Procedures and Instruments
Obstetric Balloon for Treatment of Foreshortened Vagina Using the McIndoe Technique Aubrey Rauktys,
MD,
Pranay Parikh,
MD,
and Oz Harmanli,
BACKGROUND: When conservative options such as the use of vaginal dilators fail, the McIndoe technique may be used in the surgical treatment of a foreshortened vagina. The McIndoe procedure, an approach commonly used for the treatment of vaginal agenesis, requires a mold over which a skin graft is sutured and placed inside the vagina. In most surgical descriptions, this mold is made from nonsterile foam, condoms, or gloves. Because makeshift molds can no longer be used in operating rooms owing to strict regulations, alternative methods must be employed. INSTRUMENT: The obstetric balloon is a good choice for use as a soft and adjustable vaginal mold for a modified McIndoe procedure because it is readily available as an approved device in hospitals that provide obstetric services. EXPERIENCE: This technique was successfully employed in a 54-year-old woman to treat foreshortened vagina. CONCLUSION: An obstetric balloon can be used effectively as a mold for vaginal reconstruction with the McIndoe technique. (Obstet Gynecol 2015;125:153–6) DOI: 10.1097/AOG.0000000000000580
A
foreshortened vagina may arise from various causes. The most common iatrogenic reason is gynecologic surgery, specifically excessive removal
From the Departments of Obstetrics and Gynecology and Surgery, Tufts University School of Medicine, Baystate Medical Center, Springfield, Massachusetts. Videos of the procedure discussed in this article (available online at http://links. lww.com/AOG/A591 and http://links.lww.com/AOG/A592) were presented at the annual meeting of the Society of Gynecologic Surgeons, March 23–26, 2014, Scottsdale, Arizona, and at the 2014 American College of Obstetricians and Gynecologists Annual Clinical Meeting, April 26–30, 2014, Chicago, Illinois. Corresponding author: Oz Harmanli, MD, Urogynecology and Pelvic Surgery, Baystate Medical Center, 759 Chestnut Street, S1680, Springfield, MA 01199; e-mail: [email protected] Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/15
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MD
of the vaginal wall during hysterectomy, either inadvertently or intentionally for management of malignancy.1 The vaginal cavity also may be compromised during the revision or removal of mesh used for pelvic floor repair.2 Additional causes include processes that result in subsequent scarring such as radiation therapy, autoimmune diseases, improper use of chemicals such as trichloroacetic acid, and, finally, either naturally occurring or induced hypoestrogenic states.1 Patients may experience pain and vaginal sexual dysfunction as a result of a foreshortened vagina. First-line treatment is conservative management with vaginal dilators and topical steroids or estrogen, depending on the underlying cause. If conservative therapy is not effective, the patient may be offered surgical treatment such as the modified McIndoe and Davydov procedures, which originally were designed to treat vaginal agenesis.1,3 The goal of the McIndoe approach in this setting is to add vaginal length, most commonly with placement of a split-thickness skin graft. A specific product to use as a vaginal mold to suture the graft onto is not available in most institutions. We present successful use of a Bakri balloon (obstetric balloon) as a vaginal mold for the skin graft in a modified McIndoe procedure in an attempt to treat foreshortened vagina.
TECHNIQUE A 54 year-old woman, gravida 3 para 3, was referred to our office due to her report of dyspareunia from a foreshortened vagina. She was found to have a vaginal length of 5 cm after undergoing two vaginal procedures —vaginal hysterectomy for pelvic pain followed by pelvic reconstructive surgery for prolapse. Her pertinent medical history included depression, anxiety, and hypertension. She also had been treated for presumed interstitial cystitis. Because she had not used vaginal dilators consistently for her foreshortened vagina, she requested surgical management.
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Video 1. The modified McIndoe procedure (part 1). A detailed view of the steps, including harvesting a splitthickness graft from the patient’s pannus, suturing this graft onto an obstetric balloon, and placing it inside the space created at the proximal end of the foreshortened vagina, is presented. Video courtesty of Aubrey Rauktys, MD. Used with permission.
After a detailed review of possible etiology of her pelvic pain and dyspareunia, she consented to a modified McIndoe procedure (see Videos 1 and 2, available online at http://links.lww.com/AOG/A591 and http:// links.lww.com/AOG/A592) for correction of her iatrogenically shortened vagina. Before the procedure, possible donor sites for the skin graft, including her medial thighs, buttocks, and lower abdomen, were discussed. Because she also chose to have a panniculectomy, the decision was made to use the skin from the pannus as the skin graft for vaginal reconstruction. A suprapubic catheter was placed at the beginning of the procedure. The vaginal apex was identified, and a transverse incision was made. Dissection continued cephalad until an additional 6 cm of length was achieved. To make the donor site tumescent and improve postoperative pain control, it was infiltrated with 0.25% Bupivacaine with epinephrine. Mineral oil was spread across the donor site and a split thickness skin graft obtained. The graft was kept in sterile saline while the panniculectomy was performed and skin edges were closed. Perforations were created along the graft to allow drainage of any serous fluid or blood that may have collected behind the graft, because a hematoma or
Video 2. The modified McIndoe procedure (part 2; continuation of Video 1). Video courtesty of Aubrey Rauktys, MD. Used with permission.
serous collection could cause graft failure or necrosis. The graft then was sutured around an obstetric balloon using delayed absorbable sutures, with the keratinized side adjacent to the obstetric balloon. Care was taken to spread the graft evenly and to avoid puncturing the obstetric balloon (Fig. 1). The balloon was inflated with 150 cc of sterile water, which was approximately the volume of the space that was created at the vaginal apex. Importantly, the balloon was partially deflated by approximately 30 cc before graft placement. The obstetric balloon with graft then was inserted into the vaginal canal. The balloon was protected with a malleable retractor while the distal edges of the graft were sutured to the vaginal edges circumferentially. The balloon then was reinflated to a volume of 150 cc to hold the graft in place. The labial edges then were sutured together to hold the obstetric balloon in the vagina (Fig. 2A and B). Although it may not be necessary in every case of the McIndoe procedure, we planned to keep the patient in the hospital until balloon removal at her request. Minimal to no drainage was noted from the obstetric balloon. On postoperative day 7, the balloon was deflated to 75 cc, half of its original volume, to facilitate its removal. Six hours later, the patient was taken back to the operating room, where the suprapubic catheter and obstetric balloon were removed under anesthesia. On removal, the graft appeared
Scan this image to view Video 1 on your smartphone.
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Rauktys et al
Obstetric Balloon for Vaginal Reconstruction
Scan this image to view Video 2 on your smartphone.
OBSTETRICS & GYNECOLOGY
EXPERIENCE We prefer laparoscopic Vecchietti procedure for the treatment of congenital vaginal agenesis. However, this approach is not suitable for the correction of a scarred foreshortened vagina. Although we previously have used the McIndoe method successfully for creation of a functional vagina, this is our first attempt using an obstetric balloon for this purpose.
COMMENT
Fig. 1. Split-thickness graft sutured onto the obstetric balloon. Rauktys. Obstetric Balloon for Vaginal Reconstruction. Obstet Gynecol 2015.
healthy. The patient was discharged on the next day. She was instructed to use dilators daily after her discharge. Seven weeks after the surgery, our examination revealed that the procedure created a vagina 10 cm long and accommodating 3 fingers. The patient was very pleased with her surgical outcome. She attempted intercourse and did not report dyspareunia after the surgery.
Various materials have been used as molds for graft placement, including wood, Pyrex, and silicone-based molds for vaginal reconstruction.1,4–6 Due to stricter regulations, makeshift molds from nonsterile foam and condoms or gloves can no longer be used, even when they are sterilized. Recently, soft molds have been favored; however, there is no specific mold type that is considered standard. However, an effective mold is imperative to successful surgical outcome. The mold needs to ensure time for adequate healing and avoid infection and sloughing.1,4–6 The Bakri Balloon by Cook Medical, is designed for management of postpartum hemorrhage. It is a silicone balloon that is adjustable in size by the amount of fluid used to inflate, to a maximum of 500 mL. The balloon surrounds the underlying catheter, which runs through the middle.7 The catheter tip at the end is open to allow for drainage of any fluid collection behind the balloon. Other advantages of the obstetric balloon as a mold include its soft structure, adjustability for individual patients’ needs, availability in every hospital with obstetric services, approved use in the gynecologic setting, and ease of insertion and removal. The use of inflatable devices for vaginal dilation and stenting previously have been reported for the purpose of creating a functional vagina. A similar mold type was used in a case series for pubertal girls with vaginal agenesis.4 The group designed a plastic mold with an opening in the middle for placement of a catheter to allow for drainage and saline flush if indicated. The
Fig. 2. Foreshortened vagina before (A) and after (B) the placement of the obstetric balloon with the skin graft sewn over. Illustrations by Oz Harmanli, MD. Rauktys. Obstetric Balloon for Vaginal Reconstruction. Obstet Gynecol 2015.
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Heyer-Schulte inflatable vaginal dilator also has been used as a mold for creation of a vagina; however, we were not able find any similar device for vaginal use on the market at the time of our care of this patient.8 One could postulate that the obstetric balloon could be used in creation of a neovagina as well owing to its adjustability in size. In this case, we demonstrated that the obstetric balloon is an effective choice for a vaginal graft mold in an adult patient. We believe it is more beneficial to use the obstetric balloon as a mold in these procedures than to create a mold that may not easily be replicated, sterilized, or mass produced.
//www.fda.gov/medicaldevices/safety/alertsandnotices/ucm262435. htm. Retrieved July 9, 2014. 3. Moriarty CR, Miklos JR, Moore RD. Surgically shortened vagina lengthened by laparoscopic Davydov procedure. Female Pelvic Med Reconstr Surg 2013;19:303–5. 4. Beksac MS, Salman MC, Dogan NU. A new technique for surgical treatment of vaginal agenesis using combined abdominal-perineal approach. Case Rep Med 2011;2011:120175. 5. Coskun A, Coban YK, Varder MA, Dalay AC. The use of a silicone-coated acrylic vaginal stent in McIndoe vaginoplasty and review of the literature concerning silicone-based vaginal stents: a case report. BMC Surg 2007;7:13.
REFERENCES
6. Manage postpartum hemorrhage simply and effectively. Bloomington (IN): Cook Medical; 2013. Available at: https://www. cookmedical.com/data/resources/productReferences/WH-BMBAKRI-EN-201305_WEB.pdf. Retrieved August 06, 2014.
1. Amankwah Y, Haefner HK, Brincat CA. Management of vulvovaginal strictures/shortened vagina. Clin Obstet Gynecol 2010;53:125–33.
7. Yu K, Lin YS, Chao KC, Chang SP, Lin LY, Bell W. A detachable porous vaginal mold facilitates reconstruction of a modified McIndoe neovagina. Fertil Steril 2004;81:435–9.
2. U.S. Food and Drug Administration. FDA safety communication: update on serious complications associated with transvaginal placement of surgical mesh for pelvic organ prolapse. Available at: http:
8. Maas SM, Eijsbouts QAJ, Hage JJ, Cuesta MA. Laparoscopic rectosigmoid colpopoiesis: does it benefit our transsexual patients? Plast Reconstr Surg 1999;103:518–24.
Be Social. Connect with Obstetrics & Gynecology on Facebook, Twitter, LinkedIn®, and YouTube. Visit us on Facebook: http://www.facebook.com/greenjournal Follow us on Twitter: http://twitter.com/greenjrnl Join our LinkedIn group: http://www.linkedin.com [Groups: Obstetrics & Gynecology (Green Journal)] Subscribe to our YouTube channel: http://www.youtube.com/user/greenjrnl rev 7/2013
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OBSTETRICS & GYNECOLOGY
Obstetric Balloon for Treatment of Foreshortened Vagina Using the McIndoe Technique Aubrey Rauktys,
MD,
Pranay Parikh,
MD,
and Oz Harmanli,
BACKGROUND: When conservative options such as the use of vaginal dilators fail, the McIndoe technique may be used in the surgical treatment of a foreshortened vagina. The McIndoe procedure, an approach commonly used for the treatment of vaginal agenesis, requires a mold over which a skin graft is sutured and placed inside the vagina. In most surgical descriptions, this mold is made from nonsterile foam, condoms, or gloves. Because makeshift molds can no longer be used in operating rooms owing to strict regulations, alternative methods must be employed. INSTRUMENT: The obstetric balloon is a good choice for use as a soft and adjustable vaginal mold for a modified McIndoe procedure because it is readily available as an approved device in hospitals that provide obstetric services. EXPERIENCE: This technique was successfully employed in a 54-year-old woman to treat foreshortened vagina. CONCLUSION: An obstetric balloon can be used effectively as a mold for vaginal reconstruction with the McIndoe technique. (Obstet Gynecol 2015;125:153–6) DOI: 10.1097/AOG.0000000000000580
A
foreshortened vagina may arise from various causes. The most common iatrogenic reason is gynecologic surgery, specifically excessive removal
From the Departments of Obstetrics and Gynecology and Surgery, Tufts University School of Medicine, Baystate Medical Center, Springfield, Massachusetts. Videos of the procedure discussed in this article (available online at http://links. lww.com/AOG/A591 and http://links.lww.com/AOG/A592) were presented at the annual meeting of the Society of Gynecologic Surgeons, March 23–26, 2014, Scottsdale, Arizona, and at the 2014 American College of Obstetricians and Gynecologists Annual Clinical Meeting, April 26–30, 2014, Chicago, Illinois. Corresponding author: Oz Harmanli, MD, Urogynecology and Pelvic Surgery, Baystate Medical Center, 759 Chestnut Street, S1680, Springfield, MA 01199; e-mail: [email protected] Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/15
VOL. 125, NO. 1, JANUARY 2015
MD
of the vaginal wall during hysterectomy, either inadvertently or intentionally for management of malignancy.1 The vaginal cavity also may be compromised during the revision or removal of mesh used for pelvic floor repair.2 Additional causes include processes that result in subsequent scarring such as radiation therapy, autoimmune diseases, improper use of chemicals such as trichloroacetic acid, and, finally, either naturally occurring or induced hypoestrogenic states.1 Patients may experience pain and vaginal sexual dysfunction as a result of a foreshortened vagina. First-line treatment is conservative management with vaginal dilators and topical steroids or estrogen, depending on the underlying cause. If conservative therapy is not effective, the patient may be offered surgical treatment such as the modified McIndoe and Davydov procedures, which originally were designed to treat vaginal agenesis.1,3 The goal of the McIndoe approach in this setting is to add vaginal length, most commonly with placement of a split-thickness skin graft. A specific product to use as a vaginal mold to suture the graft onto is not available in most institutions. We present successful use of a Bakri balloon (obstetric balloon) as a vaginal mold for the skin graft in a modified McIndoe procedure in an attempt to treat foreshortened vagina.
TECHNIQUE A 54 year-old woman, gravida 3 para 3, was referred to our office due to her report of dyspareunia from a foreshortened vagina. She was found to have a vaginal length of 5 cm after undergoing two vaginal procedures —vaginal hysterectomy for pelvic pain followed by pelvic reconstructive surgery for prolapse. Her pertinent medical history included depression, anxiety, and hypertension. She also had been treated for presumed interstitial cystitis. Because she had not used vaginal dilators consistently for her foreshortened vagina, she requested surgical management.
OBSTETRICS & GYNECOLOGY
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Video 1. The modified McIndoe procedure (part 1). A detailed view of the steps, including harvesting a splitthickness graft from the patient’s pannus, suturing this graft onto an obstetric balloon, and placing it inside the space created at the proximal end of the foreshortened vagina, is presented. Video courtesty of Aubrey Rauktys, MD. Used with permission.
After a detailed review of possible etiology of her pelvic pain and dyspareunia, she consented to a modified McIndoe procedure (see Videos 1 and 2, available online at http://links.lww.com/AOG/A591 and http:// links.lww.com/AOG/A592) for correction of her iatrogenically shortened vagina. Before the procedure, possible donor sites for the skin graft, including her medial thighs, buttocks, and lower abdomen, were discussed. Because she also chose to have a panniculectomy, the decision was made to use the skin from the pannus as the skin graft for vaginal reconstruction. A suprapubic catheter was placed at the beginning of the procedure. The vaginal apex was identified, and a transverse incision was made. Dissection continued cephalad until an additional 6 cm of length was achieved. To make the donor site tumescent and improve postoperative pain control, it was infiltrated with 0.25% Bupivacaine with epinephrine. Mineral oil was spread across the donor site and a split thickness skin graft obtained. The graft was kept in sterile saline while the panniculectomy was performed and skin edges were closed. Perforations were created along the graft to allow drainage of any serous fluid or blood that may have collected behind the graft, because a hematoma or
Video 2. The modified McIndoe procedure (part 2; continuation of Video 1). Video courtesty of Aubrey Rauktys, MD. Used with permission.
serous collection could cause graft failure or necrosis. The graft then was sutured around an obstetric balloon using delayed absorbable sutures, with the keratinized side adjacent to the obstetric balloon. Care was taken to spread the graft evenly and to avoid puncturing the obstetric balloon (Fig. 1). The balloon was inflated with 150 cc of sterile water, which was approximately the volume of the space that was created at the vaginal apex. Importantly, the balloon was partially deflated by approximately 30 cc before graft placement. The obstetric balloon with graft then was inserted into the vaginal canal. The balloon was protected with a malleable retractor while the distal edges of the graft were sutured to the vaginal edges circumferentially. The balloon then was reinflated to a volume of 150 cc to hold the graft in place. The labial edges then were sutured together to hold the obstetric balloon in the vagina (Fig. 2A and B). Although it may not be necessary in every case of the McIndoe procedure, we planned to keep the patient in the hospital until balloon removal at her request. Minimal to no drainage was noted from the obstetric balloon. On postoperative day 7, the balloon was deflated to 75 cc, half of its original volume, to facilitate its removal. Six hours later, the patient was taken back to the operating room, where the suprapubic catheter and obstetric balloon were removed under anesthesia. On removal, the graft appeared
Scan this image to view Video 1 on your smartphone.
154
Rauktys et al
Obstetric Balloon for Vaginal Reconstruction
Scan this image to view Video 2 on your smartphone.
OBSTETRICS & GYNECOLOGY
EXPERIENCE We prefer laparoscopic Vecchietti procedure for the treatment of congenital vaginal agenesis. However, this approach is not suitable for the correction of a scarred foreshortened vagina. Although we previously have used the McIndoe method successfully for creation of a functional vagina, this is our first attempt using an obstetric balloon for this purpose.
COMMENT
Fig. 1. Split-thickness graft sutured onto the obstetric balloon. Rauktys. Obstetric Balloon for Vaginal Reconstruction. Obstet Gynecol 2015.
healthy. The patient was discharged on the next day. She was instructed to use dilators daily after her discharge. Seven weeks after the surgery, our examination revealed that the procedure created a vagina 10 cm long and accommodating 3 fingers. The patient was very pleased with her surgical outcome. She attempted intercourse and did not report dyspareunia after the surgery.
Various materials have been used as molds for graft placement, including wood, Pyrex, and silicone-based molds for vaginal reconstruction.1,4–6 Due to stricter regulations, makeshift molds from nonsterile foam and condoms or gloves can no longer be used, even when they are sterilized. Recently, soft molds have been favored; however, there is no specific mold type that is considered standard. However, an effective mold is imperative to successful surgical outcome. The mold needs to ensure time for adequate healing and avoid infection and sloughing.1,4–6 The Bakri Balloon by Cook Medical, is designed for management of postpartum hemorrhage. It is a silicone balloon that is adjustable in size by the amount of fluid used to inflate, to a maximum of 500 mL. The balloon surrounds the underlying catheter, which runs through the middle.7 The catheter tip at the end is open to allow for drainage of any fluid collection behind the balloon. Other advantages of the obstetric balloon as a mold include its soft structure, adjustability for individual patients’ needs, availability in every hospital with obstetric services, approved use in the gynecologic setting, and ease of insertion and removal. The use of inflatable devices for vaginal dilation and stenting previously have been reported for the purpose of creating a functional vagina. A similar mold type was used in a case series for pubertal girls with vaginal agenesis.4 The group designed a plastic mold with an opening in the middle for placement of a catheter to allow for drainage and saline flush if indicated. The
Fig. 2. Foreshortened vagina before (A) and after (B) the placement of the obstetric balloon with the skin graft sewn over. Illustrations by Oz Harmanli, MD. Rauktys. Obstetric Balloon for Vaginal Reconstruction. Obstet Gynecol 2015.
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Heyer-Schulte inflatable vaginal dilator also has been used as a mold for creation of a vagina; however, we were not able find any similar device for vaginal use on the market at the time of our care of this patient.8 One could postulate that the obstetric balloon could be used in creation of a neovagina as well owing to its adjustability in size. In this case, we demonstrated that the obstetric balloon is an effective choice for a vaginal graft mold in an adult patient. We believe it is more beneficial to use the obstetric balloon as a mold in these procedures than to create a mold that may not easily be replicated, sterilized, or mass produced.
//www.fda.gov/medicaldevices/safety/alertsandnotices/ucm262435. htm. Retrieved July 9, 2014. 3. Moriarty CR, Miklos JR, Moore RD. Surgically shortened vagina lengthened by laparoscopic Davydov procedure. Female Pelvic Med Reconstr Surg 2013;19:303–5. 4. Beksac MS, Salman MC, Dogan NU. A new technique for surgical treatment of vaginal agenesis using combined abdominal-perineal approach. Case Rep Med 2011;2011:120175. 5. Coskun A, Coban YK, Varder MA, Dalay AC. The use of a silicone-coated acrylic vaginal stent in McIndoe vaginoplasty and review of the literature concerning silicone-based vaginal stents: a case report. BMC Surg 2007;7:13.
REFERENCES
6. Manage postpartum hemorrhage simply and effectively. Bloomington (IN): Cook Medical; 2013. Available at: https://www. cookmedical.com/data/resources/productReferences/WH-BMBAKRI-EN-201305_WEB.pdf. Retrieved August 06, 2014.
1. Amankwah Y, Haefner HK, Brincat CA. Management of vulvovaginal strictures/shortened vagina. Clin Obstet Gynecol 2010;53:125–33.
7. Yu K, Lin YS, Chao KC, Chang SP, Lin LY, Bell W. A detachable porous vaginal mold facilitates reconstruction of a modified McIndoe neovagina. Fertil Steril 2004;81:435–9.
2. U.S. Food and Drug Administration. FDA safety communication: update on serious complications associated with transvaginal placement of surgical mesh for pelvic organ prolapse. Available at: http:
8. Maas SM, Eijsbouts QAJ, Hage JJ, Cuesta MA. Laparoscopic rectosigmoid colpopoiesis: does it benefit our transsexual patients? Plast Reconstr Surg 1999;103:518–24.
Be Social. Connect with Obstetrics & Gynecology on Facebook, Twitter, LinkedIn®, and YouTube. Visit us on Facebook: http://www.facebook.com/greenjournal Follow us on Twitter: http://twitter.com/greenjrnl Join our LinkedIn group: http://www.linkedin.com [Groups: Obstetrics & Gynecology (Green Journal)] Subscribe to our YouTube channel: http://www.youtube.com/user/greenjrnl rev 7/2013
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OBSTETRICS & GYNECOLOGY
