Laparoscopic Neovagina
Drs. Moore and Miklos utilize the laparoscopic modification of the Davydov procedure to create vaginas in women born without them (ie MRKH syndrome/vaginal agenesis) or in women that have a shortened vagina or painful vaginal cuff following surgery (such as hysterectomy). They complete more laparoscopic vaginal and pelvic reconstructive surgeries at their center in Atlanta than any other in the US and are considered world leaders in the field. They have women travel to Atlanta for their surgeries from all over the US and are invited to lecture and operate on their techniques throughout the world. They have pioneered many procedures that are considered standard of care in the field of Urogynecology today and complete all of their abdominal procedures laparoscopically (many of which are still done through large abdominal incisions at most other centers).
The Davydov Procedure is a surgical procedure used to create a full length vagina in young women that are born without a vaginal canal or lengthen the vagina in women with surgically shortened or scarred down vaginas. It is one of the most successful procedures described for this condition and utilizes the patient's own peritoneum (the cellular layer that lines the walls of the pelvis and the abdominal cavity) as the new vaginal canal. Dr. Miklos and Moore are able to use their expertise as laparoscopic pelvic/vaginal reconstructive surgeons to be able to complete the procedure laparoscopically, ie through tiny mini-incisions in the belly which makes it an outpatient type surgery. They operate off of large Hi-def TV screens that magnify the field allowing them to complete the surgery with more precision, better visualization, less blood loss and less complications versus traditional surgery. Recovery is rapid and the procedure carries the lowest risk of scarring down or losing the length created than any other procedure described to create vaginal length.
Many surgeons use an open abdominal incision (laparotomy) to complete these type of procedures. Dr. Miklos and Dr. Moore complete the Neovagina Procedure laparoscopically. See their incisions 'laparoscopic' (small incision) versus others 'laparotomy' (big incision). Which would you rather have?
Surgical Procedure
Dr Miklos and Moore utilize their standard approach to laparoscopic pelvic reconstruction for the Laparoscopic Neovagina. Tiny incisions are made in the belly (one is hidden in the belly button) to allow access to the abdominal cavity. The procedure is completed with both a vaginal and laparoscopic approach, ie work is done from below vaginally, as well as above in the abdomen through the scope. Dr Moore and Miklos have a dedicated team of assistants to allow them to work together to accomplish the procedure. In the traditional approach to the surgery, approximately half of it is completed vaginally, however secondary to their expertise, they are able to complete most of it laparoscopically. The procedure typically takes them approximately 1 to 2 hours to complete and is completed in an outpatient type hospital setting.
Figure 1. Demonstrates the laparoscopic view down into the pelvis. The shiny covering of the pelvis (called peritoneum) will become the lining of the new vaginal canal. The arrow and dotted lines depict where the top of the vagina or dimple is located and that is the area that will be opened under direct visualization at the beginning of the procedure.
Once abdominal access is obtained, the vaginal dimple (or top of scarred down vagina in a shortened vagina) is opened to start the procedure. The most flexible part of the top of the vagina or dimple is located and with direct visualization from above laparoscopically, the vagina is opened with a large enough opening to accommodate two to three fingers.
Figure 2(A-E)
Figure 2. Vaginal photo (Fig 2) of a MRKH patient with normal appearing external vagina, however one can visualize the vagina is very shortened, and really just has a dimple where the vaginal canal should start. The dotted lines in the picture depict the incision that will be made to open up the top of the current vagina into the pelvis to enable the lengthening/neovagina procedure to be completed. The pelvic view of this incision can be seen above in Figure 1. The illustration (Figure 2 A-E) demonstrate where the incision is made in the vaginal dimple (becomes new vaginal opening) and then the probe is pushed up into the pelvis (Fig E) to incise the last layer (peritoneum).
Figure 3a.
Figure 3b.
Figure 3. Once the top of the vagina is opened into the pelvic cavity, the edges of the incised peritoneum is pulled down to the vaginal epithelium and the edges sutured together all around the opening. This is a step that can be completed vaginally, however Dr Moore and Miklos typically will complete this step laparoscopically as well. In Fig 3a, the edges of the peritoneum can be visualized and these are advanced down and sutured to the edges of the opened vaginal skin edges. In 3b, one can see that there is NO raw surface edges exposed (these can be seen in fig 3a), they are covered with the suturing of the peritoneum edges to the vaginal edges all the way around the circumference of the vagina and this minimizes risks of the vagina scarring down. This picture shows the lining of the new vagina very well, again note how there are NO raw surfaces and the peritoneal lining is very smooth and already completely epithelialized, ie it is not like a skin graft that has to heal or be accepted by the body. The depth of the new vagina can be visualize in Fig 3b.
Figure 4(A-D). The new top or apex (cuff) of the vagina is now created laparoscopically. The vaginal length is marked from below and the peritoneum up higher in the pelvis is sutured in a purse string fashion to create the new upper portion of the vagina. Care is taken to avoid the ureters (the tubes going from the kidneys to the bladder) as well as the bowel. Figure (A) and (B) show the beginning of the suture grasping the pelvic peritoneum just under the ovary and then continuing across the superior aspect which incorporates the bladder peritoneum (a releasing incision is made above this portion to allow this portion of the peritoneum to be more mobile). Figure (C) shows the suture going all the way around the peritoneum and one can visualize what will be the vaginal canal below the suture. When this suture is tied down (Fig. D), this becomes the top of the new vaginal canal. Drs. Moore and Moore can typically achieve a vaginal length of between 9 to 11 cm with this technique.
Before
After
Picture on the left shows patient with vaginal agenesis or very shortened vagina. Picture on right shows result after Laparoscopic Neovagina technique that utilizes the pelvic peritoneum to create a new vaginal canal. The shortened vagina is opened and the peritoneum from the pelvis is advanced down to the opening to create the lining of the new vaginal canal.
Post operative Care
The procedure typically takes approximately 1-2 hours for the Doctors to complete and is done in an outpatient hospital or surgery center setting. Patients can go home on the day of surgery, however most will stay overnight in the outpatient center (ie 23 hour stay). Vaginal packing is placed and usually is removed within 36-48 hours following the surgery. At this point, the patient is taught to either use dilators or her fingers to apply estrogen cream twice daily to ensure that the vagina is maintaining its length and width. Usually during the first couple of weeks, there will be a pink discharge with exam/dilation or a small amount of bleeding, which is normal. This process is typically not painful to the patient. Intercourse can start as soon as the pink discharge or bleeding stops with self-exam or dilator use, which sometimes can be as early as 2 weeks post-operatively. In most cases, vaginal dilation per se is NOT necessary. Dilators are used on a daily basis to ensure that the vagina is not scarring down at all, and maintaining its width and length, however the dilators are usually not needed to stretch, widen or lengthen the vagina (as is the case with other neovagina type procedures). Dr Moore and Miklos’s staff of nurses and assistance are inherently involved in patient teaching both pre- and post-operatively to ensure the patient is comfortable with the process.
Because of Drs. Moore and Miklos’ expertise in laparoscopic vaginal reconstruction and specifically in Laparoscopic Neovagina creation, doctors from all over the US send their patients with MRKH and/or vaginal shortening to them. This is a somewhat rare condition and there are very few centers in the US that take care of women with this problem and therefore most gyn surgeons and/or plastic surgeons have very little experience with this condition. Drs. Miklos and Moore’s laparoscopic center is known throughout the world for their cutting edge surgical expertise and successful results. Because of this, they do more of these type of surgeries than most any other center in the US and have gained a great deal of experience with the condition and the treatment options for patients with these conditions. Their center, the hospital and their staff understands that it is stressful to travel away from home for surgery and therefore address these needs specifically with helping with logistics of insurance, travel, lodging (we utilize a hotel right next to our surgery center and hospital ) and nursing support while in Atlanta. Most patients will stay in Atlanta for approximately one week total (pre and post surgery) and the staff ensures that all needs of patient and family are addressed and taken care of.
Please note: For patients traveling to Atlanta for surgery, you will be required to stay in Atlanta for 7 days after surgery for post operative care.
Surgery is of course only one step for young girls with MRKH and adequate pre-operative counseling should be completed and the patient and her family needs to be mentally ready for surgery and post-operative care, dilation, maintenance etc. Support groups and counseling are available for young women with MRKH and information about the condition, frequently asked questions, how to talk to your teen about the condition and other information can be found at www.MRKH.org
Risks of surgery
While no surgery is risk free, the risks of the laparoscopic neovagina technique that Dr Miklos and Moore utilize are very minimal, especially when compared to other surgical techniques to create or lengthen the vagina. Other techniques, including the McIndoe procedure or procedures that utilize a piece of intestine to create the vagina can be much more invasive and carry much higher risks of bowel or bladder injury, infection, bowel obstruction or scarring down of the vaginal canal post-operatively. The Laparoscopic Neovagina approach utilizing peritoneum results in a vaginal canal that has minimal risks of scarring down and has success rates of over 90% a fully functional vagina for intercourse and sexual function including orgasm. During the procedure there is direct visualization of the incision that is made at the top of the vagina into the pelvis (ie it is not a blind dissection like the McIndoe) nor are any tissue flaps or grafts required, nor any organs resected (ie bowel) to create the vagina. Simply the existing peritoneum is utilized to make a new vagina with a small incision and sutures completed laparoscopically.
Risks such as injury to bowel and bladder always exist however are very minimal risks with this surgery. The ureters (the tubes from the kidneys to the bladder) do run through the pelvis and these are checked closely prior to the end of the surgery to ensure that they were not kinked off by the suture placement. Risks of bleeding is minimal as is risk of post-operative infection. Risk of the vagina scarring down or shortening do also exist, however again with proper post-operative care, proper dilation and pelvic floor therapy, if indicated, this risk is also very minimal.
Pictures source: Fedele. Am J Ob Gyn 2010.