Laparoscopic Colectomy: the Absolute Need for a Standard Operative Technique, Croce E. must be of a sufficient length and enter the operative field on the patient's left side. If there are two monitors, the sec- ond one is placed behind the patient's left shoulder. The operating surgeon, with a camera person on his left, is posi- tioned on the patient's right side and the assistant is on his left. Four trocars are used: one 5 mm, two 10 mm, and one 5/12 mm for the mechanical stapler. To make the instru- ments as interchangeable as possible, however, it is better to use single-gauge trocars, furnished with a universal adapter and valve that allows for instruments to be insert- ed without using pistons or anything else that requires another hand (Versaport 5/12 mm, U.S. Surgical Corp.). The protracted use of multiple access sites and different instruments requires great care to avoid enlarging the cuta- neous incisions and unnecessary spillage of carbon diox- ide. It is important to avail oneself of wall stirrups as well. Pneumoperitoneum is initiated with the insertion of a Veress needle. The first trocar, 10 millimeter in diameter, is placed in the right paraumbilical site and used to pass a 30 degree laparoscope for exploration of the pelvi-abdominal cavity. It is useful to perform an eco-laparoscopy to more completely evaluate intraoperative staging. The three remaining trocars are positioned in the following sites: a 10 mm trocar at the junction of the right anterior axillary line with the transverse umbilical line through which the laparoscope is placed during the whole operation except during preparation of the rectum and creation of the anas- tomosis, at which time the laparoscope is placed through the paraumbilical trocar; a 5 mm trocar at the left anterior axillary line 3-5 cm cranial to the transverse umbilical line; a 5/12 mm trocar in the right iliac fossa (Figure 4). To avoid intraoperative wall and visceral complications, per- form the incision for trocar insertion with wall transillumi- nation, and pass the trocars under direct vision. The oper- ating surgeon performs the ligation and transection of the vascular pedicles, and incision of the mesorectal and mesenteric radix, while positioned on the patient's right side. To feel more comfortable, the operator can move between the patient's legs during mobilization of the splenic flexure. The first portion of the procedure always involves ligation of the vascular pedicles. After the omentum is placed over the transverse colon, the small bowel loops are moved, in such a way that exposes the peritoneum overlying the aorta. The peritoneum is incised medially to the right ureter in front of the right iliac artery. Then proceeding upwards, the origin of the superior mesenteric artery is identified. This area can be visualized with lateral retrac- tion by the assistant of the sigmoid towards the left anteri- or wall of the abdomen. The pedicle is ligated and divid- ed between extracorporeal knots (2), clips or by using the stapling cutter. At the beginning of our experience we performed a dou- ble ligation with extracorporeal knots. Now, we divide the vessels between metal clips, leaving proximally two or three clips. In a few cases we used a vascular stapler (Endo-GIA 30) to secure sclerotic vessels or mesenteric fat which bleeds easily. The ligament of Treitz is identified as well as the inferior mesenteric artery. The latter is ligated and dissected in the same way as the former. After the ves- sels have been divided at their origin, the mesentery is detached from the posterior plane, after identification of the left ureter through a mesenterial "window" over the left iliac artery. After incision of the superior hypogastric lam- ina, the posterior pre-sacral plane is detached, and we pro- ceed to reflect the anterior sigmoid-rectal peritoneum, fol- lowing the right ureteral pedicle and the iliac artery. Mobilization of the sigmoid loop is continued on the left side, preserving the left ureter, down to the anterior junc- tion of a peritoneal incision performed in the pre-vesical plane in male patients. In female patients, the uterus is brought forward and suspended by two endoparietal stitches to permit dissection in the recto-vaginal region. After the surgeon has moved between the patient's legs, division of the parietocolic reflection is completed, moving up to the splenic flexure, and mobilizing the transverse colon where needed. The rectal resection margin is then prepared, skeletonizing the segment, coagulating and trim- ming fat, until the rectum structures are clearly visible. Curved laparoscopic scissors greatly facilitate this dissec- tion. It is quite easy, then, to identify the superior hemor- rhoidal vessel and its branches, which are divided between metal clips or with bipolar coagulation. Resection and clo- sure of the distal margin is performed using a mechanic sta- pler. If the rectal segment has been accurately prepared for the resection, the use of an endo-GIA doesn't cause any particular problems. We prefer a 30 mm stapling device, although generally two cartridges are needed because in a small region, such as the pelvis, multiple firings make the procedure easier. The dissection is performed with aseptic technique. Mobilization of the colon for anastomosis is tested, checking to see if the descending colon will approx- imate the rectal stump. After determining the proximal extent of resection, it is useful to mark this position with one or two clips so that its identification is easier when the bowel is exteriorized. A McBurney muscle-splitting laparo- tomy incision is fashioned in the left iliac fossa sized to accommodate the resected bowel. We introduce, through the incision which is kept open with dilators, 20-25 cm of the transparent plastic bag used to cover the camera. The transected colic stump is exteriorized by grasping it with Duval forceps. When the neoplastic segment is inside the plastic tube, it is exteriorized together with its plastic bag, avoiding in this way any contact with the abdominal wall. After the colon is delivered, resection of the anastomotic artery of Drummond is completed. The proximal colonic section is closed with a purse-string suture after the stump 220 JSLS (1997)1:217-224