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Feb 25, 2021|IntraCorporeal

Robotic natural-orifice IntraCorporeal anastomosis with Extraction (NICE procedure) for complicated diverticulitis

Abstract

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/m2. 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.

First described in laparoscopic surgery over 25 years ago [1, 2], colorectal resection with intracorporeal anastomosis (ICA) and transrectal extraction of specimen (TRSE) has not gained significant traction. Early experience revealed numerous patient benefits including less postoperative pain, less opioid utilization, faster recovery, lower complication rates and greatly reduced hernia rates compared to conventional laparoscopy [3,4,5]. Yet it is estimated that this approach is offered to fewer than 1% patients presenting for a left-sided colorectal resection, primarily due to technical barriers [6].

Enabling technologies such as the robotic platform, as well as a continued push toward total intracorporeal surgery has resulted in a resurgence of intertest. Robotic right sided procedures with ICA for instance have been gaining widespread adaptation [7] but eliminating the extraction incision altogether for procedures involving the left colon has yet to be examined in earnest. 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].

We have since expanded our utilization of the robotic NICE procedure to more technically challenging cases involving complicated diverticulitis. These procedures are known to involve an inflammatory process with thickened mesentery, distorted pelvic anatomy, obliterated tissue planes and high conversion rates [9,10,11]. As such, modifications and refinements of the technique are necessary to successfully complete the NICE approach.

This study and video describe and illustrate key steps, surgical maneuvers and modifications that we have adopted over the course of consecutive cases to safely and successfully complete the NICE procedure for complicated diverticulitis. This stepwise approach affords reproducibility and consistency to help overcome the technical challenges.

Methods

Case videos were recorded on a secure and encrypted server and under IRB protocol. All procedures were performed utilizing the da Vinci Xi platform (Intuitive Surgical, Sunnyvale, CA, USA). From June 2018 to May 2020, a total of 134 consecutive elective surgical resections with primary anastomosis for diverticulitis was performed. This study consists of the subset of 60 of these patients who presented with complicated diverticulitis defined as the presence of a fistula, stricture and/or abscess at the time of surgery. The presence of abscess was confirmed in all cases with positive intraoperative cultures. Preoperative workup included confirmatory imaging as well as colonoscopy within the appropriate timeframe to confirm the presence of diverticular disease and ensure the absence of colorectal cancer or other pathology. The procedures were performed by an experienced board-certified colorectal surgeon (EMH) in one of two institutions in Texas Medical Center (Houston Methodist Hospital and Baylor St Luke’s Medical Center in Houston, Texas).

Study variables and outcome measures

Demographic data included age, gender, BMI, and American Society of Anesthesiologists (ASA) classification. Disease and operative data included diagnosis, surgical procedure, operative time, estimated blood loss (EBL), number and size of ports, splenic flexure takedown, type of anastomosis, completion of ICA, completion of transrectal extraction of specimen, and intraoperative complications. Data were collected from the electronic medical records, recorded and entered into a study protocol approved by the internal review board (IRB) (study protocol 00012111). Data were reported as frequencies (percentages) for categorical data and mean (standard deviation) and range, for continuous data. A Chi-square test, or Fisher’s exact test, as appropriate, were used for analysis of categorical data and independent t-test was used for continuous data. All comparisons were two sided, and statistical significance was defined as p < 0.05. All analysis was performed with SPSS version 26 (IBM Corp. Armonk, NY, USA).

Video recordings

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.

Briefly, the NICE procedure was performed with the patient placed in 18–22 degrees of Trendelenburg with 8 degrees of right tilt (left side elevation) (Fig. 1). We begin the procedure with optical entry (Optiview, Inc., Jacksonville, FL, USA) in the right upper quadrant (RUQ) and exchange with a 5 mm AirSeal® (ConMed Corporation, Utica, NY, USA). This RUQ access facilitates tissue retraction, suction and passing sutures by the bedside assistant. We then place the following ports: 8 mm robotic port in the right lower quadrant (RLQ), 8 mm robotic port in the umbilicus, and an 8 mm robotic port in the left upper quadrant (LUQ). The robotic boom is positioned over the left hip and robotic arm number 2 is docked to the LUQ port for use of a fenestrated bipolar, robotic arm 3 at the umbilicus for the camera, and robotic arm 4 in the RLQ for the Vessel Sealer Extend (VSE) (Intuitive Surgical Inc., Sunnyvale, CA, USA) and exchanged for the curved monopolar scissors or needle driver throughout the procedure (Fig. 2). In some cases, a 4th robotic arm is required for deep pelvic exposure and is placed in the left lower or upper quadrant for the Cadiere forceps.

figure1   figure2

We draw attention to the sigmoid colon and begin dissection in a lateral to medial fashion along the white line of Toldt in a cranial direction along the left colon. As a standard, we proceed with splenic flexure takedown by dividing the splenocolic ligament and entering the lesser sac. We then turn our attention to the area of disease in the pelvis and release the bowel from the peritoneal adhesions along the pelvic side wall. When present we then enter into the abscess cavity and drain it and/or release the fistula from its point of origin to the bladder, uterus or vagina by dropping down the disease. In preparation for the transrectal extraction, we release the left and right lateral rectal reflection as well as the anterior refection.

We turn our attention to the proposed proximal resection margin at the level of the left and sigmoid colon and develop a window in the mesentery. Mesenteric-sparing division is achieved without entering the retroperitoneum and preserving the superior rectal artery. Using the VSE in combination with the fenestrated bipolar, we divide the mesentery close to the bowel in a cranial to caudal direction until the upper third of the rectum is reached. The bowel is divided at the proximal and distal levels of resection using the VSE along with the suction nearby to aspirate any leakage of stool contents.

In preparation of the natural-orifice steps of the procedure, as assistant surgeon uses a NICE back table as shown in Fig. 3. A small sized Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) is clamped with a Kocher, lubricated and carefully inserted transanally and expands across the divided rectal wall. The rectal lumen is then dilated with a medium and large circular sizer (Fig. 4).

doctor operation equipment's   Operation Theater View

A long ring forceps is then inserted through the Alexis and grasps the divided edge of the specimen for extraction. For large specimens with a bulky mesentery, trauma during the extraction process is mitigated by thinning the specimen prior to extraction. The monopolar scissors are used to release the mesentery along the length of the bowel in a linear fashion while under traction (Fig. 5). The specimen is then extracted transrectally (Figs. 6, 7).

Operation Theater View  Operation Theater View  Diverticulitis robotic surgery Houston

In preparation for the ICA, the Alexis is inverted and removed, and the circular stapler device is introduced transrectally. The anvil is detached and then it is secured to left colon with a pursestring suture consisting of 6-inch, 3.0 barbed suture on a V20 needle (V-Loc 180™, Covidien; Mansfield, MA, USA). In the event that bowel contents have leaked from the open colon during the extraction process, the area is locally irrigated and aspirated until clear. The rectal cuff is closed around the spike of the stapler with a second pursestring suture to facilitate the colorectal anastomosis. We routinely use Firefly® (Intuitive Surgical Inc., Sunnyvale, CA, USA) perfusion assessment prior to performing the anastomosis. In cases in which the distal transection is in the lower rectum, the robotic stapler is used to close the rectal cuff.

Postoperative management

All patients received enhanced recovery pathways (ERAS) postoperatively, consisting of early ambulation, education and counseling, early feeding and multimodal opioid-sparing pain control recovery.

Results

Of a total of 134 consecutive cases of diverticulitis, 60 (44.8%) presented with complicated disease and were evaluated in this study. Half (50%) of the cohort were female and nearly half (46.7%) of the patients were ASA III. The mean age was 58.9 years old (range 22–84) and the mean BMI was 30.7 kg/m2 (range 19–37.6). Half (50%) of the cohort had a BMI ≥ 30 kg/m2 (n = 30), and 25% had a BMI ≥ 35 kg/m2 (n = 15). Thirty-two (53.3%) patients had a history of prior abdominal surgery. Complicated diverticulitis was defined as the presence of a fistula with or without abscess in 35 patients (58%), abscess cavity alone in 18 cases (30%), and stricture with or without fistula or abscess in 7 patients (12%). A comparison of the demographic features among patients presenting with complicated and uncomplicated disease is summarized in Table 1.

The mean operative time was longer in the complicated diverticulitis cohort, 231.6 ± 75.0 vs 194.9 ± 53.7 min (p = 0.004). In the complicated diverticulitis cohort, the mean estimated blood loss was 59.2 ml (range 10–250) and one patient required intraoperative blood transfusion. A 5 mm accessory assistant port was utilized in all cases. In 65.5% of the cases, we utilized three 8 mm ports and in 34.5% we utilized a fourth robotic 8 mm port. We replaced the right lower quadrant 8 mm port with a 12 mm port in 8 cases (13.3%) for use of the robotic stapler.

In the complicated diverticulitis cohort, all cases (100%) were achieved with ICA using a circular stapling device. The anvil was secured with a pursestring suture and an endoloop to the proximal colon in all cases (100%). In 86.7% of the cases, the rectal cuff was closed with pursestring suture and an anastomosis was formed without any crossing staple lines. In 13.3% of cases, the distal resection was in the low rectum and the rectal cuff was closed with the robotic stapler in preparation for the anastomosis. All but one patient (98.3%) had successful transrectal extraction of the specimen. This patient presented with near-obstructing disease in which we could not definitively rule out malignancy prior to surgery and therefore did not opt for transrectal extraction. Forty-four (73%) of the specimens required a specimen-thinning maneuver, consisting of shaving the mesentery from the colon wall to successfully extract the specimen. Splenic flexure takedown was performed in all but one patient (98.3%). A diverting loop ileostomy was created in 11 (18%) patients, all of whom had perforating disease with the presence of an abscess. There were three cases in which we identified a partial-thickness tear along the anterior wall of the rectum after the transrectal extraction of the specimen. In each case, we repaired it without complication or diversion. There were no conversions. The remaining intraoperative outcomes were similar across cohort and are outlined in Table 2.

In our assessment, we identified seven technical modifications and considerations to facilitate successful completion of the NICE procedure in the background of complicated diverticulitis. The first is to detach the most inflamed portions of the disease in a lateral to medial fashion from the attachments to the lateral pelvic peritoneum and any viscus without entering the retroperitoneum. The second is to divide the mesentery close to the bowel to minimize exposure to retroperitoneal structures and preserve the superior rectal artery. The third is to use the bipolar and Vessel Sealer Extend™ (VSE) in concert to control bleeding while dividing the thickened and chalky mesentery. The fourth is to release the lateral rectal and anterior peritoneal reflection to straighten and lengthen the rectum in preparation for the natural-orifice portions of the procedure. The fifth is to prepare a NICE back table with routine use of the rectal sizers to dilate the rectum and the sixth is to assess and thin the specimen when necessary by shaving the mesentery from the surface of the bowel prior to extraction (Table 3). The final important consideration concerns closing the rectal cuff. We prefer a pursestring closure to avoid crossing staple lines; however, if the cuff is low and wide, we opt for the robotic linear stapler for closure. The steps and considerations are featured in the accompanying video.

In our assessment, we identified seven technical modifications and considerations to facilitate successful completion of the NICE procedure in the background of complicated diverticulitis. The first is to detach the most inflamed portions of the disease in a lateral to medial fashion from the attachments to the lateral pelvic peritoneum and any viscus without entering the retroperitoneum. The second is to divide the mesentery close to the bowel to minimize exposure to retroperitoneal structures and preserve the superior rectal artery. The third is to use the bipolar and Vessel Sealer Extend™ (VSE) in concert to control bleeding while dividing the thickened and chalky mesentery. The fourth is to release the lateral rectal and anterior peritoneal reflection to straighten and lengthen the rectum in preparation for the natural-orifice portions of the procedure. The fifth is to prepare a NICE back table with routine use of the rectal sizers to dilate the rectum and the sixth is to assess and thin the specimen when necessary by shaving the mesentery from the surface of the bowel prior to extraction (Table 3). The final important consideration concerns closing the rectal cuff. We prefer a pursestring closure to avoid crossing staple lines; however, if the cuff is low and wide, we opt for the robotic linear stapler for closure. The steps and considerations are featured in the accompanying video.

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Funding

The authors received no financial support or funding for this work.

Author information

Affiliations

  1. Houston Colon PLLC, Houston, TX, USA

    Eric M. Haas, Thais Reif de Paula, Roberto Luna-Saracho, Melissa Sara Smith & Jean-Paul J. LeFave

  2. Division of Colon and Rectal Surgery, Houston Methodist Hospital, 6560 Fannin Street, Suite #1404, Houston, TX, 77030, USA

    Eric M. Haas & Jean-Paul J. LeFave

  3. Department of Biomedical Sciences, University of Houston, Houston, TX, USA

    Eric M. Haas, Thais Reif de Paula & Roberto Luna-Saracho

Corresponding author

Correspondence to Eric M. Haas.

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Disclosures

Eric M Haas is a consultant for Intuitive Surgical, Medtronic and Ethicon Endosurgical. Thais Reif de Paula, Roberto Luna-Saracho, Melissa S Smith, Jean-Paul LeFave have no conflicts of interest or financial ties to disclose.

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Accepted for Podium Presentation, Best Papers Session, SAGES 2020, Cleveland, OH, August 12–15.

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