A ‘lifeboat’ free sigmoid mucosal graft to salvage intestinal vaginoplasty after intraoperative conduit ischemia: A case report

Intestinal vaginoplasty is a preferred technique for gender affirmation but carries the rare risk of intraoperative conduit ischemia. We report a successful salvage maneuver utilizing a free colonic mucosal graft after a primary sigmoid conduit became non-viable. A 36-year-old transgender female underwent revision vaginoplasty for aggressive stenosis following a prior penile inversion. During a planned robotic-assisted sigmoid vaginoplasty, the intestinal conduit was found to be ischemic following mobilization, confirmed by absent indocyanine green (ICG) fluorescence. The team pivoted to a salvage procedure, resecting the ischemic segment via a side-to-end colorectal anastomosis. The mucosal lining was harvested from the resected non-viable segment to create a free colonic mucosal graft, which was tubularized to line the neovaginal space. The postoperative course was complicated by a resolved ileus and a readmission for minor bleeding from granulation tissue. However, evaluation under anesthesia confirmed excellent graft take. At the 12-month follow-up, the neovaginal canal remained patent, and the patient reported high satisfaction with functional and aesthetic results. Harvesting the mucosal lining from an ischemic intestinal conduit as a free graft is a robust backup solution. This technique allows for successful reconstruction without additional donor site morbidity, turning a vascular complication into a successful outcome.