Vaginal agenesis, Mayer-Rokitansky-Kuster-Hauser syndrome, has an incidence of 1 in 5,000 – 7,000  female births. If primary vaginal dilation is not successful at creating a neovagina, surgical construction has been achieved by various procedures including Davydov, McIndoe and Vecchietti.  

The McIndoe operation is a common surgical procedure utilized in creating a neovagina. A requirement for the successful long-term outcome is determined by the quality and thickness of the harvested split-thickness skin graft and continued post-operative vaginal dilation.  

Historically, the split-thickness skin graft harvest has been the first segment of the operation. In order to render the graft donor site as invisible as possible, to reduce emotional burden and avoid iatrogenic body image concerns as well as for the best cosmetic outcome; it is taken from the buttocks while intentionally avoiding the hip and thigh as harvest sites.
  
This case report video demonstrates a surgical technique that reverses the surgical sequence of the McIndoe operation, and is performed from one surgical position by harvesting the split-thickness graft from the anterior abdominal wall.  Additionally, the harvest site delayed secondary intention healing is eliminated by resecting the donor site and closing primarily.

The patient was referred for surgical management of apareunia due to vaginal agenesis.  A nine year history of primary vaginal dilation efforts only developed a shallow neovagina and attempted dilation with intercourse resulted in pain and dyspareunia. Counseling included education on the various surgical treatment options and postoperative care.  Following a thorough informed consent discussion, the patient selected the McIndoe operation.  

The technical steps of this modified McIndoe procedure include: 1. The patient is placed in lithotomy position for concomitant vaginal and abdominal exposure. 2. Identification of the vesico-rectal space and dissection up to the peritoneum. 3. The lower abdominal wall donor site is outlined and pneumoperitoneum is created for counter-traction. 4. A uniform split-thickness skin graft is harvested and a dressing is temporarily placed on the donor site. 5. The skin graft is sutured over a solid mold, transferred to a soft mold and sutured to the vaginal wall. 6. The soft mold is gently inflated to maximize skin graft cooptation and secured to the perineum. 7. The abdominal wall donor site skin is resected and converted to primary closure.

The perineal sutures were removed on post-operative day two and the patient was discharged home with the soft vaginal mold as well as post-surgery dilation instructions.  Post-operatively at six months, the neovaginal graft had excellent “take”, measured 10 cm by 3 cm and the patient was sexually active without discomfort.  The abdominal incision was well healed.

In patients that are candidates for a McIndoe as an initial operation or due to stricture of a previously constructed neovagina, the abdominal skin harvest modification utilizing a single surgical exposure provides an alternative approach that mitigates deformity of the donor site.  Additionally, due to the re-sequencing of the McIndoe surgical stages, with initial vaginal dissection and subsequent skin harvest, this modification also offers a technical advantage and option to defer skin harvest should inadvertent injury to the bladder or bowel occur during vesico-rectal dissection.

Davydov SN. Modifisierte kolpoese aus peritoneum der excavation rectouterine. Obstet Gynecol(Moscow)12:55, 1969
McIndoe AH and Bannister BJ. An operation for the cure of congenital absence of the vagina. Br J Obstet Gynaecol 45:490, 1938
Vecchietti G. Neovagina nella syndrome di Rokitansky-Kuster-Hauser. Attual Ost Gin 11:131, 1965