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


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.

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  1. 1.

    Grams J, Tong W, Greenstein AJ et al (2010) Comparison of intracorporeal versus extracorporeal anastomosis in laparoscopic-assisted hemicolectomy. Surg Endosc. 24(8):1886–1891 (PubMed PMID: 20112118, Epub 2010 Jan 29)

    Article  Google Scholar 

  2. 2.

    Swaid F, Sroka G, Madi H et al (2016) Totally laparoscopic versus laparoscopic-assisted left colectomy for cancer: a retrospective review. Surg Endosc. 30(6):2481–2488 (PubMed PMID: 26335075, Epub 2015 Sep 3)

    Article  Google Scholar 

  3. 3.

    Milone M, Angelini P, Berardi G et al (2018) Intracorporeal versus extracorporeal anastomosis after laparoscopic left colectomy for splenic flexure cancer: results from a multi-institutional audit on 181 consecutive patients. Surg Endosc. 32(8):3467–3473 (PubMed PMID: 29344788, Epub 2018 Jan 17)

    Article  Google Scholar 

  4. 4.

    Johnson CS, Kassir A, Marx DS, Soliman MK (2019) Performance of da Vinci Stapler during robotic-assisted right colectomy with intracorporeal anastomosis. J Robot Surg. 13(1):115–119. 2018 May 30)

    Article  PubMed  Google Scholar 

  5. 5.

    Bergamaschi R, Arnaud JP (1997) Intracorporeal colorectal anastomosis following laparoscopic left colon resection. Surg Endosc 11(8):800–801 (PubMed PMID: 9266637)

    CAS  Article  Google Scholar 

  6. 6.

    Scotton G, Contardo T, Zerbinati A, Tosato SM, Orsini C, Morpurgo E (2018) From laparoscopic right colectomy with extracorporeal anastomosis to robot-assisted intracorporeal anastomosis to totally robotic right colectomy for cancer: the Evolution of Robotic Multiquadrant Abdominal Surgery. J Laparoendosc Adv Surg Tech A. 28(10):1216–1222. 2018 Aug 17, PubMed PMID: 30117748)

    Article  PubMed  Google Scholar 

  7. 7.

    Ma B, Huang XZ, Gao P et al (2015) Laparoscopic resection with natural orifice specimen extraction versus conventional laparoscopy for colorectal disease: a meta-analysis. Int J Colorectal Dis. 30(11):1479–1488 (PubMed PMID: 26238472. Epub 2015 Aug 4)

    Article  Google Scholar 

  8. 8.

    Ricci C, Casadei R, Alagna V et al (2017) A critical and comprehensive systematic review and meta-analysis of studies comparing intracorporeal and extracorporeal anastomosis in laparoscopic right hemicolectomy. Langenbecks Arch Surg. 402(3):417–427 (PubMed PMID: 27595589, Epub 2016 Sep 5)

    Article  Google Scholar 

  9. 9.

    Shapiro R, Keler U, Segev L et al (2016) Laparoscopic right hemicolectomy with intracorporeal anastomosis: short- and long-term benefits in comparison with extracorporeal anastomosis. Surg Endosc. 30(9):3823–3829 (PubMed PMID: 26659237, Epub 2015 Dec 10)

    Article  Google Scholar 

  10. 10.

    van Oostendorp S, Elfrink A, Borstlap W et al (2017) Intracorporeal versus extracorporeal anastomosis in right hemicolectomy: a systematic review and meta-analysis. Surg Endosc. 31(1):64–77 (PubMed PMID: 27287905, Epub 2016 Jun 10)

    Article  Google Scholar 

  11. 11.

    Lujan HJ, Plasencia G, Rivera BX et al (2018) Advantages of robotic right colectomy with intracorporeal anastomosis. Surg Laparosc Endosc Percutan Tech 28(1):36–41 (PubMed PMID: 28319493)

    Article  Google Scholar 

  12. 12.

    Trastulli S, Coratti A, Guarino S et al (2015) Robotic right colectomy with intracorporeal anastomosis compared with laparoscopic right colectomy with extracorporeal and intracorporeal anastomosis: a retrospective multicentre study. Surg Endosc. 29(6):1512–1521 (PubMed PMID: 25303905, Epub 2014 Oct 11)

    Article  Google Scholar 

  13. 13.

    Morpurgo E, Contardo T, Molaro R et al (2013) Robotic-assisted intracorporeal anastomosis versus extracorporeal anastomosis in laparoscopic right hemicolectomy for cancer: a case control study. J Laparoendosc Adv Surg Tech A 23(5):414–417 (PubMed PMID: 23627922)

    Article  Google Scholar 

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

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Correspondence to Eric M. Haas.

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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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Minjares, R.O., Dimas, B.A., Ghabra, S. et al. Surgical resection for diverticulitis using robotic natural orifice intracorporeal anastomosis and transrectal extraction approach: the NICE procedure. J Robotic Surg 14, 517–523 (2020).

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