The Colorectal Surgeon would discuss with the patient the aim of the operation viz. the construction of a caeco-colon neovagina. A full discussion of the operative risks and indications of the operation would be undertaken. The Colorectal Surgeon would be responsible for the laparoscopic construction of the neovagina from the ascending colon on its own neurovascular pedicle, and restoration of bowel continuity. He would also be responsible for ongoing post operative management of the abdomen and bowel. Only two centimetre wounds are made on the left lower abdomen and a 3centimetre wound under the umbilicus is made. In previously operated persons or persons with inflammatory involvement of the bowel,, open laparotomy may be needed.

The Urologist, likewise, would be responsible for pre operative education of the patient, a description of the procedure from his point of view, discussing orchidectomy, amputation of the erectile rods, dissection of the penis, construction of a sensate clitoris, dissection behind the bladder and in front of the bowel to make a cavity for the neovagina, and re-routing the urethra to the anatomical position of the female. He will make a full discussion of the operative risks and the implications of the operation and be responsible for the post operative management of urinary flow and bladder problems.

The Plastic and Reconstructive Surgeon similarly, would be responsible for pre operative education of the patient regarding his part of the operation. He will discuss the dissection of the penis with the aim to raising the sensate and viable portion of skin from the glans penis to reconstruct a clitoris. He will be responsible for the raising of the skin of the penis so that it has sensation and a blood supply for reconstruction of the external female genitalia including the placement of the clitoris, construction of the labia minorafolds, dissection of the urethra and restoration to the anatomical position of the female providing a cuff of dorsal penile skin distally for anastomosis to the caeco-colo. neovagina so the anastomosis is internal. He will also be responsible for decreasing the size of the scrotal skin and using the remaining skin for the construction of the labia majora folds.

The Colorectal Surgeon will order pre-operation preparation of the bowel prior to the patient's admission to the hospital. The Operating Theatre Staff at the Southern Cross Hospital and the Ward Staff have considerable experience with gender reassignment patients during and after the approximately six hour long operation. The patient will be returned to the recovery ward with intravenous lines, catheter, drains and with prescriptions for post operative management of fluid and drugs. At the time of the pre operative consultation the patient will be informed as to the duration of stay in Christchurch. The Surgeons would prefer that the patient seek out and be under the care of a general practitioner in Christchurch. If they do not know of a general practitioner we can supply them with a list of general practitioners who would be amenable to helping the patient during their stay. We would ask the patients to prepare for a stay of approximately one month after the operation. We would ask that the patient be discharged to accommodation in the care of a relative, attendant, friend or nurse. We could arrange post operative visits by the Hospital Nurses and Domiciliary Nursing Service supplied by the Nurse Maude Association.

Post operatively we would have the patient visit the Surgeons in their consulting rooms. We would arrange and urge the patient to consult with Psychologists, post operatively so they can give the patient psychological support. We will arrange for followup collection and circulation of long term results.

The protocol that we have in Christchurch differs from protocols elsewhere in the world to our knowledge. We use portion of the ascending colon for the neovagina. This neovagina has considerable advantages over the previous operations where they use penile skin and skin graft to make the new vagina. In the case of the skin graft vagina, the vagina used to continually shrink down and require daily stretching by dilatation. The skin graft vagina did not clean itself nor was there natural lubrication. The desquamating keratin would often have a bad odour. Often the inverted penile skin vagina or skin grafted vagina was too short and was generally associated with minor problems.

The caeco-coloneovagina is ideal for those patients with a small phalus who may have insufficient material for adequate depth of vagina in the inverted penile skin technique used elsewhere. The operation for construction of the new vagina using caeco-colon was first described in England in 1990 by Turner-Warwick. He used caeco-colon construction of a vagina in 13 young girls with vaginal agenesis. Mr E G Perry (General Surgeon) adapted the use of the caeco-colon (for male to female transsexual surgery) and we have successfully used this operation in 33 patients to date (September 2000). The advantage of using the large bowel is that the bowel is naturally distensible, does not contract, it has its own blood supply so remains healthy, warding off infection. The bowel is self cleansing with a small amount of mucus so it is also self lubricated and the lining is designed to be moist. The cases that we have performed so far have been most satisfactory. One case has required dilatation of the urethra; two cases have narrowing of the introitus of the vagina which required dilatation, one patient has had loss of the clitoris due to technical problems; during the operation causing ischaemic necrosis. As the post operative oedema has resolved the function and the appearance of the external genitalia and the neovagina have proved to be anatomically correct and most satisfactory.

All fees are approximate as one can only estimate the other Surgeon's and Physician's Professional fees. Theatre fees and Anaesthetists fees vary as they are calculated according to the time in the operating theatre. The Surgery is carried out at the Southern Cross Hospital, 131 Bealey Avenue, Christchurch, New Zealand usually on a Friday afternoon once a month. Following the approximately 6 hour operation, the patient is returned to the recovery room where they may stay for approximately 3 hours before returning to the Ward.

We try to have the patients donate their own blood four weeks, three weeks and two weeks prior to the operation and the blood is then returned to the patient at the time of the operation. In the unusual event that more blood is required the patients understand that blood from blood donors may be used (all blood is screened for HIV, Hepatitis A, Hepatitis B and C) and cross matched in the usual manner. Routine post operative cares are undertaken in the Ward. The patient may be nil by mouth for approximately 24-48 hours. The bowel begins to work again approximately 3 - 4 days after the operation; drains removed at about that time. The catheter would stay in for approximately one week. The patient can be discharged on day 5 to day 7 post operation.

Breast Augmentation can cost in the vicinity of $9,000 - $11,000 done by itself, or it can be incorporated with other feminising surgery and some savings can be made.  This would be discussed at the time of your consultation.