The Transgender Dictionary
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Peritoneal

(also: bottom surgery, lower surgery, luohu, peritoneal pull-down vaginoplasty, peritoneal pull-through vaginoplasty, PPT, robotic-assisted peritoneal flap vaginoplasty, robotic davydov peritoneal vaginoplasty, robotic peritoneal pull-through vaginoplasty, robotic vaginoplasty)

Table of Contents

Introduction

Many transgender women, and some transfeminine nonbinary people, experience gender dysphoria regarding the lack of a vulva and/or vaginal canal. Having a vulva and/or vaginal canal procured through surgical means can be a great source of gender euphoria. This page will be discussing the technique known as "peritoneal vagnioplasty." For general information on vaginoplasty, click on the underlined word to go to the general vaginoplasty page, or navigate to it using the alphabet menu at the top of this page.

The first ever peritoneal flap vaginoplasty was performed on a cisgender woman born with Mayer-Rokitansky-Kuster-Hauser syndrome (meaning that she was born without a fully developed vagina) in 1933 by Russian gynecologist M.I. Ksido. In the 1960s and 1970s, the technique was more wildly published by S.N. Davydov, another Russian gynecologist. In 2019, the first published series regarding use of this technique in transgender women was written by Dr. Lee Zhao, a urologist at NYU. Unlike other vaginoplaty techniques (which have their roots in plastic surgery) the peritoneal technique was developed in the field of gynecology and has been refined for use in transgender women by urologists.

General Information

This technique is best for women with limited penile skin, as a full-depth vaginal canal can be created regardless of how much preexisting (natal) skin the patient has. Regardless, more penile skin and tissue is left available for construction of the vulva. Less preop hair removal is required than other methods. Peritoneal vaginoplasty results in a neovagina with some elasticity and less of a need for douching & dilation (compared to penile inversion). Electrolysis is required at least 6 months prior to this surgery. Patients are considered good canditates for peritoneal vaginoplasty if they have no prior exploratory laparotomy for trauma, no prior abdominal mesh surgery, prior history of pelvic radiation, and no prior history of inflammatory bowel disease (Crohn's disease, ulcerative colitis, or diverticulitis).

Peritoneal vaginoplasty can be offered as a revisionist surgery to the penile inversion technique if the patient experiences issues regarding the penile inversion technique (such as vaginal stenosis). While it is traditionally offered only for those who do not qualify for penile inversion, more and more surgeons are performing the peritoneal technique if requested by patients.

The peritoneum is the inside lining of the abdomen. Over 90% of patients express satisfaction with the peritoneal pull through technique.

While the resulting neovagina created through the peritoneal pull-through method does secrete fluid, it is not enough to be considered fully self-lubricating.

Many surgeons require that a patient have a BMI under 30. Patients who smoke are encouraged to quit smoking at least 6-8 weeks prior to surgery to ensure proper healing. A mental health evaluation, as well as 2 letters of recommendation confirming gender dysphoria, is generally required prior to surgery to ensure that the patient understands the impact of this surgery.

As a patient, it is very important to discuss your options with your surgeon ahead of time, and your personal goals regarding surgery. It is a good idea to research your surgeon ahead of time, and look for reviews and images from real people (not just the photos from the surgeon's personal website). Have consultations with more than one surgeon surgeon if possible, to make sure that you have the outcome and surgical team that is right for you.

How It Works

This laparoscopic surgery involves pulling down a section of the peritoneum (moist inner lining of the abdominal cavity). This procedure is done with the use of a single port robotic surgical system (note that not every surgery center has access to a single port robotic system, so this travel may require further travel than other techniques, such as penile inversion, which is more widly accessible). The usage of this robotic system allows surgeons to reach deep into the body through a small incision (5-8mm) made by the bellybutton. This enables the surgeon to clearly visualize the inside of the patient's pelvis. The use of the robotic system allows for a quicker and more precise surgery with smaller incisions and a lower overall risk for complications.

Through the usage of the afformentioned instruments (as well as additional surgical tools) the surgical team is able to carve out a space between the lower urinary tract (urethra, prostatic urethra, and bladder) and the rectum to be utilized for the upcoming vaginal canal. Peritoneum flaps can be pulled through (internally) to line a portion of this new cavity. The top of the neovagina is separated from the abdominal contents by closing the peritoneal lining approximately 15 cm from the vaginal opening. The remaining procedures (labiaplasty, clitoroplasty, penectomy, orchiectomy, partial urethrectomy, and other associated procedures) are similar to that of penile inversion.

Note that unlike skin grafts, flaps have a defined blood supply, and are more resistant to scarring.

Risks

There is a risk for rectovaginal fistulas. The peritoneal method is less risky than rectosigmoid vaginoplasty. The peritoneal method carries all of the same risks as penile inversion. Peritoneal vaginoplasty carries all of the risks associated with an abdominal laparoscopic procedure, including intra-abdominal organ injury, ileus, herniation, and others. There is a risk of flap failure and stenosis. There is less of a risk of prolapse compared to other methods.

There is a risk of flap failure.