Laparoscopic Neovagina Procedure with Graft. This case involves a 54-year-old G2P2, status post radical hysterectomy for cervical cancer, who complains of difficulty with intercourse. Examination reveals a shortened vagina with a total vaginal length of 3.5 cm. Aggressive dilator use had yielded no improvement in vaginal length. Many patients with iatrogenically shortened vagina are candidates for a McIndoe-type procedure. However, this depends on a sufficiently long space between the rectum and the bladder. In this case, as demonstrated by ultrasound, there is only the short length of the vagina itself between the rectum and bladder. Above that, the peritoneum itself is encountered. The Davidoff-Adamian procedure is an alternative. This involves the anastomosis of the vagina to the peritoneal cavity itself, followed by a large peritoneal purse-string suture to create the vault of a neovagina composed of peritoneum. Although it enjoys popularity in some parts of the world, some surgeons are concerned that the thin layer of peritoneum is not strong enough to prevent concern for vault failure and evisceration. In this modification, a vaginal graft of small intestinal submucosa is anastomosed to the vaginal remnant. The peritoneal purse-string sutures are then used to support the apex of the graft. As suggested by the ultrasound, laparoscopic findings confirm the proximity of the rectum, here with the surgeon's finger, and the trigone, demonstrated by the Foley bulb. A transverse incision in the apex of the vaginal remnant is made and a Breisky retractor advanced through it. A Kelly clamp again demonstrates the proximity of the rectum to the bladder base and the trigone. The peritoneum is incised against the Breisky retractor, opening the cuff of the vaginal remnant. At this point, SIS graft is formed into a cylinder over the Breisky retractor. This is then advanced into the vaginal apical opening. The Breisky retractor is then withdrawn, with care taken to hold the graft in place. At this point, the opening of the graft is anastomosed to the vaginal apical incision with a series of vicral interrupted sutures. Laparoscopically, the distal peritoneum is attached to the distal portion of the graft with the goal of maximizing the peritoneal vascular support to the graft. A PDS suture is used. With this completed on both sides, a high purse string suture of the peritoneum on the right side is collected with a PDS suture. This is included in the lateral apex of the graft itself. This is carried out on the left side as well. Inclusion of some of the remnants of the uterus sacral ligaments will assist in vault suspension. Peritoneum posterior to the graft is also included, again to promote graft support. Tie down of these sutures provides both apical support and partial achievement of the Davidoff-type vault creation. A final PDS suture is used to complete the purse string anteriorly, again including the apex of the graft. Note the extent of the anterior surface of the graft now covered by vascularized peritoneum. Finally, a permanent proline suture is used to collect a full circumference purse string suture in keeping with the Davidoff-Adamian principles. At the conclusion of the case, the total vaginal length had been increased to 10 cm. Vaginal caliber was 2 to 2.5 fingerbreadths, with some narrowing at the level of the anastomosis. A higher Schulte stent was placed and secured with labial sutures for one week. Vaginal length was restored postoperatively, and the patient continues to use dilators to preserve and enhance vaginal caliber. www.ottobock.com

laparoscopic neovagina procedure

54-year-old woman

radical hysterectomy

cervical cancer

difficulty with intercourse