Laparoscopically assisted sigmoid colon vaginoplasty

The ideal genital reconstructive procedure for many trans women aims to provide a neovagina with appropriate length, stable caliber, and - where possible - limited need for lifelong dilation. It should resist scarring, stenosis, and contracture, and deliver a satisfactory cosmetic result. Reconstructing the vagina with intestinal segments can produce a durable canal with mucosal lining that many patients find compatible with sexual activity, often with meaningful natural lubrication.

The sigmoid colon technique is a well-established bowel-based option in selected patients. It is often considered when penile skin is insufficient (for example after circumcision or when skin volume is limited), and as a secondary (redo) procedure after an unsatisfactory or failed prior vaginoplasty.

Typical advantages include adequate vaginal length, natural lubrication, potential for earlier return to intercourse when clinically appropriate, and a low rate of shrinkage relative to some other methods. The sigmoid is anatomically favorable: it lies close to the perineum, and a suitable segment often has enough length and mesenteric mobility to reach the perineum safely when harvested with correct technique.

Selection balances your goals, prior surgery, tissue availability, and medical fitness. Sigmoid-based neovagina creation is not the first choice for every patient; when penile inversion or peritoneal approaches are preferable, those are discussed first. For the cohort in whom colon vaginoplasty is indicated, the technique above supports depth, lubrication, and aesthetics in experienced hands.

The patient is positioned in an extended lithotomy position suitable for a combined abdominoperineal approach. Complete removal of the penis and both testes is performed in standard fashion. Pneumoperitoneum is established and three laparoscopic ports are used for the abdominal part of the operation.

The sigmoid colon is mobilized from its lateral retroperitoneal attachments as far as safely possible. Before the final segment is chosen, the length of sigmoid and mesentery is assessed to confirm it will reach the perineum without tension. The isolated rectosigmoid segment is typically on the order of 12-14 cm to balance adequate depth with avoidance of excessive mucus production and undue risk of postoperative prolapse. The segment is harvested with blood supply from the sigmoid arteries and/or superior hemorrhoidal vessels. A circular stapling device is used for colorectal anastomosis as a reliable method to restore bowel continuity.

Creation of the perineal cavity for vaginal replacement uses coordinated laparoscopic and perineal dissection. Meticulous technique is required to protect the rectum, bladder, and urethra. Introital or perineal skin flaps are designed for anastomosis to the rectosigmoid neovagina. Circumferential anastomosis at the introitus is avoided when it would risk “purse-string” scarring and secondary stenosis.

Urethroplasty, labiaplasty, and clitoroplasty are completed in the usual manner for gender-affirming vulvoplasty.

The neovagina is packed for 7 days. An indwelling Foley catheter remains for 14 days. At discharge, patients are typically instructed to irrigate the neovagina once daily for 2 months, then weekly thereafter, and to dilate the introitus daily with a vaginal dilator as prescribed. Instructions are individualized as healing progresses.

Reconstructing the vagina with sigmoid colon can yield an aesthetically pleasing result and a canal that many patients find well suited to sexual activity. Risks, benefits, and alternatives are reviewed in detail before consent.