In unobstructed patients, an oral polyethylene-based bowel preparation and three doses of 1-g neomycin and 500-mg metronidazole orally were given the day before surgery.

Preoperative subcutaneous heparin is administered within 2 hours of surgery, and sequential compression devices are used to help prevent deep venous thrombosis prophylaxis.

Digital rectal examination, imaging, and endoscopy are utilized to determine the relation of pathology (eg, tumor, fistulizing Crohn disease) to the vagina/prostate anteriorly, involvement of the internal/external sphincter, and relation to the pelvic side wall in the situation of bulky local tumors.

Prior to beginning the procedure, a digital rectal examination may be performed in the case of rectal tumors to ensure the need for an abdominoperineal resection.

Prior to reaching the final portion of the proctectomy, the colon has been mobilized for sufficient length for an end colostomy, and the rectal dissection has been largely performed from an abdominal approach. The presacral space entered for the posterior dissection down to the level of the levators, lateral ligaments divided, and anterior approach one layer posterior to Denonvilliers fascia to dissect the plane between the anterior rectal wall and seminal vesicles and prostate/vaginal wall.

The patient should be placed in the Lloyd-Davies synchronous position or modified lithotomy. Both arms are tucked, and the patient is secured on a bean bag. Legs are held in Yellowfins stirrups such that the weight is on the heals to prevents pressure on the peroneal nerve as it passes around the fibular head. The hips should be abducted to accommodate the perineal dissection and positioned at the end of the bed to allow ready access to the tip of the coccyx.

Prone positioning may be considered in the case of a large anterior tumor, when a posterior vaginectomy is planned, or when this is the patient preference.

A rectal washout using dilute betadine solution to remove any residual stool is performed using a red rubber catheter.

For this portion of the case, the operative technician is typically sitting on a stool between the legs, with the legs moved upward.

The table is usually moved up and Trendelenburg position to allow better access to the perineum.

An assistant may be useful to the right or left side, depending on the surgeon’s preference for retraction.