Simple resection of a high partial longitudinal vaginal septum in a woman with uterine diadelphys presented by Woojin Chung, Mount Sinai Medical Center in New York. Others include Drs. Woojin Chung, Latisha Moreta, and Lisa Dabney. There are no financial disclosures. The outline of the presentation is listed here. The objectives of this presentation are first, to review embryology development and anomalies of malarian tract, special focus on vaginal septa, second, to review management options for symptomatic vaginal septum, and third, to demonstrate simple resection of longitudinal vaginal septum. As background information, malarian ducts develop approximately 9 to 16 weeks of fetal life after development of both malarian ducts, proper fusion and absorption occur to form a normal uterus, cervix, fallopian tubes, and vagina. Malarian tract anomalies can result from failure of fusion or resorption or failure when connection with urogenital sinus goes wrong. Classification of malarian anomalies as shown here. Urine didalysis resulted from a complete failure of the malarian ducts to fuse and leaving separate urine cavities and two cervices. It constitutes 0.1% of general population and 5% of all malarian anomalies. It is usually not associated with difficulties with menstruation and coitus except when there is also a midline longitudinal vaginal septum. There are largely two types of vaginal septum. Transverse vaginal septum is due to de facto infusion of malarian ducts to urogenital sinus, usually treated with surgery. Longitudinal vaginal septum is called double vagina. It is due to incomplete fusion of lower part of the malarian ducts. It consists of 12% of malformations of the vagina. The embryological origin of the vagina is unclear, but uterine malformation is seen in 88% of cases, so it is important to check uterine anatomy once a longitudinal vaginal septum is discovered, especially when it is complete or high. There are several types of longitudinal vaginal septa. Longitudinal vaginal septa are mostly asymptomatic, but they can result in symptoms. Now, I would like to present our case. 33-year-old C-0 woman presents to clinic complaining of long history of dyspareunia, difficulty with deep penetration, and occasional post-coital bleeding. Past histories are listed here. Benign general physical exam was noted. Pelvic exam revealed 0.5 cm thick longitudinal septum from the level of midsurfaces to the level of neohymen. The two-thirds of distal vaginal septum was incomplete while one-third of proximal vaginal septum was complete. MRI was done outside of the hospital and reports revealed uterine didelphys with normal renal system. Resection of vaginal septum was recommended considering her persistent symptoms. Patient was consented for the procedure with risks, benefits, and alternatives. The goals of resection of longitudinal vaginal septum are, first, to minimize blood loss, second, reduce risk of stenosis and re-obstruction, third, avoid bowel and bladder perforations, fourth, use instruments efficiently and effectively in a confined space. After prepping and draping in a sterile fashion, Foley catheter was placed into the bladder to delineate the urethra and the bladder neck, a posterior weighted speculum was inserted into the vagina. The extent of longitudinal septum was evaluated using multiple Alice clamps. The excisional edge was marked with a marking pen. The marked area was carefully excised using a blade No. 15. The excised septum was sent to pathology. The longitudinal vaginal septum was identified between both surfaces and dressed with Alice clamps then excised carefully. Special attention was given not to enter into the posterior cul-de-sac too closely. Using 2-0 Vigra, the edges of vaginal tissue at the excision site were re-approximated in a running-locking fashion. Two surfaces were identified and dressed with a single-tooted tenoculum to give a better exposure for re-approximation of the vaginal tissue between two surfaces. Re-approximation of vaginal tissue was completed at the posterior pharynx. Final presentation after completion of the surgery is shown here. The septum is completely excised. Recap of steps of resection of longitudinal vaginal septum are 1. Grasp septum with Alice clamps or tissue forceps and apply slight traction. 2. The anterior and posterior junctions of the longitudinal vaginal septum and vaginal mucosa are then excised with scissors or cautery. 3. Pay extra attention not to excise too much tissue, which can be easily done if placed on tension. 4. Defect on vaginal mucosa is then re-approximated with interrupted sutures. At two weeks post-op visit, the excision site was healing well and patients expressed satisfaction. In summary, longitudinal vaginal septum consists of 12% of malformation of the vagina. Longitudinal vaginal septa are mostly asymptomatic but can result in dyspareunia, difficulty with sexual intercourse, difficult tampon insertion, persistent vaginal bleeding, or dysmenorrhea. If symptomatic, simple excision of longitudinal vaginal septum should be considered. These are our references. Thank you. For any questions or comments, please email at www.oojin.gmail.com.

video presentation

Dr. Woojin Chung

Mount Sinai Medical Center

high partial longitudinal vaginal septum

uterine diadelphys