This exact procedure can be done through a single incision port at the Pfannenstiel or at the umbilicus. We advise the use an additional 5 mm port at the umbilicus for the operative camera to effectively widen the visual field. This approach has been labeled the “SILS + 1 technique”. The procedure steps are otherwise identical.

After tenting the rectosigmoid, if the sacral promontory is not visible, as can occur in the obese or patients with a floppy sigmoid, grasp the mesentery closer to the pelvic brim, and flop the sigmoid over closer to the retractor, taking care not to avulse the mesentery

When difficult to get the small bowel out of the pelvis, position in steeper Trendelenburg and incise the ileocolic attachments in an inferior to superior direction to move the cecum out of the pelvis. If small bowel is still in view, have an assistant gently grasp the terminal ileum in a superolateral direction after releasing the attachments

Use caution in thin patients, when incising the peritoneum over the pelvic brim, as the Left Iliac Vein and gonadal vessels, para-aortic autonomic nerves, and left ureter may be attached to the tissue due to absence of the sacral fat pad. While the anatomy may be more visible, use excessive caution when entering the plane

To confirm you have entered the correct plane after incising over the pelvic brim, there should be instantaneous pneumodissection of the alveolar tissue