The use of modern 5mm optics with high-definition cameras and powerful light sources is much more comfortable in performing advanced laparoscopic procedures, though a 3mm optic inserted through an ancillary port may be meanwhile useful if the 5mm port is to be used for a larger instrument such as the clip applier. As for smaller instruments, they may show a weaker grasping capability and a lack of tensile strength due to increased flexibility, particularly in the presence of fibrosis or inflammation. Manipulation of tiny laparoscopic instruments may result in an increased risk of tissue damage during dissection [16, 74, 76�C79]. Apart from these precautions, moving from standard laparoscopic technique to needlescopic colorectal resections is not to be considered as approaching a new technique but simply an adaptation of a well-established practice and does not require a long learning curve.

None of the steps of the operation has shown difficulties resulting from the use of miniaturized instruments. A good exposition of the surgical field has been always achieved during vessel ligation and viscera dissection, transection, and anastomosis. Building on the experience gained from needlescopic procedures such as cholecystectomy and appendectomy, we decided not to give up the greater definition provided by 5mm scopes, since the 3mm optics are still less performant for more advanced and complex procedures. The 3mm grasper has been shown to provide good traction, also during gentle dissection.

We used a simple trick to overcome its aforementioned limits: a wad of gauze held within the jaws of the instrument itself was used for lifting and retracting viscera in order to increase its strength and decrease the risk of injury of other organs. One aspect that has been reconsidered performing needlescopic colorectal surgery is the position of trocars: we thought it would be logical to incorporate the only 12mm port that must necessarily be placed for the introduction of the stapler in the minilaparotomy which is generally a transverse suprapubic incision; we therefore started introducing the stapler from a suprapubic port not only for low rectal resection but also to transect the upper rectum and transverse colon. The use of the stapler from the suprapubic port did not result in substantial differences in bowel transection.

Nevertheless, performing an intracorporeal side-to-side mechanical ileocolic anastomosis from the suprapubic port requires wider mobilization of the transverse colon in order to place it parallel to the stapler. Approximation and orientation of the ileal and colonic stumps is best achieved by pulling on two stitches placed at each end of the anastomosis, Batimastat the proximal one being held by the 3mm grasper in the right hypochondrium and the distal one passing through the 12mm suprapubic port.