vaginal vault prolapse repair relies on either the use of patient 's tissue or synthetic materials and can be carried out abdominally or vaginally .
sacrospinous fixation and abdominal sacrocolpopexy are the commonly performed procedures , and the literature is in favor of the second due to its reported higher success rate .
laparoendoscopic single - site ( less ) is a new surgical arena in the development for a great number of indications for urological procedures .
we report a case of complete vaginal vault prolapse which was treated with polypropylene mesh by less sacrocolpopexy with conventional laparoscopic instruments .
a 52-year - old white woman presented with a complete vaginal vault prolapse for 4  years .
five years before , she had been treated by vaginal hysterectomy due to uterine myomatosis .
after 1  year , she developed stress urinary incontinence and was submitted to transobturatory sling and perineoplasty .
another year after , the patient demonstrated a complete vaginal vault prolapse on physical examination ( stage iv based on point c of the pelvic organ prolapse quantification , pop - q ) .
the risks and benefits of the surgery were explained to the patient , and she was asked to sign an informed consent approved by institutional review board .
she was treated by 3.5-cm transumbilical laparoendoscopic single - site sacrocolpopexy using an alexis wound retractor xs ( applied medical , rancho santa margarita , ca , usa ) .
a surgical glove was attached using three trocars ( two of 10  mm and one of 5  mm ) that were fixed to the outer ring of the wound retractor as previously described ( fig .  1 ) .
patient was positioned in dorsal lithotomy and a y - shaped polypropylene mesh was passed through the trocar . only conventional laparoscopic instruments and a 0 laparoscope were used for intrabdominal dissection of vagina and peritoneum . to achieve a good surgical field ,
a valve was inserted into the vagina to help the dissection of the posterior peritoneum between vagina and rectum .
it was made a mesh with a  y  format for adequate fixation on the anterior and posterior vaginal wall and the sacrum , with enough length to reach the pelvic floor .
the mesh was fixed to the vaginal fornix using two continuous sutures ( anterior and apical in vaginal wall ) hold in extremities by polymer clips ( hem - o - lok ; weck , research triangle park , nc ) .
an external percutaneous suprapubic retraction suture in the mesh helped to achieve good presentation for posterior vaginal suture .
the last helical suture was fixed by polymeric clips to the sacral periosteum from the promontory to achieve good vaginal positioning without tension ( fig .  2 ) .
1transumbilical laparoendoscopic single - site sacrocolpopexy using an alexis wound retractor xs. a surgical glove was attached using three trocars ( two of 10  mm and one of 5  mm ) that were fixed to the outer ring of the wound retractorfig . 
2the mesh was fixed to the vaginal fornix using two continuous sutures ( anterior and apical in vaginal wall ) hold in extremities by polymer clips .
the last helical suture was fixed by polymeric clips to the sacral periosteum from the promontory to achieve good vaginal positioning without tension transumbilical laparoendoscopic single - site sacrocolpopexy using an alexis wound retractor xs. a surgical glove was attached using three trocars ( two of 10  mm and one of 5  mm ) that were fixed to the outer ring of the wound retractor the mesh was fixed to the vaginal fornix using two continuous sutures ( anterior and apical in vaginal wall ) hold in extremities by polymer clips .
the last helical suture was fixed by polymeric clips to the sacral periosteum from the promontory to achieve good vaginal positioning without tension a second generation cephalosporin was administered immediately before the surgery and was supported by 7  days .
the total operative time was 2.5  h. blood loss was less than 100  ml .
postoperative hospital stay was 18  h. the patient was referred to the outpatient clinic 1  week postoperatively . during this visit ,
no complications including wound infections , intra - abdominal abscess formation , and urinary incontinence were observed .
the patient became very satisfied with her surgical scar and with the functional result after a 3-month follow - up .
the surgery resulted in an apical anatomic success ( stage 0 of the pop - q ) .
mesh procedures are gaining in popularity , and preliminary data from this technique for correcting vaginal vault is encouraging . as the aging population increases ,
the incidence of prolapse will also rise , older techniques using native tissue will continue , while new techniques using the mesh need to be studied further .
a systematic review evaluated the efficacy and safety of mesh in surgery for uterine or vault prolapse using 54 studies involving 7,054 women .
for sacrocolpopexy ( average follow - up 23  months ) , the risk of clinical recurrence ranged from 0% to 6% , persistent symptoms from 3% to 31% , and mesh erosion from 0% to 12% . comparing minimally invasive approaches , there are preliminary evidences that laparoscopy offers some advantages over vaginal repair
. descargues et al . compared the safety and the efficacy of the laparoscopic and vaginal technique for the surgical management of pelvic organ prolapse .
the anatomical results in the medium term ( 30  months ) seem more favorable to laparoscopy than transvaginal approach , as well as functional results but they still need to better evaluated .
single - port laparoscopy , also known as less surgery , has emerged as an attempt to further enhance cosmetic benefits and reduce morbidity of minimally invasive surgery .
refinement and modification of laparoscopic instrumentation , such as preventing or actively articulating instruments , have resulted in a substantial increase in the description of less in urology over the past 2  years .
technical feasibility has been demonstrated for a broad range of extirpative and reconstructive procedures . however , most comparative studies for other indications observed better esthetic results with no advantage regarding operative and recovery parameters .
we find only one series of 13 cases of less sacrocolpopexy in literature and the authors showed comparable efficacy and superior cosmetics compared to alternative approaches .
less surgery has many technical challenges , such as loss of triangulation and tissue manipulation , internal and external clashing of instruments and handles , and visualization of the structures in a more medial perspective .
the technique we describe in this article attempts to reproduce the principles of the conventional repair associated with facilitative maneuvers , using only conventional instruments .
the use of the alexis wound retractor provides atraumatic circumferential retraction of the fascial opening .
the glove expands with insufflation providing additional distance among the instruments , better triangulation , lesser clash , and greater freedom of movement for instruments .
this homemade single - port device , first described by ryu , also has the advantage to use freely the number and the size of the ports , associated with the lower cost when compared to the purpose - built multichannel ports .
the alexis consists of one inner ring , an outer ring , and a cylindrical plastic sleeve .
the cylindrical plastic sleeve was then pulled outward to cinch the inner ring toward the parietal wall and furling the outer ring and the plastic sleeve outward .
as the outer ring was turned inside out , a latex surgical glove was adapted to it and continued furling together until the sleeve had created complete tension .
this incremental retraction and furling of the sleeve drew the inner and outer rings together on either side of the abdominal wall , thereby creating tension in the sleeve between the rings that retracts the edges of the abdominal wall apart atraumatically , and also providing an effective seal , preventing gas leakage .
the tips of the second , third , and fourth finger of the latex surgical glove were excised , a 10-mm trocar was inserted through the middle finger for the laparoscope and gas insufflation , and 10-mm and 5-mm trocars were inserted at the second and the fourth finger for conventional rigid laparoscopic instruments , respectively , and tied tightly to the glove using 2 - 0 cotton .
we performed a knotless technique , using hem - o - lok clips in the extremities of the sutures to facilitate the reconstruction .
this option is especially useful in less procedures when there are no articulated needle holders or graspers due to acute angulation among the instruments .
the use of hem - o - lok had been already described during laparoscopic partial nephrectomy .
further prospective studies comparing long - term results to standard laparoscopy are awaited to indicate the real application of less sacrocolpopexy in the modern urological armamentarium .
we believe that less represents a new provocative step forward in the arena of minimally invasive surgery .
 the aim of this paper was to report a case of a patient with stage iv vaginal vault prolapse treated by laparoendoscopic single - site ( less ) sacrocolpopexy using an alexis retractor and a surgical glove attached to three trocars through a 3.5-cm umbilical incision . 
 only conventional laparoscopic instruments were used for intrabdominal dissection of vagina and peritoneum . 
 the mesh was fixed to the vaginal fornix and to the sacral periosteum from the promontory using running sutures hold in the extremities by polymer clips . 
 the posterior peritoneum was closed over the mesh . 
 less sacrocolpopexy performed with conventional instruments is a difficult but feasible and efficient technique to treat vaginal vault prolapse that respects the principles of conventional laparoscopic or open repairs . 
 alexis retractor associated with knotless sutures are technical options that simplify less reconstructive surgical maneuvers . 
Introduction
Case report
Discussion