If the intention of the procedure is to perform an end ileostomy at the completion of the operation, then the port may be placed through a circular incision of a diameter ranging 2.5–3.5 cm, in the right lower quadrant in the pre-marked site of the ileostomy. The incision is carried down to the anterior rectus sheath, which is then sharply incised, the abdominus rectus muscles are bluntly retracted, and the posterior rectus sheath is identified and incised. The GelPOINT device (Applied Medical, Rancho Santa Margarita, CA) is inserted and pneumoperitoneum created. Three trocars are inserted into the port, a 12 mm trocar and two 5 mm trocars. The 12 mm trocar will be the insertion site for the 30° laparoscope and stapler. The laparoscope will be positioned at the medial aspect of the GelPOINT. Each 5 mm trocar will be placed along either side of the camera to triangulate their position. If the patient is to receive a primary anastomosis without ileostomy, then a 2.5–4.5-cm longitudinal periumbilical incision is created or an incision between the umbilicus and the pubic symphysis. The incision is carried down to the fascia, and the fascia is opened under direct visualization. Placement of the single-port device and trocars proceeds in the same manner as stated in the previous paragraph.

Mobilization of the right colon may potentially be the most challenging aspect of the operation because it is located directly under the access site (in the case of creation of the end ileostomy) and is at a greater risk for conversion.

In benign disease the mesentery can be ligated close to the bowel wall and the rollover technique can be utilized. The operating table is placed in Trendelenburg and tilted to the left, until the small bowels fall out of the pelvis, exposing of the right lower quadrant. The operation begins with creation of an ileal window and transection of the terminal ileum flush to the cecum for inflammatory bowel disease or 10 cm proximal to the ileocecal valve. The mesenteric edge is now progressively ligated with an energy device toward the cecum. The cecum and mesentery are mobilized laterally and the mobilized mesentery ligated again (see Video 22.1). The back and forth lateral mobilization and mesenteric ligation is performed identifying the duodenum and mobilizing the hepatic flexure. The cecum and subsequent colon are rolled over to the right side of the patient and then inferiorly.

For malignant disease high ligation of the mesenteric vessels is necessary, and the technique follows the medial to lateral or lateral to medial approach previously described. The overall principles of the lateral to medial mobilization are that the lateral attachments are exposed and dissected off of the cecum and ascending colon, then the ileocolic and right colic pedicles are located and divided. The cecum and ascending colon are retracted medially, exposing the white line of Toldt. The white line is incised in a caudad to cephalad direction, approaching the hepatic flexure. During this avascular dissection both the right ureter and duodenum are to be clearly identified before pursuing ligation of the vascular pedicles. The cecum is retracted anteriorly and laterally, which allows the ileocolic pedicle to be visualized, isolated, and divided with the Ligasure device. The mesenteric division is continued medially through the small bowel mesentery to approximately 10 cm proximal to the ileocecal valve. The general principles of the medial to lateral mobilization are that the ileocolic pedicle is identified and ligated, and then the colon is mobilized medially to laterally in a submesenteric plane. The cecum is retracted anteriorly and laterally, placing the ileocolic pedicle on slight tension. The right ureter and duodenum are visualized prior to ligation of the pedicle. The pedicle is isolated and divided with a bipolar energy device. The right colic artery is also identified and ligated. Mobilization of the ascending colon occurs in an avascular plane below the mesentery and above Gerota’s fascia, medially to laterally, where the white line of Toldt is incised, laterally, in a caudad to cephalad direction toward the hepatic flexure.