V57 - Robotic Assisted Excision of Sigmoid Neovagina: Technical Approach and Considerations

Purpose/Background: Colonic interposition for neovaginal reconstruction is a complex procedure that poses unique long-term management challenges for colorectal surgeons. These segments can be difficult to evaluate endoscopically and are prone to developing diversion colitis due to their exclusion from the fecal stream. We present the case of a 42-year-old individual born with congenital adrenal hyperplasia and ambiguous genitalia who underwent sigmoid colon interposition for neovaginal reconstruction in childhood and later developed symptomatic diversion colitis requiring definitive surgical management.

Methods/Interventions: Our patient underwent a robotic-assisted neovaginal sigmoidectomy and hysterectomy. Upon abdominal entry, careful attention was paid to delineate the complex pelvic anatomy. Dissection was performed in a stepwise fashion, beginning with lysis of adhesions between the neovagina, colorectal anastomosis, and abdominal wall. This was followed by isolation of the mesentery of the sigmoid conduit, and care was taken to preserve collateral blood flow to the posterior colorectal anastomosis. Once the uterus, neovagina, and anastomosis were clearly defined, a hysterectomy was performed. Further pelvic dissection was carried to the level of the levator muscles, ensuring preservation of the intact, functioning colon, rectum, and urinary tract. The specimen was extracted via the perineum, and the introitus was closed in multiple layers.

Results/Outcomes: The procedure was completed robotically without complications in four hours, with minimal blood loss. The sigmoid conduit and uterus were successfully excised while maintaining the integrity and vascular supply of the colorectal anastomosis. The patient tolerated the procedure well, resumed a diet on postoperative day zero, and was discharged home on postoperative day two. Final pathology was benign, and the patient remains well at follow-up, with resolution of symptoms and an improved quality of life.

Conclusion/Discussion: This case underscores the importance of a thoughtful, multidisciplinary approach and meticulous anatomic understanding in addressing rare and complex pelvic reconstructive pathology. Robotic-assisted dissection facilitated precise identification of critical structures, enabling a safe, effective operation and an excellent clinical outcome.