Dr. Narender Kaushik was very unpleased with all available surgical procedures for MtF transgender patients. The only surgical procedure that to him was promising enough to reach great results in every aspect of what Dr. Kaushik saw as mandatory for a good GCS/SRS procedure, was the sigmoid colon approach, that still had a few quirks that definitely wanted improvement.
In long hours of evaluation and progressive approach considerations, Dr. Narender Kaushik’s efforts finally resulted in the best GCS/SRS procedure available today – his OLMEC SIGMA-LEAD GCS/SRS.
It is solely and exclusively practiced by Dr. Narender Kaushik here at OLMEC HEALTHCARE, the Premier Transgender Surgery Institute, in Delhi, India and has become the gold standard for MtF genital reassignment surgery.
The hallmark of his technique is something one would never expect from a surgery like this:
The MtF patient will usually have a painless and woundless recovery which progresses very fast and with minimal post-op aftercare
The OLMEC SIGMA-LEAD GCS/SRS
The OLMEC SIGMA-LEAD GCS/SRS consists of 2 stages wich will be performed right after each other. In the first stage, the vulva – the external female genitalia – will be created. In the second stage, the highly refined and improved rectosigmoid colon vaginoplasty will be performed.
Stage 1 of the OLMEC SIGMA-LEAD GCS/SRS consists in creating external female genitalia that look as natural as possible. You will have labia majora, labia minora, a clitoral hood and a clitoris. The clitoris and the labia minora will be fully sensate and arousable.
The clitoris is derived from the glans.
The clitoral hood and labia minora are made from penile skin – including penile preputial skin.
The labia majora are made from scrotal and penile skin.
The procedure is carried out either laparoscopically or with an open approach.
A 2 to 3 inches incision is made in the left groin (lateral Pfannenstiel incision).
After the muscle incision, the peritoneum is opened. The sigmoid colon segment is being inspected. The sigmoid colon and its mesentery are assessed for proper length and for the existing vascular pattern. The usual plan is to harvest a 15-22 cm long segment of rectosigmoid colon, depending on the individual patient requirements. OLMEC
SIGMA-LEAD colon graft length requirements are small. The distal most part in the form of a rectosigmoid graft is used. This graft has low secretion properties and discharge after surgery using this technique is mild and soon settles down within a couple of months.
nvariably the sigmoid colon mesentery is found adherent to the lateral wall. The adhesiolysis is carried out gently by sharp and blunt dissection. The gonadal vessels and the left ureter (urine duct between kidney and bladder) are encountered. These are safeguarded posteriorly. The sigmoid colon is mobilized to the maximum possible extent – up to the lower part of the descending colon. Similarly, the rectosigmoid part is mobilized in the pelvis. During this process, the pulsating internal iliac vessels can very well be appreciated.
The mesentery is inspected medially as well laterally and any additional restriction in mobility is freed. The vascular pattern is assessed. In obese patients the mesentery is fatty and transillumination is an excellent way to see the vascular pattern while performing the open surgical approach. One of the branches of the inferior mesenteric artery is selected. Preferably the proximal pedicle – a sigmoidal branch of the inferior mesenteric artery – with good pulsation is chosen to get the antegrade segment of the sigmoid colon’s vascular supply. The proximal pedicle is more reliable and the only one vessel which is usually sufficient.
Should the proximal pedicle not be reliable, then distal pedicle is identified preferably having two vessels – with the distal pedicle consisting of branches of the superior rectal artery.
The identification of the marginal arcade is extremely important. Safeguarding the pedicle and the marginal arcade, the mesentery is sequentially ligated and divided between ligatures through the whole length of the selected segment of the colon. The application of anchor sutures between the anterior and the posterior leaves of the mesentery are needed and set to avoid the shearing of the arcade. This should be considered an indispensable, mandatory step.
As a routine measure, the bowel is prepared one day prior to operation. An additional wash intraoperatively avoids the spillage of still possibly existing colon contents. In our practical experience, this 5-minute routine has resulted in almost zero percent wound infection rate. With a small opening at the proximal division point of the sigmoid colon, the colon is irrigated and washed proximally as well as distally until clear effluent can be observed in sump suction outpour. The same procedure is repeated towards the rectal segment.
The colon graft is separated by dividing it proximally. The proximal end of the graft is closed rapidly – it would be the distal end in case the distal pedicle had to be used instead. This closed end will form the upper end of the vagina. The division is completed at the distal division point. The distal end is assessed for its blood supply and the graft is left with its pedicle in anatomically correct position to avoid kinking.
The continuity of the sigmoid colon is restored with anastomosis of the proximal and the distal end. This is achieved with either standard staple anastomosis or hand-sewn anastomosis.
The peritoneal reflection over the anterior wall of the rectum is incised transversely. The vaginal cavity between the bladder anteriorly and the rectum posteriorly is created by sharp and blunt dissection. Anteriorly, the bulb of the Foley’s catheter in the urinary bladder acts as an excellent guide when felt with the surgeon’s fingers. The posterior guide is the perineal surgeon’s digit in the rectum. It is mandatory to make enough space and dissect the muscles properly to avoid constriction of the cavity in the future.
The sigmoid colon graft is delivered through the vaginal cavity that got created. This action has to be performed in an extremely gentle way to avoid the shearing of the mesenteric arcade and also to avoid tension on the pedicle. The lie of the pedicle is extremely important to avoid kinking. A single go-accurate delivery move proves to be key to avoid injury.
The distal end of the colon is sutured with the inverted penile skin flap left over from the stage 1 procedure and the posterior triangular scrotal flap in a zigzag/ star-shaped manner to avoid constriction of the junction site.
This way an outer 2 to 3 inches of vagina are created with penile skin and the inner 5 to 9 inches are created by colon graft.
After the surgery is completed the patient benefits from:
Cosmetically the vaginal opening looks more natural compared to colon surgeries performed so far because the red portion of the sigmoid colon graft’s mucosa is invisible from the outside.
Over time, the color of the inner colon segment also gains a normal pinkish vaginal hue. Since the part of the sigmoid colon is distal – the rectosigmoid part, which produces less discharge and is small in length – the issue of excessive secretions by the colon graft is overcome.
After surgery, you will wake up with a dressing in your genital area and on your groin. Both of these dressings are painless. The groin dressing will be removed after 2-3 days. You will have dressings in the perineal region and left groin area.
For the next 4-5 days, you will be on IV (intravenous ) medications, which are antibiotics and pain killers.
After 2-3 days you will usually be allowed to take in liquids again, depending on when wind begins to pass through your anus.
The catheter will be removed after 6 to 7 days. Also after 6-7 days you will start walking again.
Dilation will be started 5-7 days after surgery. Dr. Kaushik will instruct you on how to do dilation properly and you will learn it fast.
You have to maintain local hygiene, which consists of washing your genitalia with a betadine mix (water and betadine solution) for about 3 weeks.
It will also be required that you wear a sanitary pad for the initial few weeks after surgery until discharge becomes less.
Sexual activity usually can be resumed after 1 ½ – 2 months.
The usual hospital stay for Indian clients is 7 to 10 days.
For overseas patients, a stay of three weeks is recommended to ensure complete recovery under Dr. Kaushik’s personal supervision before departure.
Any minor touch up procedure – should it be needed – will be done during this time period.
You can find the Dilation Instructions after OLMEC SIGMA-LEAD GCS/SRS.