A point on the sigmoid is selected for division, and the mesenteric border is meticulously cleared for a distance of approximately 2 cm. Active pulsations must be present in the mesentery. The cleared area must be free of diverticuli. The purse-string clamp is applied obliquely to the bowel so as to preserve the 2-cm cleared bowel proximally. This is necessary as the 2-cm zone will be enclosed within the stapler anvil and will become the upper “doughnut.” If the wall is not carefully cleaned of fat, or if too thick a turn-in is created with a purse-string suture that is placed freehand, the entire circumference of the bowel may not be brought inside the instrument. This will result in an incompetent anastomosis and leak. Accordingly the placement of the purse-string sutures and the examination of the upper and lower “doughnut” rings for intact purse-string sutures with 360 degrees of full-thickness bowel wall turn-in are most important steps with these instruments. A 00 polypropylene suture on a long, straight Keith needle is passed through the special openings in the purse-string clamp, and a purse-string suture results. A straight Kocher clamp is applied on the colon distal to the purse-string clamp and the bowel is divided in between. The rectosigmoid is retracted forward toward the symphysis as the peritoneum is incised and the rectal segment mobilized from the presacral space using mesorectal dissection (Plate 70). The posterior rectal wall is cleared of fat until at least 2 cm of only the bowel wall is exposed approximately 5 cm or more distal to the tumor. In the male and very obese patient, it is difficult to properly place the purse-string clamp and even more difficult to insert the Keith needle to complete the purse-string anastomosis. Under such circumstances, a noncrushing vascular clamp is placed across the area cleared for the anastomosis similar to that shown in Plate 80, Figures 4 & 5. A Kocher clamp secures the proximal specimen and the bowel is divided. The end of the sigmoid should be brought down to the divided end of the rectum to verify once again the adequacy of mobilization in order to avoid any chance of tension on the suture line of staples. Additional mobility may be gained by ligating and dividing the inferior mesenteric vein just below the inferior margin of the pancreas. The decision now must be made whether to perform an open sutures anastomosis as shown in Figures 8 & 9 on Plate 80 or to use the transrectal circular stapler after placing the rectal stump purse-string suture by hand in a very low anastomosis. In these cases some surgeons prefer to place the purse-string suture in the very short rectal stump from below using an anal speculum. More frequently, it is technically easier to maintain compression of the rectal wall with a right angle vascular clamp while a purse-string suture is placed in the protruding mucosa. Absorbable traction sutures can be placed to serve as stay sutures, while the purse-string suture of 00 polypropylene sutures includes both in the muscular and mucosal layers. Also this suture must be placed closeto the cut edge so as to ensure a snug approximation of the entire bowel wall about the stapling instrument when it is tied. Blunt EEA sizing instruments are passed into the open proximal bowel lumen and into the rectum to define the largest-diameter stapler possible. The assistant gently dilates the anus and inserts the circular EEA stapler from below. The remainder of the procedure is same as described in METHOD 1.