After the patient is brought into the OR, he or she is carefully transferred to the OR table. The anesthesiologist then intubates the patient and inserts a naso-/orogastric tube. The patient is placed in modified lithotomy using Allen® (Allen Medical Systems, Acton, MA) stirrups with legs oriented so that the toes, knees, and shoulders are in line. The knees should be slightly flexed and the thighs flattened parallel to the bed so that the surgeon can maintain the greatest range of motion of his hands and laparoscopic instruments.

The use of a Bean Bag placed directly on the table with both arms tucked can prevent sliding of the patient while using steep Trendelenburg and reverse-Trendelenburg positions. The patient’s extremities should be well padded to avoid any trauma at bony prominences.

It is important to provide 3–4 cm of exposure of the perineal area off the edge of the operating table before commencing the surgery to allow easy passage of the circular stapler. Additional care should be taken to regulate the temperature of the patient with the use of heating devices such as Bair Hugger®, Arizant Inc., Eden Prairie, MN.

If patient had a stoma site marked preoperatively, the site is marked with a needle tip to prevent losing the mark during the preparatory wash.

We routinely use ureteral stents for deep pelvic surgery. A urologist places these stents to facilitate safe laparoscopic pelvic dissection by providing tactile and visual confirmation of the safety of the ureter.

Rectal irrigation is undertaken with Betadine® Solution (aqueous solution of 10% povidone-iodine) (Purdue Products L.P., Stamford, CT). The abdomen is prepped and draped in the usual sterile manner, taking care to position the sterile towels along the anterior axillary line for proper trocar placement and across the xiphoid and pubis for possible laparotomy.

It is preferable to use laparoscopic draping with built-in pockets to attach the insufflation tubing, camera cord, light cable, and cautery cord around the perimeter of the patient’s abdomen. The Steri-Drape™ (3M™ Medical, St. Paul, MN) plastic pouches or other holsters are useful for organizing and securing the laparoscopic instruments onto the sterile field.

The laparoscopic-stapled LAR consists of several steps (Fig. 14.1). This procedure can be performed totally laparoscopically (port site wounds only) and laparoscopic-assisted (port sites and specimen extraction site). Both approaches start by establishing pneumoperitoneum. There are two common techniques of laparoscopic entry into abdominal cavity to maintain pneumoperitoneum—closed (Veress) and open (Hasson), based on surgeon preference.

The open Hasson technique is preferable due to its ease and minimal risk of injury to peritoneal structures. The incision is made above or below the umbilicus depending upon the height of the patient and the distance of the umbilicus from the pubis. An extension of this incision may be used for specimen extraction, thereby providing somewhat better cosmesis. The Hasson technique starts with a vertical 1.5-cm long skin incision with #15 blade scalpel or diathermy, dissecting the subcutaneous tissues to the level of fascia. The fascia is grasped with Kocher clamps or similar instrument to better visualize and incise that layer. Anchoring sutures are placed on the edges of the fascial incision with 2-0 Vicryl™ (Ethicon Inc., Summerville, NJ) or silk to form handles for the Hasson trocar. The preperitoneal fat is gently spread to expose the peritoneum, which is grasped with smaller clamps and divided, taking care to ensure that there is no intervening bowel. The 12-mm Hasson trocar is then introduced into the abdominal cavity and secured with the previously placed anchor sutures. The insufflation tube is attached and carbon dioxide pneumoperitoneum with a pressure of up to 15 mm Hg is established.

A 30-degree 10-mm camera is obtained from out of the warmer or thermos and attached to the light and video processor cables. White balance of the camera is done on a laparotomy gauze or any other uniformly white surface.