Robotic NICE Procedure With Natural Orifice-Assisted Small-Bowel Resection and Anastomosis for Complicated Diverticulitis with Enterocolic Fistula

Abstract

See Video on DCR YouTube Channel at https://youtu.be/VKdcmmr0XsA We first reported on the safety and feasibility of robotic Xi technology to complete natural orifice left-sided colorectal resection with transrectal extraction of specimen and intracorporeal anastomosis (ICA) in 2018.1 We termed this the NICE (Natural orifice IntraCorporeal anastomosis with transrectal Extraction) procedure and have since developed a stepwise approach to maximize efficiency and reproducibility and offer this to all our patients presenting with diverticulitis as our standard of care. The NICE procedure has been shown to be a feasible and reproductible procedure by other groups.2 This approach obviates the need for an abdominal wall incision and any extracorporeal surgical maneuvers and is associated with numerous patient benefits.3 For those presenting with more complex diverticulitis, such as the presence of abscess, fistulizing disease, or stricture, minimally invasive approaches are associated with complications and high conversion rates due to numerous technical challenges.4 To help overcome the technical obstacles, we modified the NICE approach and offered 7 key steps to facilitate safe and efficient resection with transrectal extraction and ICA.5 Although relatively rare, up to 6% of cases of diverticulitis with fistulas involve the small bowel.4 To our knowledge, this is the first report of a total intracorporeal small-bowel resection and anastomosis performed via a transrectal approach. IMPACT OF INNOVATION In our expanding experience with total intracorporeal robotic surgery, we have found that, in addition to facilitating ICA and extraction of specimen, the rectum can also serve as a natural orifice to facilitate concomitant small-bowel resection. We present a video illustration of the NICE procedure for diverticulitis complicated by an enterocolic fistula in which small-bowel resection and anastomosis is performed in addition to the colorectal resection and ICA through the rectum. TECHNOLOGY MATERIALS AND METHODS The NICE procedure is performed for complicated diverticulitis with fistula formation to the small bowel. The routine steps of the NICE procedure have been published previously.1 We do not use ureteral stents in complex diverticulitis cases. In brief, access is gained with a 5-mm optical Airseal access port (CONMED, Utica, NY) in the right upper quadrant. The da Vinci Xi platform (Intuitive Surgical Inc, Sunnyvale, CA) is used with three 8-mm robotic ports (Fig. 1). The coloenteric fistula is identified and the omental attachments are released. In preparation for the small-bowel resection, the mesentery is divided and then the small-bowel fistula is released from the sigmoid. A suture line is placed to close the small-bowel lumen to prevent inadvertent succus leakage. A lateral-to-medial dissection is performed. The white line of Toldt is incised and the paracolic gutter is developed. Splenic flexure mobilization is routinely performed in part to mitigate any extra tension that results from a mesenteric-sparing dissection and to facilitate a complete sigmoid resection. The intersigmoid fold is released as is the lateral and anterior rectal refection to mobilize the rectum.FIGURE 1.: Robotic port placement. MCL = mid-clavicular line; SUL = spine-umbilical line.The proximal level of resection is chosen, and the bowel is divided using the Vessel Sealer Extend (Intuitive Surgical Inc). Because tactile feedback is absent, visual inspection of the bowel wall is additionally performed once divided to ensure that no stigmata of disease are present. A mesenteric-sparing division is then performed staying close to the bowel wall while preserving the superior rectal artery until the distal level of resection is reached in the upper third of the rectum. The rectum is divided, the rectal sizers are introduced to dilate the lumen followed by placement of a small Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA) in prepara