I * Optional the risk of injury of abdominal organs. With some experience, the task becomes easy and very rapid. However, in the case of previous abdominal surgery, we usually inflate the abdominal cavity using the Veress needle in the left subcostal area, in order to insert the first cannula as far lateral as possible, in the right hypochondrium, to avoid potential areas of adhesions.

As said above, the first cannula (12 mm), which is used for the optical device, is positioned on the midline 3-4 cm above the umbilicus. The two operating cannulae are introduced, one at the junction between the umbilical line and the right midclavicular line, and the other 8-10 cm inferiorly, on the same line. The latter is a 12-mm operating cannula to allow the introduction of a linear stapler at the time of bowel resection. This cannula accommodates the following: scissors (monopolar, high-frequency hemostasis device, clip, staplers), a monopolar hook, surgical loops, a suction-irrigation device, and an atraumatic grasper.

A fourth cannula is placed on the left midclavicular line, at the level of the umbilicus. This is a 5-mm cannula, which accommodates an atraumatic grasper used for retraction and exposure during the medial approach for the dissection of the left mesocolon. When performing mobilization of the splenic flexure, this cannula becomes an operating cannula. A fifth 5-mm cannula is placed 8-10 cm above the pubic bone, on the midline, and is used for retraction. For most of the procedure, it accommodates a grasper used to expose the sigmoid and descending mesocolon. At the end of the procedure, the incision at this cannula's site is lengthened to allow extraction of the specimen.

We sometimes use an additional cannula, which is a 5-mm cannula situated on the right midclavicular line in the subcostal area and accommodates an atraumatic grasper used to retract the terminal portion of the small intestine laterally at the beginning of the dissection, and to retract the transverse colon during the mobilization of the splenic flexure.

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