Darwish Hymenotomy Technique in Cases of Postpubertal Imperforate Hymen
Condition: Imperforate Hymen
MeSH terms: Menstruation Disturbances
Study type: Interventional

Summary: 
      This study aims to test the use of a 10 mm laparoscopy trocar tip for formation of a new
      vaginal orifice with preservation of an annular hymen (Darwish hymenotomy technique) in cases
      of post pubertal imperforate hymen (IH). A prospective interventional case series done at a
      minimally invasive surgery unit of a tertiary university hospital between July 2013 and
      October 2019 comprising patients with primary amenorrhea and hematocolpus. Circular
      hymenotomy using a 10 mm laparoscopy trocar tip and sleeve done under general anesthesia was
      done in 36 cases. Documented vaginal patency with formation of an annular hymen in all cases
      was reported on follow-up visits without reported intraoperative complications. Patient and
      family satisfaction with excellent sensation of preserved hymen was also documented. Using a
      10 mm laparoscopy trocar tip for formation of a new vaginal opening with preservation of
      annular hymen (Darwish technique) in cases of postpubertal IH is a simple, effective and safe
      procedure suitable for Islamic and conservative societies with excellent impact on the
      psychological and emotional status of the patient and her family.
    

Detailed description: 
      This study is a prospective interventional case series conducted at the Minimally Invasive
      Surgery Unit of the Woman's Health University Hospital, Assiut, Egypt, between July 2013 and
      October 2019. It was approved in May 2013 by the local ethical committee of the faculty of
      Medicine, Assiut University. After detailed explanation of the study, all cases or parents
      signed an informed consent to participate in this study. It comprised 43 cases with primary
      amenorrhea and hematocolpus. Patients' complaints included a gradually progressive central
      abdominal mass, pelvic pain getting worse over time disturbing her studies, urinary
      retention, dysuria, constipation and dyschezia separately or collectively depending on the
      chronicity of retained menstruation. Clinical examination started by downward labial traction
      to separate the labia majora and minora sufficiently to visualize the distal introitus. Girls
      with only IH as diagnosed after puberty (postpubertal) without any suspicion of associated
      congenital anomaly were included in this study. Low transverse vaginal septum was diagnosed
      in 4 cases that were excluded from this study. Differentiation between IH and transverse
      vaginal septum relied mainly on clinical examination in the lithotomy position with insertion
      of a uterine sound into the dimple. If the sound fails to go up, it is a case of IH. If it
      goes up this means a low transverse vaginal septum that requires an advancement operation
      with fixation of the edges of the septum to the introitus. In such cases, hymentomy will fail
      with reformation of the septum as it is thick in contrast to the thin hymen. During
      examination, distal vaginal atresia was excluded by the absence of hymnal distension on
      Valsalva and absence of its bluish discoloration in addition to far existence of the
      hematocolpos away from the vulva. It was reported in two cases that were also excluded from
      the study. If the abdominal mass was noticed to be deviated to one side, a possibility of
      type I obstructed hemi-vagina and ipsilateral renal agenesis (OHVIRA) raised and a
      confirmatory MRI was requested. Only one case with OHVIRA type I (Blind hemi-vaginal septum
      without an opening) was detected and excluded from the study. This case presented with
      primary amenorrhea due to a rudimentary contralateral horn. Clinical examination of 36 cases
      with IH was relatively easy as the patient presented with a vaginal bulge of thin hymenal
      tissue with a dark or bluish hue caused by the hematocolpos behind it. If the physical
      examination revealed a bulging hymen and ultrasonography confirmed the diagnosis of
      hematocolpos, further imaging was not required. In selected cases with ambiguous diagnosis,
      MRI was requested to assess the vaginal and the perineum in a meticulous way. For surgical
      safety, prepubertal girls with IH were excluded.

      The procedure stars by putting the patient in the lithotomy position in the OR. After
      induction of general anesthesia, sterilization and toweling of the perineum was done.
      Insertion of an indwelling urethral catheter and PR to exclude other anomalies or
      abnormalities were done. The tip of a 10 mm laparoscopy trocar with a sharp triangular point
      (Karl Storz, Tuttlingen, Germany) was inserted in the center of the most bulging point of the
      IH. Once the edge of the sleeve followed the tip of the trocar tip into the hymen, no further
      advancement of the trocar tip was made to avoid unintentional injuries by the trocar itself.
      After its withdrawal, the sleeve was left insitu for drainage of the retained blood.
      Suprapubic pressure was not done to avoid ascending infection by the negative pressure. After
      complete stoppage of flow of the retained menstruation the sleeve was removed. Usually no
      further intervention was needed. If oozing points were seen, a gentle bipolar coagulation was
      used. The remaining hymenal ring was evaluated and documented in the patient's file whether
      intact circular or not. All technical steps are shown in figure 1. After recovery, the
      patient was kept for few hours in the postoperative ward then discharged. She was advised to
      come for follow-up after the coming menstruation or after 40 days if no menses occur. She was
      examined to ensure patency of the vagina, the integrity of the hymen and sonographically to
      ensure absence of retained menstruation and to assess both kidneys. Subsequent follow-up
      visits were optional whenever they notice any change in the menstrual flow. Otherwise
      telephone calls were kept with them thereafter. Outcomes included hymenal ring integrity on
      naked eye examination, patient satisfaction, relief of symptoms, and a feeling of well-being.
      Due to rarity of cases, the same patient was used to compare preoperative and postoperative
      results.
    

Intervention name(s): (Darwish hymenotomy technique)
Intervention type(s): Procedure
Intervention description(s): Formation of an annular hymen in cases of postpubertal imperforate hymen using a laparoscopic trocar (Darwish hymenotomy technique)
Intervention model: Single Group Assignment
Intervention model description: Formation of an annular hymen in cases of postpubertal imperforate hymen using a laparoscopic trocar (Darwish hymenotomy technique)
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: imperforate; hymenotomy; annular; laparoscopic; trocar; postpubertal; hymen