In this video, we present reconstruction of the vagina with gracilis muscle flap and full-thickness skin graft. Our patient is a 30-year-old African-American female with a history of Meyer-Rokitansky-Kuster-Hauser syndrome, who initially underwent a McIndoe vaginoplasty, which then failed due to inconsistent dilator use. She then underwent a second McIndoe procedure, however, as she was nervous about a second failure, she decided to wear her vaginal mold for 24 hours a day. And as a result of continued use, she developed necrotic vaginal lesions and later presented to the urogynecology clinic with a rectovaginal fistula, which was then confirmed on MRI. MRKHS, also referred to as vaginal agenesis or mullerian aplasia, is the congenital absence of a vagina with varying degrees of uterine development due to incomplete development of the mullerian duct, which normally becomes the uterus, fallopian tubes, cervix, and upper one-third of the vagina. While the exact cause is unknown, it's generally considered a spontaneous multifactorial mutation. The prevalence is between 1 in 4,000 and 1 in 10,000. It is only seen in newborn females. It first presents as amenorrhea or infertility. The most recent ACOG committee opinion on vaginal agenesis states that self-dilation is the preferred initial treatment. However, if the patient declines conservative management, then the McIndoe vaginoplasty is the preferred procedure. Though not demonstrated in this video, briefly, the McIndoe involves harvesting a skin graft and placing it over a vaginal mold, which is then inserted into the introidal area and held in place by suturing the labia together. On post-operative day 12, the labial sutures are cut, the vaginal form is removed, and a soft rubber and silicone vaginal insert is placed into the vagina to be worn for varying lengths of time, allowing for continued formation of the neovagina. The patient was taken for an exam under anesthesia, confirming the presence of a 1 cm rectovaginal fistula. Given the failure of the McIndoe procedure, a gracilis muscle flap was chosen. The gracilis muscle, one of five adductor muscles of the thigh, is often chosen for a flap due to its proximity to the perineum and its ability to be easily transposed along its blood supply from the median femoral circumflex artery. It is innervated by the obturator nerve. The posterior vaginal flap was elevated, and the granulation and scar tissue was then dissected off laterally down on either side of the rectum to establish space for the gracilis flap that would then be placed. The apex of her previous neovagina was released and dissected in the plane between the bladder and the rectum up to the peritoneal reflection. The edges of the rectal fistula were then debrided and irrigated copiously. The gracilis muscle was then identified by palpating its origin at the ischiopubic ramus and its insertion at the pes anseranus, just posterior to the sartorius muscle. A full thickness skin graft was harvested superior to the donor muscle and completely elevated off the subcutaneous region. The dissection was then carried down to the gracilis muscle, where the muscle was freed distally and proximally. The posterior aspects of the gracilis were then separated from the adductor muscles of the thigh. The fascia between the muscles was then opened, and the medial femoral circumflex pedicle was identified. The muscle was then divided off the symphysis pubis and was rotated 180 degrees. Then facilitating advancement of the muscle towards the perineum. After creation of a pocket between the thigh dissection and the perineum, the gracilis was then transposed into the vagina so that it was overlying the site of the rectovaginal fistula. The muscle belly was then secured both laterally and at the apex of the vaginal vault with 3-0 delayed absorbable suture. In order to add an additional layer of protection, In order to add an additional layer of protection, a full thickness skin graft was then secured over the gracilis flap with 3-0 delayed absorbable suture. The vaginal reconstruction was then supported with a bolster created from a sponge and xeriform. This was then held in place by suturing the introitus closed. A drain was placed in the medial thigh and the incision was closed in the usual fashion. In order to allow for sufficient healing of the newly harvested flap, an ileostomy was then performed. The most common cause of flap failure is vascular compromise. However, hematomas, seromas, and surgical site injuries can also impact the success of the flap. A systematic literature review looking at the use of the gracilis muscle flap for treatment of the rectovaginal fistula found that at a median follow-up of 21 months, healing was present in between 33% and 100% of cases, with the largest studies showing rates between 60% and 90%. Five months after the initial surgery, she then had her ileostomy reversed. At a 6-month follow-up, the fistula is well healed and she has a total vaginal length of 5.5 cm. The patient is successfully using her neovagina for vaginal intercourse.

African-American female

Meyer-Rokitansky-Kuster-Hauser syndrome

McIndoe vaginoplasty

rectovaginal fistula

gracilis muscle flap reconstruction