Mayer–Rokitansky–Kuster–Hauser syndrome is the most common disease in the congenital absence of a vagina, whereas androgen insensitivity syndrome is less common. Patients with MRKH syndrome have normal genotype, endocrine status, and ovarian function. Severe dysplasia of the paramesonephric duct is often accompanied by urinary tract malformation. Pre-operative chromosome examination should be performed, and a sex hormone test is recommended to understand endocrine function simultaneously. It is best to perform heart and urinary examination before surgery to determine if there is any developmental abnormality to facilitate the diagnosis and classification of the disease. Proper diagnosis of the underlying disease is important, and these associated deformities should be excluded pre-operatively to avoid surgical injury.

Although the incidence of MRKH is not high, it seriously affects the psychological and social status of patients. The treatment should focus both on the vagina reconstruction and on the function to improve the psychological status of patients. For patients with MRKH syndrome, the treatment methods include non-operative pressure method and surgical treatment, and individual selection should be made according to the patient’s age and needs. The nonsurgical method involves gradual dilatation of the vaginal dimple at the introitus. This requires time and strong patient motivation. As the procedure is painful and self administered, compliance is usually very poor [6, 7]. Surgical treatment is the main method. The development of artificial vaginoplasty has taken more than 100 years, with various procedures, including the amniotic method, the sigmoid vaginoplasty [6, 7], the peritoneal vaginoplasty, and the vestibular mucosal levitation vaginoplasty [6, 8]. These surgical methods have their characteristics and some disadvantages, such as long mucosal formation, long-term vaginal mold use, hair growth, skin flap prolapse, and an obvious scar in the donor area. The sigmoid vagina replacement is a good choice for vaginoplasty, its advantages include: little narrowing after vaginal formation, no need to wear a mold for a long time, the intestinal mucus can play a lubricating role, and the appearance and organizational structure are close to the normal vagina [9]. However, the disadvantages of traditional open sigmoid vaginal replacement surgery limit its extensive development. The most important disadvantages are long operation time, great interference with the abdominal and intestinal tract, gastric tube placement to prevent intestinal obstruction, slow post-operative recovery, and a long hospital stay [10]. In addition, the larger post-operative surgical scar on the abdomen affects the appearance and causes an unnecessary psychological burden to the patients. Laparoscopic surgery significantly reduces the above disadvantages. With the application of an ultrasonic knife, updated endoscopic instruments, and increasingly improved surgical techniques, laparoscopic sigmoid vaginal replacement surgery has gradually replaced the traditional open surgery.

At present, the operating technology of sigmoid vaginoplasty has been mature, and the average operation time, blood loss, complications, and post-operative complications reported in the literature are low, so it is a good surgical method [11, 12]. Selecting the grafted intestinal segment with sufficient length and a good blood supply is necessary, and the end-to-end anastomosis of the sigmoid colon under laparoscopy is of great concern. The traditional sigmoid colon anastomosis method is to pull the sigmoid colon out from the abdominal or vaginal cavity. Before that, we need to test the mesenteric vascular tension of the descending colon distal end to pull the descending colon distal end smoothly. We need to fully open the peritoneum of the sigmoid colon as far as possible so as to free the inferior mesenteric vessels and to facilitate pulling the distal end without tension. However, sometimes, even if the submesenteric blood vessels are fully dissociated, it is still difficult to pull the distal end of the descending colon out of the cavitation, so it is necessary to pull it out of the abdominal wall incision to avoid injury. In our hospital, the sigmoid colon was pulled out of the abdominal wall for anastomosis at an early stage. The right lower abdominal incision was required to be extended by 2.5–3 cm. In a recent case of sigmoid transvaginal surgery, we optimized the laparoscopic incision so that the abdominal incision was no longer lengthened. Still, instead, the drill was inserted through the vaginal cavitation. The drill was inserted into the broken end of the intestine under the laparoscope and sutured, all other steps being the same as in traditional surgery, further reducing the risk of traction (Fig. 1). What needs to be improved is the technique of laparoscopy. Nowadays, with the improvement of laparoscopic technology, this does not prolong the operation time or increase the risk of infection, so it is worth popularizing. Some hospitals have started to use the single-hole operation, which requires further equipment, with single-hole instruments, single-hole endoscopic techniques, and surgical techniques, and there is still a risk of poor navel healing [13]. Our optimization of this operation is based on the incision of the traditional laparoscopic surgery, which no longer lengthens the incision, does not need training in the single-hole technique, makes full use of the natural cavity and vaginal cavity to achieve the same surgical effect, and does not increase the operative time with the skillful operation and suturing skills required for laparoscopic surgery.

A–D Total laparoscopic sigmoid vaginoplasty

The sexual life of the neovagina after the operation is a key problem that deserves our attention. Our post-operative follow-up found that married patients or those with sexual partners reported high sexual satisfaction, good lubrication with drainage, and an acceptable odor range. Considering each mean domain score, those women with MRKH syndrome treated by laparoscopic sigmoid vaginoplasty (and completing the FSFI questionnaire) could be considered “normal” in terms of desire, arousal, lubrication, orgasm, and global sexual satisfaction. Other studies have also reported that sigmoid colonic vaginal replacement is associated with better sexual satisfaction [6, 7, 14]. Although overall satisfaction with sexual activity was high, there were limitations because the scores of various indicators for women in sexual activity were not separately listed and compared.

For vaginal replacement surgery, in addition to the sigmoid colon method, peritoneal vaginal replacement is also a common way of operation [2, 14]. Still, it takes a long time to use the vaginal mold after the operation. The width and depth of the artificial vagina are not enough, which may affect sexual satisfaction. There is also a risk of bladder or rectal injury and rectal–vaginal fistula [15]. Davydov’s laparoscopic neo-vaginoplasty is also an alternative way to treat MRKH. It showed a shorter operation time with relatively more post-operative complications (19.0%) [2]. Robotics-assisted surgery is also feasible [16], but it increases the economic burden of patients and it is not conducive to the promotion of its wide use in hospitals. In recent years, vaginoplasty using biological mesh [17,18,19] has also appeared. However, the high price of biological mesh limits its wide use, and its long-term efficacy and mesh-related complications still need to be further tracked (Table 3).

In addition to MRKH syndrome, laparoscopic sigmoid vaginoplasty should also be used in international sex-change surgery and has received satisfying results [20]. At present, most literature indicates that patients’ sexual satisfaction and sexual life index scores after sigmoid vaginoplasty are better than those after use of other surgical methods [6, 7, 14]. The sigmoid vaginal replacement method reported by our center had no intra-operative or post-operative complications, and the patients who were followed up showed that the surgical effect was also highly satisfactory. We believe that laparoscopic sigmoid vaginoplasty conducted by skilled surgeons in an endoscopic center is worthy of further promotion.