Laparoscopic Assisted Neo-Cervico-Vaginal Anastomosis by Rail-Road Procedure In Cervico-Vaginal Atresia

Summary

This protocol demonstrates laparoscopic-assisted neo-cervico-vaginal anastomosis in a patient with cervico-vaginal atresia using the rail-road method.

Abstract

Cervico-vaginal atresia is a rare entity, difficult to diagnose and treat, with a higher rate of complications. It is classified as type 1b mullerian anomaly per ASRM and subclass C4 per ESHRE classification. The increased rate of re-stenosis and sepsis makes the surgery challenging. Also, the young adolescent age group makes compliance difficult, necessitating an empathetic yet efficient approach. We aim to compare and observe the two repair techniques: laparoscopic v/s open. A stepwise narrative protocol describing this modified technique, which uses a key-hole fundal incision to reach the endometrial cavity, drain the collected menstrual blood, and use the rail-road method to produce a neo-cervico-vaginal anastomosis. A total of 15 cases have been performed, with significant symptom relief (p < 0.01). The outcome measures are relief of symptoms, regularity of menses, adequate vaginal length, and stenosis. The procedure employed is a variation on previously performed hysterotomies, a rather invasive procedure. As a result, the rate of postoperative infection and morbidity has decreased dramatically. It has achieved a successful long-term outcome, with no patients requiring hysterectomy; hence, it has emerged as a promising approach that maintains anatomical and functional integrity, preserves future fertility, and reduces the risk of adolescent endometriosis. Technically, despite being a challenging procedure, laparoscopic repair has an edge over the open technique due to its minimally invasive nature, thereby emerging as a promising tool for a better future.

Introduction

Cervico-vaginal agenesis is a rare condition, and the true occurrence rate is unknown¹. However, the prevalence of vaginal agenesis is 1 in 4000–5000 live female births², and cervical agenesis is 1 in 80,000–100,000 live births³. These patients have the typical genetics and phenotype of a female with normal endocrine function. This disorder may be genetic, acquired from a random gene mutation, or a developmental abnormality⁴. It shares a clinical entity that, with its varied presentation, poses a diagnostic dilemma to clinicians, which is diagnosed during or after puberty, usually when the impact on fertility and pregnancy is affected⁵. The presenting symptoms can range from primary amenorrhea with or without cyclical dysmenorrhea to acute urinary retention⁵. The disorder needs awareness and public awareness. Understanding the precipitating cause becomes important. Variation in presentation makes interventions categorized according to need; thus, judicious treatment becomes of utmost importance.

It becomes the foremost duty to promote patient awareness of the numerous and varied anomalies, as not all anomalies require intervention, and the when and how to treat them needs to be addressed. The prognosis of these patients needs meticulous follow-up. Historically, patients with cervical atresia used to undergo hysterectomies due to increased morbidity from incapacitating pain, as well as occasional fatality and sepsis. The success rate of uterovaginal anastomosis is less than 50%, and most patients require multiple surgeries, while many develop cervical stenosis⁶. The laparoscopic technique used for neo-cervix creation involves a small fundal incision reaching up to the endometrial cavity, evacuating the collected menstrual blood through that incision as opposed to exposing the patients to hysterotomy and cutting open the uterus and vagina, throughout the length as previously done.

Given their ubiquity and clinical importance, a reliable classification system appears particularly valuable for their management, as efficient categorization enables more effective diagnosis and therapy, as well as greater understanding of their pathophysiology⁷. Correcting the anomaly prior to commencing assisted reproductive technologies can increase the possibility of reproductive success by increasing the chance of implantation and reducing the likelihood of complications occurring after pregnancy occurs⁸. The procedure here tries to recognize the treatment options and their outcomes, and future prognosis. Regular menses, relief of symptoms, and adequate vaginal length define procedural success and prognosis and are measured as the primary outcome.

Protocol

This study was conducted with the approval of the ethics committee of the All India Institute of Medical Sciences, Patna (Ref no. AIIMS/Pat/IEC/2023/1017). Informed consent was obtained from the participant included in the study for the submission of the manuscript to the journal. The reagents and the equipment used are listed in the Table of Materials.

1. Recruitment of patients

1. Conduct an ambispective observational study.
   NOTE: This study was conducted at a tertiary care center from January 2016 to December 2025.
2. Include all patients diagnosed with cervico vaginal atresia according to the ASRM diagnostic criteria 2021 who are managed within a single unit.
3. Include a total of 20 patients who undergo laparoscopic-assisted cervico-vaginal anastomosis using the rail-road method.
4. Retrieve all relevant medical records. Contact patients either telephonically or in person when required.
5. Obtain informed consent from patients and their relatives. Provide detailed information regarding the condition, procedure, and prognosis during the consent process.

2. Preoperative patient preparation

1. Record the symptoms, clinical presentation, family history, and associated comorbidities.
2. Perform a thorough clinical examination and document the presence or absence of secondary sexual characteristics.
3. Assess bone age using ultrasonography, hormonal evaluation (serum luteinizing hormone, follicle-stimulating hormone, thyroid-stimulating hormone, prolactin, and estradiol), and upper limb radiography.
4. Perform magnetic resonance imaging where required to corroborate findings.
5. Evaluate associated skeletal and renal abnormalities using ultrasonography. Perform karyotype analysis, X-ray of the lumbosacral spine, and intravenous pyelography where indicated.
6. Obtain comprehensive pre-anesthetic clearance prior to the procedure.
7. Obtain re-consent and ensure written informed consent is documented.
8. Verify and confirm all preoperative prerequisites prior to proceeding.

3. Operative procedure

1. Prepare and check separate laparoscopic and vaginal instrument trolleys.
2. Position the patient in the low lithotomy position using stirrups.
3. Catheterize the patient.
4. Perform McIndoe vaginoplasty using combined sharp and blunt dissection.
5. Create pneumoperitoneum. Place one supraumbilical 10 mm primary port and three 5 mm ports according to the diamond principle in laparoscopy.
   1. Position the first 5 mm port 2.5 cm above and medial to the anterior superior iliac spine (ASIS). Place the second ipsilateral 5 mm port 4 cm above with a 60° working angle relative to the primary port. Insert the contralateral 5 mm port 2.5 cm above and medial to the ASIS on the opposite side. Avoid injury to the inferior epigastric vessels and their branches.
6. Identify anatomical structures, including the uterus, cornual regions, ovaries, cervical bud, bowel, bladder, and surrounding structures.
7. Dissect the anterior uterovesical peritoneal fold and mobilize the bladder inferiorly from the cervical interface. Dissect the posterior rectovaginal peritoneal fold. Use scissors or an energy device as appropriate.
8. Incise the vesicouterine and rectouterine pouches.
   NOTE: In cervical atresia, this step is critical due to the possible absence or partial presence of the cervix, increasing the risk of injury to adjacent structures and complicating canalization.
9. Make a precise laparoscopic incision at the uterine fundus using a laparoscopic needle, advancing perpendicular to the surface to access the endometrial cavity (Figure 1).
   NOTE: Perform this step in the immediate postoperative phase to identify retained menstrual blood within the cavity. The appearance of blood confirms correct entry. This approach minimizes risks such as rupture, adhesions, infection, and hemorrhage compared to earlier invasive techniques.
10. Drain the collected menstrual blood completely using laparoscopic suction.
11. Advance the suction cannula through the endometrial cavity and guide it through the cervix into the vagina externally.
12. Identify the anterior and posterior cervical surfaces using the suction cannula as a guide. Anchor these to the vaginal epithelium using non-absorbable polypropylene (No. 0) sutures to create a neo-cervix (Figure 2).
13. Reconstruct the anterior and posterior cervical lips (Figure 3).
14. Insert a 6 F catheter along with a vaginal mold covered with surgicel or amnion. Guide the catheter tip through the endometrial cavity to the fundus using the rail-road technique with laparoscopic assistance.
    NOTE: This step confirms successful anastomosis and patency of the neo-uterine cervicovaginal tract.
15. Remove the suction cannula and suture the fundal incision.
16. Achieve hemostasis.
17. Close secondary ports under direct vision, followed by closure of the primary port.
18. Place stay sutures in the vagina to secure the vaginal mold in situ.
19. Perform perineal dressing postoperatively.
    NOTE: See Supplementary Video 1 for the procedure details.

4. Follow-up and postoperative care

1. Re-evaluate the patient on postoperative day 7 to assess graft uptake. Remove vaginal stay sutures.
2. Replace the vaginal mold and collect a high vaginal swab for culture and sensitivity testing.
3. Discharge the patient with the intrauterine catheter in situ. for 6 weeks.
4. Administer hormonal therapy for 6 weeks and schedule follow-up after withdrawal bleeding.
5. Advise the patient on hygiene maintenance and instruct regular use of the vaginal mold.
6. Review swab culture reports to assess for infection.
7. Record symptoms and clinical improvement during follow-up visits.
8. Evaluate for infection, dysmenorrhea, vaginal length, and cervical patency.
9. Counsel and encourage consistent use of vaginal molds. Provide progressively sized molds (e.g., dental molds) as required.
10. Provide a structured chart outlining danger signs, precautions, and a follow-up schedule, including emergency guidance.
11. At the first follow-up after withdrawal bleeding, assess for vaginal infection, measure vaginal length using POP-Q measuring tools, collect swabs if needed, and remove the intrauterine catheter (Figure 4). Reassess the patient’s technique for vaginal mold usage and reinforce counseling on proper and regular use.
12. Schedule follow-up every 3 months and advise additional visits as needed (SOS).

Results

A total of 15 patients had laparoscopic neo-cervico-vaginal anastomosis. Comparable demographic features noted. The age distribution, clinical symptoms, and outcomes of patients were noted. 66.66% were in the age group 15–17 years, with the most common symptoms observed being primary amenorrhea associated with cyclical dysmenorrhea (Table 1). Significant symptomatic relief observed in all operated patients (regular menses), with an average vaginal length of 5.2 +/- 1.90 cm. Four patients underwent re-loo...

Discussion

Cervico-vaginal atresia is a rare entity, difficult to diagnose and treat with a higher rate of complications⁸. It is classified as type 1b mullerian anomaly per ASRM and subclass C4 per ESHRE classification. The cervical atresia itself is classified into various types, including those in which the Cervical Os is obstructed, fibrous/ fragmented, or hypoplastic⁹. Historically, the reported procedure had hysterectomy as the ultimate treatment option in such malformations

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Karl Storz HD spies laparoscopy & Hysteroscopy set	Karl Storz Germany	IMAGE1S platform
Karl Storz HD spies laparoscopy & Hysteroscopy set	Karl Storz Germany	IMAGE1S platform
Base Connect Processor	Karl Storz Germany	TC200EN
Base Connect Processor	Karl Storz Germany	TC200EN
Link Processor	Karl Storz Germany	TC300
Link Processor	Karl Storz Germany	TC300
Camera Head	Karl Storz Germany	TH102
Camera Head	Karl Storz Germany	TH102
Xenon Light Source 300watt	Karl Storz Germany	20133720-1
Xenon Light Source 300watt	Karl Storz Germany	20133720-1
Light Cable	Karl Storz Germany	495NCSC
Light Cable	Karl Storz Germany	495NCSC
Trolley	Karl Storz Germany	UG230
Trolley	Karl Storz Germany	UG230
AIDA Recording System	Karl Storz Germany	WD250
AIDA Recording System	Karl Storz Germany	WD250
Hamou Endomat Irrigation	Karl Storz Germany	26331020-1
Hamou Endomat Irrigation	Karl Storz Germany	26331020-1
CO2 Endoflator	Karl Storz Germany	26430520-1
CO2 Endoflator	Karl Storz Germany	26430520-1