The optimal location of the SILS port for visualization and dissection in pelvic cases is 20 cm cranial to the pubic symphysis. Depending on the patient’s anatomy, the port can be placed at the umbilicus/ supraumbilical, through a Pfannenstiel incision or—in a patient with a predetermined diverting ileostomy—through the stoma site. After exploration of the abdomen, the splenic flexure is taken down in a medial to lateral fashion. A medial to lateral retroperitoneal dissection of the colon is performed, and the inferior mesenteric vein and artery are ligated. The ureter and gonadal vessel are identified and preserved during the retroperitoneal dissection. The pelvic dissection is started just above the sacral promontory, opening the retroperitoneum to the right of the superior rectal artery and inferior mesenteric pedicle, assuring the preaortic nerves and superior hypogastric plexus are left down and undisturbed. The pelvic dissection is executed in a circumferential fashion, starting posteriorly down to the pelvic floor, moving to the right lateral and left lateral sidewalls, then anteriorly. The posterior dissection is performed in the areolar plane between the visceral mesorectal fascia and the parietal endopelvic fascia; anterior traction on the rectum facilitates this step (Fig. 5.2). The rectosacral fascia is sharply opened, allowing pneumodissection to aid the sharp dissection and separate the posterior mesorectum from the endopelvic parietal fascia. The dissection proceeds inferiorly down to the levators in a plane anterior to the nerves. The dissection down to the pelvic floor facilitates the subsequent anterolateral dissection. For the lateral and anterior segments, the rectum is re-grasped with tension directed caudally and fluidly moved contralaterally or posteriorly to aid the dissection. The lateral dissection begins on the right side, moving in a posterior to anterior direction, assuring the lateral mesorectal fascia is intact (Fig. 5.3). The cul-de-sac peritoneum is opened, and dissection continues between Denonvilliers’ fascia and the anterior mesorectum before sharply dividing the lateral stalks at the lateral border of the mesorectal fascia. The retraction is then shifted to the right, and the lateral dissection is repeated on the left. After completing the posterior dissection and dividing the lateral stalks, the levators and Waldeyer’s fascia are visible. Waldeyer’s is incised posteriorly and laterally at the anorectal junction to expose the rectal tube past the puborectalis and posterior mesorectum. The anterior dissection commences with meticulous, sharp dissection to separate the rectoprostatic or rectovaginal plane from the anterior mesorectal fascia (Fig. 5.4). The dissection continues past the anterior mesorectum to expose the rectal tube at the anorectal junction. With the rectal tube circumferentially mobilized down to the anorectal ring, the distal rectum is divided. The proximal bowel is exteriorized through a wound protector, the specimen transected with appropriate margins in viable tissue, and the anvil of the intraluminal stapler placed and secured. The bowel is returned intra-abdominally and an anastomosis created with the transanal stapler .