A laparoscopic TSME can be considered in many, but not all, patients. Patients with certain comorbidities, such as extreme obesity or severe pulmonary dysfunction, may not tolerate prolonged Trendelenburg positioning and/or insufation, as can be seen intraoperatively by high airway pressures or CO choose to partially mitigate these concerns by using lower insufation pressures (such as 10–12mmHg instead of the standard 15), but this may still be insufcient. Another option is to perform only the splenic exure mobilization laparoscopically, which typically uses reverse Trendelenburg positioning, and then completing the pelvic dissection via a Pfannenstiel or lower midline incision. In addition to these patient factors, there are also tumor characteristics that may make a laparoscopic approach more challenging: a large, bulky tumor or presence of a colonic stent can prevent adequate retraction and visualization. Occasionally, adding another assist port can help, but not always. Additionally, presence of a perforated tumor or involved radial margins may require dissection outside the standard TME planes. This can result in a bloodier eld, impeding laparoscopic visualization. Further, ensuring a negative radial margin in the setting of extreme brosis, such as after an intense radiation reaction, reoperative surgery, or previous perforation, can be dif­cult without direct tactile feedback. However, except for patient intolerance of laparoscopy, the cases listed above are relative contraindications and highly depend on the skill of the individual surgeon.