Undoubtedly, the wound is more conspicuous; however, issues related to cosmesis clearly remain secondary to the

ultimate successful outcome of performing a complex operation with a small incision, which remains “dwarfed” by the size of the patient’s girth.

Most importantly, the lateral aspects of the dissection are then undertaken using the planes developed anterior and pos­terior to guide the dissection. The lateral mobilization of the mesorectum often remains underestimated and arguably rep­resents the most challenging plane to demonstrate due to the redundancy of the lateral tissues. The retroperitoneal adipose tissues displace the mesorectal plane and diminish efforts for appropriate traction and countertraction. The tendency is to dissect more laterally, which oncologically is not necessarily worse; however, such dissection brings into play the branches of the hypogastric artery and anterolaterally the nervi erigen­tes in a male and the uterine vessels in a female. For obvious reasons, this lateral dissection can prove consequential and potentially disastrous. As we know, the appropriate plane gen­erally is bloodless. Nuisance bleeding suggests imprecise dis­section and continued dissection will prove humbling. If this occurs, you should stop and redirect your dissection to another area to fi nd the right plane (e.g., if bleeding occurs while dis­secting anterior to posterior in the lateral aspect, change to posterior to anterior or vice versa). Dissection to the pelvic fl oor and into the hiatus should be confi rmed by performing intraoperative digital rectal exam and palpating circumferen­tially. Overall, the pelvic dissection in an obese patient and especially an obese male with a narrow pelvis represents one of the truly most diffi cult operations. This demands patience, persistence, meticulous method, and capable and experienced assistants. The reward remains a bloodless fi eld, an intact anal anastomosis and sphincter preservation.