epidemiologic studies, mean total vaginal length has been shown to be between nine and ten centimeters. Prior surgery has been shown to predict shorter total vaginal lengths and also lower levels of sexual function based on FSFI scores. Vaginal reconstructive surgery carries the highest risk of vaginal scarring or shortening, and vaginal lengths of less than seven centimeters have been shown to have a significant negative effect on overall sexual function. A surgically shortened vagina has traditionally been very difficult to correct or gain significant length, and most procedures have shown very low success rates. In the current video, we present a novel technique of vaginal lengthening utilizing a modified laparoscopic davidov neovagina technique. The patient is a 52-year-old female who has a history of total vaginal mesh and postoperatively suffered from pain, mesh extrusion, dyspareunia, and vaginal shortening. Two years after original implant, the vaginal mesh was removed. However, she continued to suffer from dyspareunia postoperatively and was found to have a total vaginal length of only five and a half centimeters. Significant scarring was also palpated at the apex of the vagina, and the patient had significant pain with palpation of the apex. The patient consented to undergo a modified laparoscopic davidov procedure. This is the minimally invasive surgery traditionally utilized for vaginal agenesis and MRKH patients to create a functional full-length vagina. The pelvic peritoneum is utilized to create the lining of the new vagina. The procedure begins with a placement of a probe vaginally and laparoscopic access into the abdomen. The bladder is retrograde filled to be able to isolate and identify the vesicovaginal junction. Once the bladder is identified, the probe is placed further up into the vagina to create tension at the vaginal apex so that the peritoneum overlying the apex can be incised. The bladder is then dissected off the apex of the vagina, and utilizing a monopolar instrument, the scar tissue at the apex is cut through and a colpotomy is created. It�s very important that the width of this colpotomy is wide enough to accommodate at least a 2-plus exam, as you do not want a stricture in the vaginal canal at this point. Following this, the peritoneum is then mobilized down to the colpotomy site. The peritoneum will be sutured all the way around the colpotomy so that the peritoneum is sutured to the vaginal epithelium. This can be done either from below vaginally or it can be completed from above laparoscopically, depending on the total vaginal length at the beginning of the procedure. Traditionally, in vaginal agenesis patients or MRKH patients, this portion of the procedure is completed vaginally, because the junction is way down near the introitus. In a surgically shortened vagina, this junction may be 5 or 6 centimeters deep, and therefore, we can modify the procedure to complete this portion all laparoscopic. A 2-ovicular suture is utilized to suture the peritoneum down to the vaginal epithelium in an interrupted fashion. Again, great care needs to be utilized at this point to not constrict this opening. This will be the midpoint of the vaginal canal, and one does not want to have a stricture at this point. Additionally, one must also be careful not to place a suture in the bladder at this point. The bladder has been previously mobilized off of the anterior apical aspect, and only the peritoneum should be sutured to the vaginal epithelium. Once the peritoneum has been circumferentially sutured to the vaginal epithelium at this point, it again is checked to ensure that there's adequate caliber and diameter of the vagina at this junction. The next step is to create the new apex of the vagina. The pelvic peritoneum is utilized as the upper portion of the vaginal canal, and the peritoneum is sutured in a pursing fashion around the pelvic brim. This creates the new apex of the vagina. Care must be taken to just grasp the peritoneum itself, and one must identify the ureter prior to suturing in the peritoneum in this region. The ovary and tube are lifted up. If they are present, the peritoneum is grasped and the ureter is identified. A bite to the peritoneum above the ureter is taken, and then one below this area. Utilizing this technique minimizes the chance of constricting or suturing the ureter itself. The suture is taken across the epiploca of the rectum, again into the sidewall of the peritoneum after first identifying the ureter on the left side as well, and continued in a pursing fashion all the way to the starting point to the peritoneum overlying the bladder. Once this is completed, this is then tied down with an extracorporeal knot tire and sutured in place. It should be noted that the ovaries are out of the surgical field, as are the tubes, if present, and therefore nothing is getting caught up in the purse-string suture itself. The suture is cut, and then a second suture is placed for further support. Typically, we will utilize one 2-0 monocryl suture, as well as a 0-PDS suture for this portion of the procedure. We ensure that the ovaries and tubes are out of the field, and there�s no constricting of the rectum or sigmoid. Total vaginal length at the end of the procedure was 12 centimeters. This patient�s vaginal length was increased from 5.5 to 12.5 centimeters, as per the measurements seen on the video. A vaginal pack is removed at 24 to 48 hours after surgery, and the patient can become sexually active in as little as 4 to 6 weeks postoperatively, with no long-term dilation necessary. Vaginal shortening following pelvic floor surgery is historically a very challenging and difficult problem to treat. We have found that the modified laparoscopic davidov procedure is an excellent option for these patients.

vaginal shortening

pelvic floor surgery

vaginal lengthening

laparoscopic davidov neovagina technique

sexual function