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Robotic port placement of a 5 mm accessory port in the right upper quadrant and additional 8- or 12-mm robotic ports
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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, t...
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Citations
... In 2018, we reported the successful utilization of the da Vinci Xi technology to facilitate left-sided colorectal resection with transrectal extraction of specimen and intracorporeal anastomosis which we termed the robotic NICE procedure [11,12]. We have since refined our technique and offer this approach as our standard for left-sided resection of both benign and malignant disease. ...
... The surgical technique of Lap EAS and robotic NICE have been described in prior work [11][12][13][14]. In Lap EAS cases, a Pfannenstiel incision is made to extract the specimen and the anvil to the circular stapler (Ethicon, Inc., Somerville, NJ) is secured in an extracorporeal fashion to the proximal colon in preparation for the anastomosis. ...
... In 2018 we first reported the successful application of da Vinci Xi robotic platform to perform left-sided colorectal resections using natural orifice total intracorporeal surgery and termed it the NICE procedure [11,12]. We have since reported high success rates regardless of patient characteristics such as high BMI [26] or disease process such as complicated diverticulitis with abscess and fistula [27]. ...
Introduction
We introduced the robotic NICE procedure for left-sided colorectal resection in 2018 in which the entire procedure is performed without loss of pneumoperitoneum and without an abdominal wall incision by performing natural orifice-assisted transrectal extraction of the specimen and intracorporeal anastomosis. We compare the results of the NICE procedure versus conventional laparoscopic resection, which was our standard approach prior to 2018.
Methods
A matched pair case–control study compared patients following the NICE procedure versus those who underwent laparoscopic left-sided colorectal resection with conventional extracorporeal-assisted technique. Cases were performed at an Academic Medical Center and recorded in a prospective database to analyze perioperative outcomes.
Results
From a total cohort of 352 patients, 83 were matched in each group. When comparing the NICE procedure vs. the Extracorporeal-Assisted laparoscopic group, there were no significant differences in age (58.5 vs. 59.3 years old), sex (47 vs. 42 Female), body mass index (27.4 vs. 27.5 kg/m²), ASA, diagnosis, or type of surgery. Operative time (198.8 vs. 197.7 min), blood loss (56.0 vs. 53.3 ml), intraoperative complications (0.0% vs. 0.0%), and conversion rates (0.0% vs. 0.0%) were similar in both groups. The NICE procedure was associated with significantly earlier return of bowel function (40.7 vs. 23.6 h), shorter length of stay (3.1 vs. 2.2 days), and lower total opioid use (94.6 vs. 70.5 morphine milligram equivalents). Overall, there were no differences in postoperative abscess formation, complications, readmission, or reoperation rates.
Conclusion
When compared to conventional laparoscopic resection, the NICE procedure is associated with short-term benefits including earlier recovery and less opioid use without increased operative time or increased risk of complications. Multicenter studies are recommended to validate benefits and limitations of this technique.
... on the mesentery and may result in postoperative trauma and impaired bowel motility. [10][11][12] The surgical results of IA and EA methods in right colectomy have been extensively compared in many randomized and non-randomized studies. IA demonstrated significantly better cumulative results for the following outcome parameters: overall complications, time to first bowel movement, postoperative pain, length of incision, surgical site infection, anastomotic leak, conversion rate, and incisional hernia. ...
The primary aim was to investigate the operative outcomes of intracorporeal (IA) and extracorporeal (EA) anastomosis in left-sided minimally-invasive colectomy.
A comprehensive literature search was conducted for studies comparing operative outcomes and follow-up data of IA versus EA in minimally-invasive left colectomy. Studies that investigated recto-sigmoid resections using transanal circular staplers were excluded. Data from eligible studies were extracted, qualitatively assessed, and included in a meta-analysis. Odds ratios (ORs) and mean differences with 95 per cent confidence intervals were calculated.
Eight studies with a total of 750 patients were included (IA n = 335 versus EA n = 415). IA was associated with significantly lower overall morbidity (OR 0.40, 95% CI 0.26–0.61, p < 0.0001) and less frequent surgical site infection (SSI) (OR 0.27, 95% CI 0.12–0.61, p = 0.002) as primary outcomes compared to EA. Of the secondary outcomes, length of incision (SMD -2.51, 95% CI -4.21 to -0.81, p = 0.004), time to first oral diet intake (SMD -0.49, 95% CI -0.76 to -0.22, p = 0. 0004) and time to first bowel movement (SMD -0.40, 95% CI -0.71 to -0.09, p = 0.01) were significantly in favor of IA, while operative time was significantly shorter in the EA group (SMD 0.36, 95% CI 0.14–0.59, p = 0.001).
IA proves to be a safe and feasible option as it demonstrates benefits in terms of lower overall morbidity, fewer rates of SSI, smaller incision length, and faster postoperative gastrointestinal recovery despite a longer operative time compared to EA.
... The NICE procedure is a natural orifice left-sided colorectal resection utilizing the rectum to extract the specimen and complete an intracorporal anastomosis utilizing robotic Xi platform. Following early experience, we reported a stepwise approach [14,15] and refined technique to facilitate widespread utilization in unselected patients with more complex disease presentation, as complicated diverticulitis [16]. ...
... The DaVinci Xi® platform (Intuitive Surgical, Sunnyvale, CA, USA) was utilized in all surgical procedures. The robotic NICE procedure stepwise technique for diverticulitis was described in previous work [14,16]. Briefly, the key steps include lateral to medial dissection of left/sigmoid colon, release of the lateral and anterior reflection of the rectum, division of the bowel at the proximal and distal margin of resection and mesenteric-sparing division with preservation of the superior rectal artery. ...
... In 2018, we first published successful completion of leftsided colectomy for benign and malignant disease with natural orifice transrectal extraction and ICA using robotic Xi technology [14]. We then developed a stepwise technique to facilitate an efficient and reproducible approach that could be offered to consecutive unselected patients [16]. ...
Introduction
We implemented the NICE procedure as a robotic natural orifice colorectal resection utilizing the rectum to extract the specimen and complete an intracorporal anastomosis for diverticulitis in 2018. Although complicated diverticulitis is associated with higher rates of conversion and post-operative morbidity, we hypothesized that the stepwise approach of the NICE procedure can be equally successful in this cohort. We aimed to compare feasibility and outcomes of the NICE procedure for uncomplicated and complicated diverticulitis.
Methods
Consecutive patients presenting with diverticulitis who underwent robotic NICE procedure from May 2018 through June 2021 were included. Cases were stratified into uncomplicated and complicated diverticulitis (fistula, abscess, or stricture). Demographic, clinical, disease, intervention, and outcomes data were analyzed. The main outcome measures were return of bowel function, length of stay, opioid consumption, and postoperative complications.
Results
Of a total of 190 patients, those presenting with uncomplicated diverticulitis (53.2%) were compared to those with complicated diverticulitis (47.8%). Uncomplicated diverticulitis had fewer low anterior resections (15.8% vs 49.4%; p < 0.001) and shorter median operative time (186 vs 220 min; p < 0.001). Both cohorts had equal rates of successful intracorporeal anastomosis (100%) and successful transrectal extraction (100% vs 98.9%; p = 0.285). Both cohorts had similar return of bowel function (median 21 h and 18.5; p = 0.149), median length of hospital stay (2 days, p = 0.015) and mean total opioid use (68.4 MME vs 67.3; p = 0.91). There were also no significant differences in overall postoperative complication rate over a 30-day time period (8.9% vs 12.5%; p = 0.44), readmission (6.9% vs 5.6%; p = 0.578) and reoperation (3% vs 4.5%; p = 0.578).
Conclusion
Despite being inherently more complex and technically challenging, complicated diverticulitis patients have similar success rates and post-operative outcomes compared to uncomplicated diverticulitis patients when undergoing the NICE procedure. These results implicate the benefits of robotic natural orifice techniques may be even more pronounced in complicated diverticulitis patients.
... In 2018, we reported on the successful utilization of the Robotic Xi technology to facilitate left-sided colorectal resection with transrectal extraction of specimen and intracorporeal anastomosis which we termed the Robotic NICE procedure [11,12]. The robotic platform helps overcome many of the challenges of this total intracorporeal approach and we have since optimized this technique and developed a reproducible stepwise procedure [13]. ...
... Once placed, the patient is positioned with 8-degree left side elevation and 18-20 degrees of Trendelenburg and the robot is docked. A lateral to medial mesenteric sparing approach is performed [11,13]. The dissection commences by incising the white line of Toldt along the left colon and exposing the paracolic gutter by retracting on the colonic mesentery. ...
... In spite of the enthusiasm with natural orifice techniques in left-sided colorectal resections, adaptation has been limited chiefly due to technical barriers and there has been a general consensus that these procedures should be reserved for selected patients only [20,21]. In 2018 we published the first report describing the application of daVinci Xi® robotic technology for this natural orifice total intracorporeal surgery and termed it the NICE Procedure [11,12]. We thereafter developed a stepwise technique with ten defined steps to facilitate reproducible results in an expanded patient population [13]. ...
Background:
The Robotic NICE procedure is a total intracorporeal natural orifice approach in which specimen extraction and anastomosis is accomplished without an abdominal wall incision other than the port sites themselves. We aim to present the success rate of the NICE procedure in a large cohort of unselected consecutive patients presenting with colorectal disease using a stepwise and reproducible robotic approach.
Methods:
Consecutive patients who presented with benign or malignant disease requiring left-sided colorectal resection and anastomosis between May 2018 and June 2021 were evaluated. Data abstracted included demographic, clinical data, disease features, intervention data, and outcomes data. The main outcome was success rate of Intracorporeal anastomosis (ICA), transrectal extraction of specimen (TRSE), and conversion rate.
Results:
A total of 306 patients underwent NICE procedure. Diverticulitis was the main diagnosis (64%) followed by colorectal neoplasm (27%). Median operative time was 219 min, and the median estimated blood loss was 50 ml. ICA was achieved in all cases (100%). TRSE was successfully achieved in 95.4% of cases. In 14 patients (4.6%), an abdominal incision was required due to inability to extract a bulky specimen through the rectum. There overall postoperative complications rate was 12.4%. Eight patients (2.6%) experienced postoperative ileus. There were no superficial or deep surgical site infection (SSI). Eleven patients (3.6%) developed organ SSI space including 5 patients with intra-abdominal abscess and 4 patients with anastomotic leak. There was one mortality (0.3%) due to toxic megacolon from resistant Clostridium difficile. The 30-day reoperation rate was 2.9% (n = 9) including six patients presenting with organ space SSI and three patients with postoperative obstruction at the diverting loop ileostomy site.
Conclusion:
The NICE procedure is associated with a very high success rate for both intracorporeal anastomosis and transrectal specimen extraction in a large cohort of unselected patients.
... To date, most left-sided anastomoses are performed at least partially extracorporeally, placing the anvil into the bowel through an extraction site. This is potentially limiting as it can place tension on the mesentery of the bowel which has been hypothesized to increase the rate of postoperative ileus [1,6] and may also potentially increase the need for the surgeon to further mobilize the bowel to exteriorize. It also potentially alters the incision pattern that the surgeon would use for the procedure as the extraction site needs to be reached easily by the left colon. ...
... Further pilot studies have discussed robotic techniques for left-sided colorectal disease, including a case series describing robotic sigmoidectomy for diverticulitis that included robotic total ICA using the da Vinci Xi robotic platform [6]. This study demonstrated feasible technique with robotic total ICA with short post-operative LOS and minimal postoperative complications [6]. ...
... Further pilot studies have discussed robotic techniques for left-sided colorectal disease, including a case series describing robotic sigmoidectomy for diverticulitis that included robotic total ICA using the da Vinci Xi robotic platform [6]. This study demonstrated feasible technique with robotic total ICA with short post-operative LOS and minimal postoperative complications [6]. Although this study introduced the concept of the robotic left total ICA, it is limited by the small number of cases. ...
Background
Although there is extensive literature on robotic total intracorporeal anastomosis (TICA) for right colon resection, left total ICA using the da Vinci Xi robotic platform has only been described in short case series previously. In this study, we report on the largest cohort of robotic left total ICA, provide a description of our institution’s techniques, and compare outcomes to robotic left partial extracorporeal anastomosis (PECA).
Methods
Patients who underwent robotic left colectomy for any underlying pathology from July 1, 2016 through April 30, 2020 were identified by procedure code. A technical description is provided for two unique techniques performed at our institution. Outcomes included operative time, length of stay, supply cost, post-operative ileus, post-operative morbidity and mortality and need for complete mobilization of the splenic flexure.
Results
From a review of our institution’s data, 83 robotic TICA cases were identified and 76 robotic PECA cases were identified. Common procedures included low anterior resection, sigmoidectomy, left hemicolectomy, and rectopexy with resection. TICA was associated with significantly shorter intraoperative time compared to PECA.
Conclusions
Our series shows that TICA is a safe and feasible technique that does not increase the risk of adverse outcomes. Using either the anvil-forward or anvil-backward technique, we were able to reliably reproduce this method in a total of 83 patients undergoing left colon resection for either benign or malignant diseases.
... We first reported on the feasibility of robotic natural-orifice ICA with transrectal extraction of the specimen for left colectomy in 2018 and termed it the NICE procedure [6]. Thereafter we reported a stepwise technique to afford a reproducible and consistent approach [8]. ...
... The procedures were recorded and analyzed. The defined steps of the NICE procedure have been previously described [6,8]. Surgical maneuvers and modifications specifically addressing complicated diverticulitis are additionally described below. ...
... Enabling technologies, such as the robotic platform and modernized instrumentation, along with the strive for even less invasive approaches has led to a resurgence of interest [6]. We reported our initial experience using robotic technology and developed a stepwise approach that we named the NICE procedure [6,8]. We have since expanded this approach to more challenging procedures such as complicated diverticulitis. ...
Background
Totally intracorporeal surgery for left-sided resection carries numerous potential advantages by avoiding crossing staple lines and eliminating the need for an abdominal incision. For those with complicated diverticulitis, minimally invasive surgery is known to be technically challenging due to inflamed tissue, distorted pelvic anatomy, and obliterated tissue planes, resulting in high conversion rates. We aim to illustrate the stepwise approach and modifications required to successful complete the robotic Natural-orifice IntraCorporeal anastomosis with transrectal specimen Extraction (NICE) procedure in this cohort.
Methods
Consecutive, elective, unselected patients presenting with complicated diverticulitis defined as fistula, abscess and stricture underwent the NICE procedure over a 24-month period. Demographic and intraoperative data were collected, and video recordings were reviewed and edited on encrypted server.
Results
A total of 60 patients (50% female) underwent the NICE procedure for complicated diverticulitis with a mean age of 58.9 years and mean BMI of 30.7 kg/m ² . The mean operative time was 231.6 min. All cases (100%) were achieved with intracorporeal anastomosis using a circular stapling device. All but one patient (98.3%) had successful transrectal extraction of the specimen. Forty-four (73%) of the specimens required a specimen-thinning maneuver to successfully extract the specimen and there were no conversions. We identified seven key technical modifications and considerations to facilitate successful completion of the procedure which are illustrated, including early release of the disease, mesentery-sparing dissection, dual instrument control of the mesenteric vasculature, release of the rectal reflection, use of NICE back table, specimen-thinning maneuver, and closure of the rectal cuff.
Conclusion
We present a stepwise approach with key modifications to successfully achieve totally robotic intracorporeal resection for those presenting with complicated diverticulitis. This approach may help overcome the technical challenges and provide a foundation for reproducible results.
... [1][2][3] More recently we developed a stepwise approach for left-sided ICA with the added benefit of natural orifice transrectal extraction of specimen called the NICE procedure. 4,5 After completion of more than 200 NICE procedures, we aim to apply robotic intracorporeal, as well as natural, orifice techniques to successfully perform total intracorporeal restorative proctectomy with ileal pouch-anal anastomosis (RP with IPAA). ...
Background:
In 2018, we described a robotic natural orifice assisted left-sided colorectal resection with intracorporeal anastomosis and transrectal extraction of the specimen and termed it the NICE procedure. More recently, we have explored the feasibility, safety, and utility of performing total handsewn intracorporeal anastomosis without the use of a circular stapler device. Our aim is to present a technical video and initial experience depicting the unique steps to accomplish the NICE procedure with colorectal end to end handsewn anastomosis.
Technique materials and methods:
We performed 20 NICE procedures with end-to-end handsewn intracorporeal anastomosis. A video depicting the essential steps with two variations of the handsewn techniques is presented along with the short-term outcomes.
Results:
The most common indication for NICE procedure was complicated diverticulitis followed by rectal cancer and deep infiltrative endometriosis of the rectum. The mean operative time was 235 minutes (99-294 min) and there were no intraoperative complications or conversions. Handsewn end to end intracorporeal anastomosis was successful in all patients. Natural orifice transrectal extraction was successful in 17 of 20 (85%) patients. The mean postoperative length of stay was 2.1 days (± 1.05 SD). There was a total of three major complications. One patient developed a deep surgical site infection, and another patient had an organ space abscess. Both required readmission and were treated with antibiotics alone. One patient, who had a diverting ileostomy performed at the time of the index procedure, developed a subclinical dehiscence of the anastomosis which healed without intervention but resulted in a delay in ileostomy reversal. There were no additional readmissions and no reoperations or mortalities.
Conclusion:
Robotic NICE Procedure and colorectal end to end handsewn anastomosis is feasible and safe in this initial series. This technique can be successfully performed in a total intracorporeal fashion without the need for an abdominal wall extraction incision or any circular stapling devices.
Aim
A sigmoidectomy is the most definitive surgical treatment for recurrent diverticulitis. While it is usually accomplished via transabdominal specimen extraction and stapled anastomosis, the robotic platform can facilitate novel approaches and techniques. This is the first report of the initial experience with robotic sigmoidectomy with natural orifice specimen extraction and hand‐sewn anastomosis (NOSHA).
Methods
A prospectively maintained database of NOSHA procedures performed between 2018 and 2020 was retrospectively examined. The technique was described and variables across preoperative, intraoperative, and postoperative timeframes were presented. The Clavien‐Dindo (CD) classification system was used to describe postoperative complications.
Results
Sixteen patients with recurrent diverticulitis treated with NOSHA were included in this study. Trans‐anal specimen extraction and an intracorporeal hand‐sewn anastomosis was achieved in all patients. However, two patients (12.8%) required specimen de‐bulking prior to extraction. The mean operating time and was 171.7 minutes, and patients had a return of bowel function within an average period of 35.2 hours. The mean hospital length of stay was 2.9 days. In total two (12.8%) complications were seen; one postoperative ileus managed conservatively and one readmission due to abdominal pain which resolved without intervention. No anastomotic leaks or reoperations were observed.
Conclusion
Robotic NOSHA appears to be a viable technique for the surgical management of diverticulitis. Further studies are needed to establish its utility for various diseases and its reproducibility across clinical practices.
Natural orifice-assisted colorectal resection serves the advantage of utilizing the rectum for extraction of the specimen and facilitates a total intracorporeal anastomosis. This technique carries many patient benefits resulting from eliminating the need for an extraction incision including decreased surgical site infection rate and reduced pain and hernia risk. Although first described over 25 years ago, it is estimated that less than 1% of laparoscopic procedures are accomplished in this fashion. Recently, there has been much enthusiasm using the enabling technologies afforded by the robotic platform. We present a stepwise approach to perform Natural orifice Intra-Corporeal anastomosis with Extraction – the NICE procedure – for benign disease requiring a left-sided colorectal resection.
