A detailed history and physical examination is essential preoperatively to determine if the patient is suitable for a laparoscopic approach. Rectal neoplasia after preoperative neoadjuvant chemoradiation or T4 rectal tumor extension to the sacrum, bladder trigone, prostate, posterior vaginal wall, or side pelvic wall with ureteral or major vessel involvement should be addressed preoperatively with appropriate staging workup. In these cases, laparotomy may be the best option, or if the procedure can be accomplished laparoscopically, a hybrid approach with a single-port laparoscopic technique at the suprapubic area with subsequent conversion to a Pfannenstiel incision may be considered.

Potential intraoperative consultation to other subspecialties, such as gynecology for addressing an incidental neoplastic adnexal pathology, urology for ureteral or bladder tumor involvement or other surgical service, may be necessary. It is the primary surgeon’s responsibility to communicate with the consulting service regarding the feasibility of a singleincision laparoscopic approach in order to avoid a lengthy single-incision procedure that may lead to conversion to hand-assisted laparoscopy or to a laparotomy.

A restorative proctocolectomy allows for extraction of the specimen via the single port or transanally, in case of a planned coloanal or ileoanal pouch hand-sewn anastomosis. A full-thickness rectal division is performed at the level of the dentate line. In case of underlying colonic or rectal neoplasia, the size of the tumor determines if it can be extracted without tension via the single-port wound protector. In general, tumors up to 7 cm can be extracted via a 5-cm maximum length single incision. The procedure can still be performed with elongation of the incision for extraction of larger tumors. In that case, the benefit of the single port is eliminated, with the exception of the avoidance of use of multiple laparoscopic ports. If the single port is placed via the new ileostomy site, then partial approximation of the fascia may be required prior to maturation of the ileostomy.

A large palpable tumor preoperatively with fixation to the abdominal wall or other organs may be a contraindication to single-incision laparoscopy, although excision en bloc with soft tissue abdominal wall is still possible via a single incision in some cases.

It is important to define the underlying pathology—benign versus malignant disease and the location of the lesion—preoperatively. Neoplasia may require formal lymphadenectomy with preferable high ligation of the involved vascular supply. This may not be necessary in benign conditions such as ulcerative colitis or polyposis syndromes without dysplasia or neoplasia.

In case of a planned ileoanal pouch anastomosis, particular attention is paid to the preservation of the ileocolic vascular pedicle in order to maintain the vascular supply of the pouch. The ileal pouch can be fashioned extracorporeally, following extraction of the colon and rectum via the single incision wound protector.

Previous abdominal surgeries with extensive abdominal or pelvic adhesions may increase the operative time.

Preoperative colonoscopy is necessary to justify the planned restorative proctocolectomy.

Diagnosis of ulcerative colitis and exclusion of Crohn’s disease by colonoscopic biopsy and by an experienced pathologist
and/or with the assistance of other laboratory workup, such as Prometheus test, are necessary in order to establish the need for restorative proctocolectomy with ileoanal anastomosis.

Colonoscopic evidence of terminal ileitis by biopsy may assist in the diagnosis of Crohn’s disease and avoidance of an ileoanal pouch formation.

Diagnosis of ulcerative colitis with proctitis and involvement of the anal canal by colonoscopy or rigid proctoscopy and biopsy is necessary in order to establish the need for anal mucosectomy and hand-sewn ileal pouch anastomosis.

Contrast-enhanced computed axial tomography (CAT) scan of the abdomen/pelvis assists the surgeon to decide on the feasibility of a single-incision laparoscopic approach. It also helps in identifying the exact location of large colonic or rectal neoplastic lesions, the potential involvement of adjacent organs or structures, and the potential presence of mesenteric adenopathy and/or metastases as well as inflammatory processes (phlegmon, abscess, fistula, or obstruction).

Endorectal ultrasound or rectal protocol magnetic resonance imaging (MRI) may assist with the staging of rectal carcinoma and identification of the anal sphincter muscle involvement. The latter would be a contraindication of a restorative proctocolectomy and may also delineate the anatomy of the anal sphincter in case of previous obstetric trauma or episiotomies.

Fecal incontinence—Wexner score preoperatively may assist with the diagnosis of fecal incontinence. Preoperative fecal incontinence may lead to poor functional outcome following an ileoanal pouch anastomosis.

Preoperative barium enema or small bowel follow-through contrast study may assist with the diagnosis of Crohn’s disease.

A carcinoembryonic antigen (CEA) level is obtained in malignancies as a tumor marker.

Full bowel preparation is administered the day prior to surgery to reduce the weight and volume of the colon. This facilitates the laparoscopic handling of the colon and the extraction of the specimen via a small 3.5-cm single incision.

Obtain preoperative medical or pulmonary cardiac clearance as necessary.

Correct anemia, electrolyte imbalances, and malnutrition preoperatively as needed.

Wean off preoperative steroids to preferably less than 20 mg prednisone per day, if possible.

Give consideration to weight loss prior to surgery, especially in cases of chronic preoperative steroid usage. A short and thick ileal mesentery may preclude an ileoanal pouch anastomosis.

Intravenous (IV) antibiotics are administered prior to skin incision.