The patient is placed on the operating table in the modified dorsal lithotomy position with the hips abducted 30°. A Foley catheter is inserted into the bladder. The skin from the breast to the perineal area is surgically prepared.

The abdomen is opened through a lower midline incision extended around the umbilicus. Pfannenstiel incisions are not appropriate for this operation.

The abdominal cavity should be explored, and all suspicious areas of tumor should be identified and removed for frozen section analysis.

Once the decision has been made to proceed with the operation, the peritoneum is opened along the right common iliac artery down to the external iliac artery. All lymphatic tissue is removed, with care taken to preserve the ureter. The ovarian vessels seen crossing the common iliac artery will be ligated.

The round ligament is clamped, transected, and tied at the pelvic wall. The posterior leaf of the broad ligament is opened, and the entire external iliac artery is exposed.

The lymph nodes are removed from the external iliac artery, vein, and obturator fossa. The ovarian vessels are clamped, transected, and tied. The same procedure is performed on the other side.

The hypogastric artery is cleaned of lymph node tissue. The ureter can be seen medial to the hypogastric artery crossing the common iliac artery. The obturator nerve is seen in the obturator fossa.

The obturator fossa has been cleaned of lymph nodes, and the obturator nerve has been preserved. The hypogastric artery is clamped, ligated, and incised with its branches. The same procedure is carried out on the opposite side.

The mesentery of the rectosigmoid colon is opened in an avascular area, and a rubber drain is passed through this opening as a source of traction on the colon. The peritoneum covering the mesentery is opened. Care is taken at this point to identify the left ureter because the mesentery of the rectosigmoid colon generally points to the left ureter at its base.

The colon is retracted caudad. A finger has been inserted in the opening of the mesentery under the rectosigmoid colon. The peritoneum covering the medial side of the mesentery is opened.

The vessels in the mesentery of the rectosigmoid colon have been clamped and tied with 2-0 suture.

The linear stapler has been applied to the rectosigmoid colon slightly below the sacral promontory. It is activated, transecting the rectosigmoid colon between double rows of staples.

The remaining portion of the mesentery attached to the rectum is clamped, incised, and tied with 2-0 suture.

Cephalad retraction is made on the combined specimen of the uterus and rectosigmoid colon. A hand is inserted into the presacral space to dissect the rectum from the sacrum down to the coccyx.

It is important to keep the dissecting hand in the midline to prevent evulsion of the presacral veins on the lateral margin of the sacrum. These can be a source of troublesome bleeding if lacerated.

The stalks of each side of the rectum are progressively clamped, incised, and tied with 2-0 suture. This frees the rectum from its lateral attachments.

The anterior leaf of the broad ligament is incised down and across the bladder peritoneum. The vesicoperitoneum is elevated and sutured to the skin for retraction, and the bladder is dissected off the lower uterine cervix and anterior vagina for a distance of at least 6-8 cm below the tumor level.

The uterus is retracted medially. The paravesical and pararectal spaces are dissected. Notice that in taking down the rectal stalks the posterior wall of the pararectal space has been removed. The ureter crosses the superior medial portion of the web as it enters the tunnel. The hypogastric artery and vein have been retracted medially. The external iliac artery and vein have been retracted laterally, revealing the obturator fossa and nerve.

The dissection of the ureter is carried down to the web by delicately elevating the ureter with a vein retractor. The attachments of the ureter to the web are lysed with Metzenbaum scissors. A Kelly clamp is inserted on top of the ureter underneath the tunnel toward the bladder. The dotted line indicates the incision to be made in the web adjacent to the pelvic wall.

The tunnel is taken down in successive bites and tied with 3-0 synthetic absorbable suture. When the tunnel has been completely transected, the course of the ureter can be seen all the way to the ureterosacral junction. The web is taken down in successive bites and tied with 0 suture all the way to the levator muscle.

The specimen is free of lateral attachments to the pelvic wall and, posteriorly, from the sacrum. The specimen, consisting of the uterus, its lateral attachments, rectum, and the ureterosacral and rectal stalk ligaments along with the hypogastric artery, vein, and its branches, can be elevated. The ureter is freed all the way to the bladder.

By firm cephalad traction on the specimen, the vagina has been transected with a scalpel at the level of the levator muscle. The rectum is transected below the tumor but preferably above the levator sling.

The completed operative field, the stumps of the various lateral attachments of the uterus and rectum, the dissected ureters, and the intact bladder are shown. The vaginal cuff is reefed with a 0 suture and left open. The rectum is available for reanastomosis of the descending colon.

The descending colon is mobilized. The splenocolic ligament is clamped and tied. The peritoneum lateral to the descending colon is opened along the line of Toldt to the pelvic brim.

The surgeon mobilizes the rectosigmoid and descending colon further by transecting the left colic branch of the inferior mesenteric artery. An attempt should be made to preserve as many of the branches of the inferior mesenteric artery as possible to give maximum blood supply to the descending colon at its anastomosis with the rectum. If the marginal artery of the colon is intact, however, the inferior mesenteric artery itself may be clamped and tied at the aorta to produce complete mobility of the colon. There must be no tension on the J pouch colorectal anastomosis. The marginal artery of the colon allows sacrifice of the superior hemorrhoidal and left colic branches of the inferior mesenteric artery if needed to achieve a tension-free anastomosis.

A rectal reservoir colonic J pouch has been constructed. The opening in the inferior portion of the J pouch is stapled to the rectal stump with the automatic surgical stapler (EEA stapler) inserted through the anus and activated.

The descending colon has been formed into a rectal J pouch colonic reservoir and stapled to the rectum. The vaginal cuff has been closed. The ureters have been suspended with the Sakamoto stitch.

Maximum peritonealization has been achieved.

In all radiated cases, and in any case in which there is some doubt about the healing properties of the anastomosis, a protective temporary diverting loop colostomy should be performed. This may be closed in 2-3 months, after the rectal J pouch colonic reservoir has healed.