Vaginally-assisted laparoscopic sacrocolpopexy, or VALS, is a modified approach to laparoscopic sacrocolpopexy. Walter Reed Army Medical Center and Inova Health Systems presents VALS for patients with uterovaginal prolapse. Lines are drawn from the umbilicus to the anterior superior iliac spines. A 5-millimeter port is placed in the left lower quadrant, 2 to 3 centimeters medial and superior to the anterior superior iliac spine. An 11-millimeter port is placed midway between the lower left quadrant port and umbilicus. The right lower quadrant 5-millimeter port is inserted opposite the 11-millimeter left quadrant port. The left lower quadrant 5-millimeter port is placed close to the spine to maximize the distance to the 11-millimeter port, which fosters easier needle management and presacral access. A vaginal or laparoscopic-assisted vaginal hysterectomy is then performed. The colpotomy incision is made with a scalpel, rather than energy, in order to avoid devascularizing the vaginal cuff. With the uterus removed, the attachment of the mesh through the vagina can now be started. The edge of the anterior cuff is grasped with Alice clamps, and the vagina is then inverted over the surgeon's finger or a round probe to allow dissection of the vesicovaginal space using metzenbaum scissors. Similar to the laparoscopic approach, the anterior dissection is typically extended down to the level of the trigone when possible. A polypropylene mesh strap is then cut. The sacral end of the mesh is narrowed to allow easier mesh handling on the sacrum. The mesh is then tapered on one side to preserve continuity of the laser-cut edge. This smoother edge will be placed on the left side against the rectum. The mesh is then hand-sewn to the upper anterior vaginal wall The distal end of the mesh strap is typically anchored as distal in the vesicovaginal space. Four to six sutures are typically used. The proximal portion of the mesh strap is then placed intraperitoneal. The posterior dissection is now performed similar to that done on the anterior cuff, utilizing the surgeon's finger or a round probe. The level of posterior dissection is more variable, but typically extends to at least the mid-posterior vaginal wall. A rectal finger and a ring finger A rectal finger and vaginal thumb is used to further delineate the rectovaginal space. Once again, a polypropylene mesh strap is hand-sewn to the posterior vaginal wall using permanent monofilament sutures. The mesh is anchored as distal in the rectovaginal space as is allowed based on the extent of the prior dissection. Again, four to six sutures are used. The proximal portion of the mesh strap is then placed intraperitoneal. The vaginal cuff is closed with an absorbable running suture. Once vaginal mesh attachment is complete, the remainder of the operation is performed laparoscopically. The sigmoid colon is retracted to the left. The right ureter and sacral promontory are identified. The peritoneum of the right pararectal space is opened from the sacral promontory down to the previous rectovaginal space dissection. Appropriate mesh tension will appear tight due to the effect of pneumoperitoneum. This needle technique is utilized for easy handling. The proximal mesh arms are individually fixed to the anterior longitudinal ligament of the sacrum using permanent multifilament polyester or monofilament nylon sutures. The posterior mesh is attached first. Then the anterior mesh is attached to the sacrum. A third suture is placed through both mesh straps. The mesh is then retroperitonealized. Systoscopy is performed to rule out bladder injury and to ensure ureteral patency. Laparoscopic sacrocolpalpexy using transvaginal mesh attachment or VALS is another tool in the myriad of techniques that can be employed for treatment of advanced uterovaginal prolapse. This technique may help shorten operative times in patients undergoing concurrent hysterectomy.

vaginally-assisted laparoscopic sacrocolpopexy

VALS

uterovaginal prolapse

mesh attachment

laparoscopic hysterectomy