitoneum with a pressure of 1.73 kPa, a 1.0 cm skin incision was made at 2.0 cm above the umbilicus to place a 10 mm trocar as an observation hole, and a 30° laparoscope was placed to investigate the abdominal and pelvic cavities. Under direct vision, small incisions were made at the point of McKenzie and the equivalent of the right “left McKenzie point” and the midpoint of the line between the right McKenzie point and the umbilicus, and 10 mm, 10 mm and 5 mm trocars were placed and laparoscopic instruments were inserted. The intestinal segment is excised to form the vagina in the following steps. The metastatic intestinal segment was selected laparoscopically, and the ileum was lifted 15-20 cm from the ileocecal region to observe the vascularity and distribution, and the ileocecal segment that was relatively free and had independent vascular innervation was selected to be about 15-18 cm long. The distal end was temporarily ligated with a No. 7 silk suture, and the proximal end was wrapped and sutured to form a “cervix”, and the two severed ends of the ileum were placed in front of the mesenteric tip for end-to-end anastomosis, and the mesenteric notch of the ileum was intermittently sutured. The transferred intestinal segment and the anastomosed ileum were returned to the abdominal cavity, and the incised abdominal wall was sutured layer by layer. After completion of vaginal cavity creation in the perineal group, the pneumoperitoneum was re-established. The peritoneum at the apex of the cavity was incised laparoscopically for approximately 4 cm, and the patient was placed in a 10° head-down position, and the distal end of the ileal segment was pulled down into the cavity by extending a toothless oval forceps through the cavity. Intermittent suturing of the pelvic floor peritoneal notch and fixation of the proximal end of the ileocecal segment under laparoscopy, and if necessary, a negative pressure drainage tube can be built into the pelvis to drain from the 5mm puncture hole depending on the blood leakage. 1.2.2. Perineal group: Inject 1:200,000 epinephrine saline 200 ml of hydraulic swelling in the perineal vestibular recess, make an “X” shaped incision, separate bluntly inward along the urethral bladder and rectal space up to the peritoneum, and expand to a diameter of 5 cm on both sides. In eight patients, the scrotal flap or inguinal flap was used to reconstruct the vagina, and the vagina became narrow, shallow, or could only allow the passage of one little finger, or was only 1 to 3 cm deep, and in one case, the reconstructed vagina was complicated by rectal fistula, and fecal water overflowed from the reconstructed vagina through the fistula, so the previously reconstructed vagina was removed and the fistula was repaired.) After the peritoneum at the top of the cavity was cut by the abdominal group to connect with the cavity, the distal end of the intestinal segment was pulled back along the contralateral edge of the mesentery in an arc, and the blood supply of the transferred intestinal segment was checked to be good, and the circumference of the wall of the intestinal end was sutured with the mucosal edge of the skin of the vestibular incision by Z-plasty, paying attention to avoid tension and non-twisting of the tibial mesentery. Negative pressure drainage was placed between the vaginal cavity and the intestinal wall, negative pressure ball drainage and iodoform gauze were built into the cavity of the transferred intestinal segment, and the incision was sutured in sequence. 1.3. Postoperative treatment Same as general intestinal anastomosis. After the patient’s anus was exhausted 48h after surgery, the gastrointestinal decompression tube could be removed, and the negative pressure drainage between the vaginal cavity and the intestinal wall could be removed in 2-3 d. In 12 d, the iodoform gauze and negative pressure drainage were removed from the “vagina” and the catheter was removed. Depending on the wound healing, the stitches are removed in stages. The mold is placed for 3-6 months, and the duration of placement is gradually reduced according to the degree of tightness. In the early postoperative period, some cases had excessive vaginal discharge and some of them had skin rash around the external vaginal opening (irritated by alkaline intestinal fluid), so it was necessary to change 2-3 sanitary pads daily and pay attention to local cleanliness. 2. Results Among the 69 cases, 4 cases inadvertently damaged the rectum or bladder during cavity creation or pelvic floor peritoneum incision, which were repaired immediately intraoperatively, and no complications remained at postoperative follow-up. At follow-up from 1 month to 7 years, the intestinal function of the donor area recovered well, and there was an incisional scar of about 3 cm in the concealed area of the right lower abdomen (Mac’s point incision). The reconstructed vaginal mucosa was wet, moist, red, elastic, with folds, milky white watery discharge and no odor; the depth was greater than 12 cm and could accommodate a columnar prosthesis of more than 3,0 cm in diameter, and circumferential peristaltic-like contractions of the intestinal wall could be palpated on palpation. Most patients had satisfactory sexual life 2 months after surgery, and a few patients had a small amount of blood leakage at the beginning of sexual life due to friction of the cavity wall, which disappeared after 1 to 2 weeks. In one case, lateral anastomosis was performed with a linear cutter at both ends of the ileum under total laparoscopy, and the anastomotic obstruction occurred six months after surgery, and the obstructed segment of the anastomosis was reanastomosed by open excision to restore patency. In four cases of sexually active patients with postoperative vaginal orifice stenosis (mostly due to postoperative placement of molds), three cases recovered after surgical excision of the external contracture ring, and one case of sexually active patient with vaginal urethral fistula due to post-traumatic pelvic fracture one year after surgery; 3. There are many vaginoplasty methods, but there are fewer reports of ileal transfer vaginoplasty, and it is mostly open surgery. After ileal transfer vaginoplasty, the vagina will not secrete a lot of smelly mucus like the sigmoid colon, and vaginal bleeding at the beginning of sexual life will not disappear completely until several months later. Moreover, the ileum is richer in blood flow than the sigmoid colon, and the anastomosis can heal easily after intercepting the intestinal segment, which has less influence on the defecation habit; the mesentery is more free, and there is less tension after the transfer. In 1996, Ohashi et al. successfully performed laparoscopic vaginoplasty of sigmoid colon transfer, which was considered to be a concealed incision, less traumatic, less disturbing to the intra-abdominal environment, early recovery of gastrointestinal function, and most importantly, less prone to intestinal adhesions and other complications of open surgery. On the basis of nearly 100 cases of vaginoplasty with inguinal flap and abdominal flap, we have created laparoscopic transfer vaginoplasty with transfer of ileocecal segment with vascular tip based on the successful experience of laparoscopic sigmoid vaginoplasty abroad, and 69 cases have been completed clinically with satisfactory results. 3.2. Operation points Selecting the position of the abdominal wall puncture trocar and body position should be conducive to the cooperation of the abdominal and perineal groups, and the right lower limb extension and abduction may not obstruct the operation of the right hand of the abdominal group, and when enlarging the Mae’s point puncture hole for the interception and anastomosis of the extra-abdominal intestinal segment, the requirement of not affecting the aesthetic appearance of the abdomen should be satisfied as far as possible. In terms of anatomical characteristics, the ileocecal segment 20 cm from the ileocecum is closest to the pelvic perineum, and the mesenteric position of the transferred intestinal segment is low, so that the transplanted intestinal segment can be incorporated into the artificial vaginal cavity without affecting the blood supply, and it is close to the anterior abdominal wall, which makes it easy to separate the mesentery and cut the anastomosed intestinal canal under laparoscopy, and it is also more convenient to raise the intestinal segment outside the abdomen if necessary. The distal ileum is supplied by the ileocolic artery and the proximal ileum is supplied by the rest of the ileocolic artery. The male pelvis is narrower and deeper, so a longer ileal segment (18 cm) should be taken in patients with transsexualism. Placement of the mold The transplanted ileocecal segment has a certain curvature and should be rotated along the curvature during the pull-down process, so that part of the mesenteric margin opposite to the intestinal wall can be cut to enlarge the external opening, and Z-plasty incision and suturing of the external opening of the intestinal end can effectively prevent the stenosis of the external opening. The mold should be placed in the curvature of the intestinal segment. In patients with sexual fetishes, the external opening of the reconstructed vagina is easy to be narrowed, so the mold should be placed for a longer period of time to effectively expand the external opening. In the early stage when the wound healing is not stable, a condom should be placed first and then the mold coated with lubricating paraffin oil should be placed, which can effectively prevent the mold from rubbing against the intestinal wall and avoid the tearing of the distal suture of the intestinal segment. Compared with the traditional caesarean section, the laparoscopic incision is hidden, avoiding the exposure of intra-abdominal organs and less blood and body fluid loss; the trauma is light and the disturbance to the intra-abdominal environment is small, and the gastrointestinal function recovers early after the operation, reducing the complications of open surgery and the tendency to Complications such as intestinal adhesions are reduced; there is no need to apply the airless ascending method and the complex laparoscopic stapling device that extends into the abdominal cavity through the neovaginal cavity [6]. We believe that laparoscopic transfer vaginoplasty of the ileocecal segment is a new functional vaginoplasty that is less traumatic and more acceptable to patients, because it preserves the normal vulvar shape, avoids the disadvantages of open interception of the intestinal segment and the application of flaps and skin grafts to reconstruct the vagina, which leaves obvious scar deformities in the donor area and makes the reconstructed vagina narrow and shallow, Therefore, we believe that laparoscopic ileal transfer vaginoplasty is a new method of functional vaginoplasty that is less invasive and easily accepted by patients.