A Minimally Invasive Option for Gender-Affirming Vaginoplasty

Peritoneal Pull-Through Vaginoplasty (PPV) is a gender-affirming surgical technique that utilizes peritoneal tissue—a smooth, glistening membrane from the abdominal cavity—to line the innermost portion of the neovagina. This method offers several advantages, especially in terms of texture, appearance, and compatibility with laparoscopic access.

→ What Is Peritoneal Tissue?

The peritoneum is a thin, moist membrane that lines the abdominal and pelvic cavities. When used in neovaginal construction, it provides:

• A smooth, non-keratinized surface that mimics the look of natural vaginal mucosa
• A moist, pink, glistening appearance for aesthetic benefit
• Excellent healing and integration when combined with other graft materials

However, it is important to note that the peritoneum is not a mucosal tissue and lacks secretory glands.

→ Does Peritoneal Tissue Provide Self-Lubrication?

One of the most common misconceptions is that peritoneal tissue provides true self-lubrication. While the peritoneal lining retains surface moisture and appears glistening, it does not secrete fluid like glands found in a biological vagina or in colon vaginoplasty, where natural mucus production is possible.

As a result, patients undergoing peritoneal pull-through vaginoplasty must continue to use water-based lubricating gel during vaginal dilation and penetrative sexual activity, just as those who undergo skin graft techniques. This ensures tissue protection, reduces friction, and supports long-term neovaginal health.

→ How Deep Can the Neovagina Be With PPV?

The final vaginal depth in PPV depends on both patient anatomy and surgical technique. In most cases:

• The peritoneal section provides 4–6 cm (1.5–2.5 inches) of lining at the neovaginal apex
• This is combined with a penoscrotal skin graft to achieve total neovaginal depths of approximately 13–15 cm (5–6 inches)
• The overall depth is comparable to traditional skin graft vaginoplasty and sufficient for most sexual activities

→ Why Laparoscopic Technique Is Required

PPV requires access to the peritoneum inside the abdomen, which must be done through laparoscopic surgery. This minimally invasive technique uses small abdominal incisions and a camera-guided approach for precision harvesting.

Benefits of laparoscopic PPV include:

• Minimal external scarring
• Faster recovery time
• Reduced risk of adhesions or complications
• Precise control over tissue dissection and positioning

→ Is Lubricant Still Required After PPV?

Yes. Despite the moist appearance of the peritoneal lining, it does not produce its own lubrication. All patients must:

• Use water-based lubricants during vaginal dilation and penetrative intercourse
• Avoid dry or high-friction contact that may cause microtears, irritation, or inflammation
• Strictly follow the WIH Hospital vaginal dilation schedule, particularly during the first 1–2 years postoperatively, to maintain depth and prevent neovaginal narrowing

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