Surgical resection for diverticulitis using robotic natural orifice intracorporeal anastomosis and transrectal extraction approach: the NICE procedure

  • Ramon O. Minjares
  • Bertha A. Dimas
  • Shadin Ghabra
  • Jean-Paul J. LeFave
  • Eric M. HaasEmail author
Original Article


Numerous studies have confirmed significant benefits of intracorporeal anastomosis (ICA) following colorectal procedures; however technical challenges have limited this approach following conventional laparoscopic surgery. The robotic Xi platform serves as an enabling technology and has resulted in a surge of reports for right-sided ICA, however, there are no reports involving more complex left-sided procedures such as diverticulitis. Furthermore, there are no reports of natural orifice-assisted techniques using robotic Xi in which the specimen can be removed and the anvil can be placed transrectally, thereby completely eliminating the need for an abdominal wall incision other than for port sites. We present a pilot study to investigate the safety, feasibility and short-term outcomes of robotic Natural orifice-assisted IntraCorporeal anastomosis with transrectal Extraction of specimen, called the robotic NICE procedure. Consecutive patients presenting for elective resection for diverticulitis with formation of a colorectal anastomosis were entered into an IRB database. All patients underwent the robotic NICE procedure. Demographic data, intraoperative data and outcomes data were assessed and analyzed. Ten patients (five males and five females) underwent resection. The mean age and BMI were 56 years (43–66) and 29 kg/m2 (21–35). All procedures were successfully completed including transrectal extraction of the specimen and formation of an ICA. The mean operative time was 198 min (146–338) and mean EBL was 35 ml (15–50). Mean time to first flatus was 16 h (10–22) and mean length of stay was 1.9 days (1.6–2.6). There were no intraoperative or postoperative complications. There was no unexpected ICU stay, reoperation or readmission. Colorectal left-sided resections such as for diverticulitis were safely accomplished using natural orifice-assisted extraction of the specimen as well as complete intracorporeal anastomosis in this pilot study. The NICE procedure resulted in early return of bowel function, short length of stay and low complication. The complete elimination of abdominal wall incision likely accounts for these findings and larger cohorts of patients are to be investigated to explore this promising approach afforded by robotic technology.


Diverticulitis Intracorporeal anastomosis Natural orifice surgery NICE procedure Robotic colectomy Transrectal extraction of specimen 



The authors thank Colton Wiley for his contribution with data collection and analysis.

Compliance with ethical standards

Conflict of interest

The authors (Ramon O. Minjares, Bertha A. Dimas, Shadin Ghabra, Jean-Paul J. LeFave) declare that they have no conflict of interest. Eric M. Haas, MD is a consultant for Medtronic and Intuitive Surgical.


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Copyright information

© Springer-Verlag London Ltd., part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Minimally Invasive Colon and Rectal Surgery, Department of SurgeryThe University of Texas Medical School at HoustonHoustonUSA
  2. 2.Division of Colon and Rectal SurgeryHouston Methodist HospitalHoustonUSA
  3. 3.Southeast Clinical Research Associates, Inc.HoustonUSA

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