Robotic NICE Procedure Using Handsewn Technique

We analyzed our results with an intention-to-treat analysis including all 20 patients. Intracorporeal handsewn anastomosis was successfully accomplished in all cases (100%). Natural orifice transrectal extraction was successfully achieved in 17 of 20 patients (85%). Three patients with malignant disease required a Pfannenstiel incision because of a bulky specimen that prevented extraction through the rectum. Twenty patients underwent the NICE procedure for complicated diverticulitis (75%), colorectal cancer (15%), and deep infiltrative endometriosis of the rectum (10%). The mean age was 54 years and most patients were female (60%). The mean BMI was 30.8 kg/m 2 , and 50% of the patients were classified as ASA II and 50% as ASA III (Table 1 ). The mean operative time was 235 minutes (99–294 min) and mean estimated blood loss was 61 mL (15–200 mL). There were no intraoperative complications and no conversions. For patients with benign disease, bulky specimens necessitated intracorporeal shaving of the mesentery for safe transrectal extraction. A total of 5 patients underwent diverting loop ileostomy, all of whom underwent successful closure at a median of 9 weeks (Table 2 ). Malignant cases (15%) required an abdominal wall extraction incision because of bulky disease. The mean time to first flatus was 16.4 hours, and the mean hospital length of stay was 2.1 days (±1.05 SD). There were of 3 complications. One patient developed a deep surgical site infection, and another patient had an organ space abscess. Both patients required readmission and were treated with antibiotics alone. The third patient, who had a diverting ileostomy performed at the time of the index procedure, developed 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 (Table 3 ). Additionally, there were no reports of incontinence to gas or stool at the final postoperative follow-up. Demographic data on patients undergoing the NICE procedure and handsewn anastomosis NICE = Natural orifice IntraCorporeal anastomosis and transrectal Extraction. Intraoperative outcomes of patients undergoing the robotic NICE procedure with handsewn anastomosis NICE = Natural orifice IntraCorporeal anastomosis and transrectal Extraction. Postoperative outcomes of patients undergoing robotic NICE procedure and handsewn anastomosis NICE = Natural orifice IntraCorporeal anastomosis and transrectal Extraction; POD = postoperative day.

For benign disease, we use three 8-mm robotic ports and a 5-mm AirSeal port (Optiview, Inc., Jacksonville, FL) as depicted in Figure 1 . We do not need to use the linear stapler in these cases; therefore, we avoid not only an extraction incision but also the use of a 12-mm port, thus reducing the risk of a Richter hernia. The patient is positioned with an 8-degree left side elevation and 18 to 20 degrees of Trendelenburg, and the robot is docked. We perform a previously described lateral to medial mesenteric sparring approach. 5 , 6 In brief, we begin the dissection by incising the white line of Toldt along the left colon and exposing the paracolic gutter by retracting on the colonic mesentery. We then proceed with splenic flexure takedown when performed. We turn our attention to the pelvis and release the lateral attachments along the intersigmoid fold and then divide the right and left rectal reflection as well as the anterior reflection to release all the peritoneal attachments. We then choose our proximal line of resection and divide the colon using the vessel sealer extend with a minimal use of energy. We then perform a mesenteric sparing dissection, staying close to the bowel and preserving the superior rectal artery. Dissection is carried to the distal level of resection in the rectum, which is then transected with the vessel sealer extend. Sizers are then passed through the rectal cuff followed by placement of the small Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA) and extraction of the specimen. The retractor is then removed in preparation for the end-to-end handsewn anastomosis. Port placement. *Right lower quadrant 8-mm port in benign disease and 12-mm port in malignant disease for the use of a robotic linear stapler. For malignant disease, the port site configuration is the same as in benign disease, except that we use a 12-mm robotic port (instead of an 8-mm port) in the right lower quadrant to facilitate the use of a robotic stapler. We use the linear stapler to close and divide the specimen to avoid intra-abdominal contamination in the presence of malignant pathology. We perform a previously described medial to lateral approach with high ligation of the pedicle and oncologic lymph node dissection. 4 Following the dissection and mobilization, we use the robotic linear stapler to divide the bowel at the proximal and distal levels of resection, thereby keeping the specimen intact. We then remove the staple line along the proximal colon and rectum, extract the specimen, and prepare for the handsewn ICA. In cases in which there is a concern for trauma to the rectum because of a bulky specimen, we complete the handsewn anastomosis and thereafter extract the specimen through a Pfannenstiel incision. For the handsewn single layer end-to-end ICA, we present 2 techniques. In the first technique, we use two 6-inch and one 9-inch 3.0 V-Loc suture (V-Loc 180, Covidien, Mansfield, MA) on a v20 needle (Fig. 2 ). The first suture bite is taken in the posterior wall of the bowel in the midline, and once it is passed through the loop, a full-thickness running layer is completed in the left direction and then locked by taking a bite in the reverse direction. Similarly, the second 6-inch suture is placed in the posterior midline and a running layer is formed in the right-sided direction and then locked. The anterior wall of the anastomosis is completed by placing the 9-inch suture in the left lateral position at the level of the first locked suture and running it baseball style until the locked suture on the right is met. Any gaps are reinforced by placing interrupted 3.0 Vicryl sutures (Ethicon; Cincinnati, OH). For the second technique, only two 9-inch V-Loc sutures are used (Fig. 3 ). The first suture is placed in the posterior midline and run in a baseball style to the left. At the left lateral portion of the anastomosis, a transition bite is taken to change the direction of the suture bites to facilitate closure of the anterior wall. Once one-third of the anterior wall is closed, the second suture is secured in the posterior midline and run to the right and then transitioned along the anterior wall. The anterior portion of the anastomosis is completed by resuming the left-sided suture along the anterior layer to meet the right-sided suture. Reinforcing interrupted 3.0 Vicryl is then placed as indicated. We evaluate the integrity of the anastomosis with both direct endoscopic visualization as well as an air insufflation test. End-to-end handsewn colorectal anastomosis with 6-6-9 barbed suture technique. End-to-end handsewn colorectal anastomosis with 9-9 barbed suture technique.

We present our technique for an end-to-end handsewn colorectal anastomosis. The NICE procedure for benign and malignant disease can be successfully performed in a total intracorporeal manner without the need for any circular stapling devices. Furthermore, it obviates the need for an abdominal wall extraction incision.