Robotic natural-orifice IntraCorporeal anastomosis with Extraction (NICE procedure) for 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. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00464-021-08350-z.