The patient is placed in Trendelenburg position with the left side air-planed up. This gives maximal exposure to the descending and sigmoid colon and helps elevate the small bowel out of the pelvis. Once this is achieved laparoscopically, the robot is docked to the left of the patient. First, the lateral attachments of the rectosigmoid colon are taken down. This allows elevation of the sigmoid colon to identify the inferior mesenteric vascular bundle. Dissection then proceeds medial to lateral, underneath the inferior mesenteric artery (IMA), over the left common iliac, identifying the left ureter (Fig. 12.3). A window is made around the IMA and divided with the robotic vessel sealer device (Fig. 12.4). The dissection is continued until the peritoneal reflection is taken down up to the splenic flexure. The pelvic dissection is then initiated, going posteriorly over the sacral promontory in a total mesorectal excision (TME) plane down to the tip of the coccyx (Fig. 12.5). The lateral stalks are divided. Lastly, the anterior peritoneal reflection is taken down, identifying the seminal vesicles (Fig. 12.6). A digital rectal exam is then performed to ensure that the dissection is completed up to 1–2 cm above the dentate line. After this is confirmed, the robotic stapler is used to divide the distal rectum. The mesocolon is then taken with the robotic vessel sealer device up to the splenic flexure (Fig. 12.7). At this point, the robotic arms are undocked and repositioned to access the transverse colon. The patient is then placed in reversed Trendelenburg and the splenic flexure is taken down. The omentum is dissected off of the transverse colon opening up the lesser sac (Fig.12.8). The mesentery of the transverse colon is divided with the robotic vessel sealer device going past the midline toward the ascending colon. The robotic arms are then undocked again and repositioned to access the ascending colon and hepatic flexure. At this point the patient is placed left side down for better exposure. The hepatic flexure and ascending colon are dissected off of the duodenum, being sure to identify the right ureter. The ileocolic vessel is then isolated. After the entire right colon is fully mobilized, the suprapubic port is opened approximately 4 cm and an Alexis wound retractor is placed. The entire specimen is delivered through this port site. A handheld LigaSure is used to divide the terminal branches of the ileocolic vessels flushed to the right colon. The terminal ileum is divided with a GIA stapler and the specimen is removed (Fig. 12.9). Before the terminal ileum is exteriorized to form the J pouch, the surgeon must make sure that the small bowel mesentery is not twisted. This is confirmed when the mesentery is configured so that only the duodenum and no small bowel is seen to the right of the ileocolics (Fig. 12.10). The terminal ileum is then prepared. Thirty cm of the distal ileum is folded on itself to make a pouch of 15 cm in length using the Echelon stapler (Fig. 12.11). An EEA stapler is then used to create the ileoanal anastomosis. Care is taken not to rotate the pouch and to ensure there is no tension on the anastomosis. A protective loop ileostomy is then created in the right lower quadrant (Fig. 12.12).