Laparoscopic Vecchietti Procedure for Vaginal Agenesis

INTRODUCTION: Müllerian agenesis occurs in 1 in 4500 female births. There are several surgical options when non-surgical vaginal dilation fails. The laparoscopic Vecchietti procedure is a minimally invasive option that creates a neovagina by stretching the introital mucosa with a spring mechanism with high anatomic and functional success rates. OBJECTIVE: To review müllerian agenesis, the anatomy, presentation, and management considerations. To demonstrate the modified surgical technique for this minimally invasive neovagina procedure. METHODS: Two 5-mm, lateral incisions allow a blunt suture retriever to dissect through the pre-peritoneal space under direct laparoscopic guidance, to enter at the peritoneal cavity at the superior edge of the bladder dome. Peel-away Angio catheters are used to pass through the rectovaginal space and after cystoscopy, a Proline suture is threaded through a Lucite vaginal olive, pulling at the vaginal dimple apex through the 5-mm ports and attached to a spring-loaded apparatus taped to the patient’s abdomen. The sutures are tightened daily by the patient, to maintain tension, lengthening the vaginal dimple 1 cm per day. RESULTS: Over 8 days, the vagina was lengthened 1 cm per day with minimal discomfort treated only with ibuprofen. Self-dilation from postoperative days 8–26 achieved dilation sufficient for pain-free vaginal intercourse that was sustained over 8 years, without urinary complications. CONCLUSIONS: When self-non-surgical vaginal dilation is not successful in the treatment of vaginal agenesis, the modified Vechietti procedure may offer a minimally invasive option with good long-term anatomic and functional outcomes.