warranted. This will allow the rectal stump to be grasped with clamps and re-stapled with an open linear stapler. If it is not possible to staple across the rectal stump, there are two remaining options. The rst option is a handsewn purse string on the rectal stump. All of the staples must rst be removed. The purse string can be placed intraabdominally from an open or laparoscopic approach. With the use of a 2-0 monolament suture, a purse string is sewn in a full-thickness Connell fashion. This can be particularly challenging because of limitations of the laparoscopic instru­mentation, and because visualization from an open approach is poor at best. A sec­ond option is to place the purse string transanally. With the patient in the lithotomy position, the legs are frog-legged in the stirrups to expose the anus. The anus in then everted with Lone Star retractor. An operating anoscopy is passed into the anal canal, and the purse string is then placed in the same fashion as above. In either the transabdominal or transanal technique, the stapler is inserted into the rectum, and the spike is deployed before the purse string is cinched down. The purse string is then tied around the spike of the stapler, ensuring that the rectal wall is securely and circumferentially drawn into the stapler. The ultimate fallback for when the rectal stump cannot be salvaged is a mucosectomy with a handsewn coloanal anastomosis. This will work for all the described types of reconstruction. Once again, the patient is placed in high lithotomy position to expose the anal canal. The anal canal is everted with a Lone Star retractor. If the top of rectal stump is visible and easily accessed, the staple line is excised, and the anastomosis is created. Otherwise, a mucosal incision is made circumferentially 1–2cm above the dentate line. The sub­mucosal plane is developed and dissected in a cephalad fashion, and eventually the dissection becomes full thickness resecting the rest of the rectal stump. The idea is to preserve as much of the internal sphincter as possible. With the dissection com­pleted, the rst sutures are placed in the rectum at the 12, 3, 6, and 9 o’clock posi­tions. The sutures are placed from inside the lumen to the outside, and the needles are left on the suture. Next the proximal colon is grasped transanally and delivered into the anal canal. The sutures are then sutured to the proximal colon in an outside to inside fashion, so the knots for each suture are inside the lumen. Each quadrant is then completed with full-thickness, interrupted sutures.