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The anvil is introduced transanally. A stitch is attached to the detachable plastic part of the anvil and the needle is left in place. Once the anvil is introduced in the abdominal cavity, the rectal stump can be stapled and the proximal end of the rectum sectioned is then removed in a laparoscopic bag. The proximal end of the anastomosis, in this case the small bowel for an ileorectal anastomosis, is located. An incision is made with the hook cautery in the small bowel in order to introduce the anvil. The bowel is held steadily while the anvil is introduced in the bowel. The stitch is then passed from the cautery opening to the point where the anvil is meant to come out. By pulling the stitch, the anvil is guided through the bowel until it is completely brought out. Then, the detachable plastic part is removed from the anvil and extracted through a trocar.
The viability of the small bowel can be assessed by means of indocyanine green . The distal part of the small bowel is transected, far enough from the anvil. In this case, a side to end anastomosi s was performed, therefore approximately 3 to 5 cm have been left between the anvil and the stapler line.
The stapler is then gently introduced transanally. The spike is guided out in the usual fashion and attached to the anvil. The stapler is then ready to fire ensuring the bowel is correctly oriented and tension-free.
