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Video

Session: Ongoing Videos

VM51 - Robotic-assisted Natural-orifice IntraCorporeal anastomosis and transrectal Extraction (NICE) for Cancer: A Modified Approach with Side-to-End Anastomosis and Stapled Colotomy Closure

ONGOING VIDEOS
Location: ASCRS Connect Lounge, Hall B1/B2, Ground Level

    Video Presentation(s)

  • Mark Heimberger, MD

    Colorectal Surgery Fellow
    Stony Brook University
    Oakdale, NY, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

    • Author(s)

  • Michael H. Froehlich, MD (he/him/his)

    General Surgery Resident
    Stony Brook University Hospital
    Stony Brook University Hospital
    Stony Brook, NY, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

  • CM

    Christopher M. Mazis, MD

    General Surgery Resident
    Stony Brook University Hospital
    Yaphank, New York, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

  • DN

    Deborah Nagle, MD

    Chief, Division of Colon and Rectal Surgery
    Stony Brook University Hospital
    Stony Brook, New York, United States

    All of the relevant financial relationships listed below have been mitigated.
    Cook Medical: Clinical Trial Investigator (Ongoing); Exero: Clinical Trial Investigator (Ongoing); Intuitive: Teaching (Ongoing); Virtual Incision: Consultant (Ongoing)

    • Senior Author(s)

  • NA

    Nicholas J. Ahn, MD

    Assistant professor
    Stony Brook University Hospital
    Port Jefferson, New York, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

All of the relevant financial relationships listed below have been mitigated.
Mark Heimberger, MD: This individual has no financial relationships with ineligible companies.
Michael H. Froehlich, MD: This individual has no financial relationships with ineligible companies.
Christopher M. Mazis, MD: This individual has no financial relationships with ineligible companies.
Deborah Nagle, MD: Cook Medical: Clinical Trial Investigator (Ongoing); Exero: Clinical Trial Investigator (Ongoing); Intuitive: Teaching (Ongoing); Virtual Incision: Consultant (Ongoing)
Nicholas J. Ahn, MD: This individual has no financial relationships with ineligible companies.
Image or Table (Do Not add text here):

Purpose/Background: In this video, we demonstrate a “side-to-end” intracorporeal anastomosis during a NICE procedure for cancer. The case involves a 69-year-old male with a biopsy-proven sigmoid adenocarcinoma that was found on screening colonoscopy. Natural-orifice IntraCorporeal anastomosis and transrectal Extraction (NICE) is a novel technique in Colorectal Surgery that further minimizes post-operative pain and facilitates recovery. The described technique in the existing literature of the NICE procedure consists of an “end-to-end” anastomosis, where the anvil is hand-sutured in a purse-string fashion to secure anvil around the open lumen of the descending colon, which serves as the proximal end of the anastomosis.

Methods/Interventions: Here we present a novel variation in technique, where a side-to-end anastomosis is performed. In this variation of the procedure, the anvil is placed entirely through the lumen of the open proximal end and brought out through a colotomy along the antimesenteric border proximal to the end of the colon. The end is then closed with the robotic stapler. The anastomosis is finally completed in the standard fashion. The proximal end is brought down to the pelvis and docked with the spike, which has been brought through the rectal stump. The anastomosis is finally completed with firing of the stapler.

Results/Outcomes: This “side-to-end” technique provides advantages compared to the traditional handsewn purse-string “end-to-end” anastomotic technique. Typically, “side-to-end” anastomoses are performed in cases for diverticulitis. In patients such as this one with extensive diverticulosis of the sigmoid colon, this technique prevents any diverticula from being incorporated into the staple line by having the stapling surface along the antimesenteric side of the colon. Furthermore, we find anecdotally that this method is faster and improves operative time.

Conclusion/Discussion: Performing a NICE procedure for cancer previously provoked concern for seeding of the tumor in the rectum as it is removed transrectally. Numerous studies have shown no difference in recurrence, disease-free, or overall survival during natural orifice versus transabdominal extraction10-24. Our video highlights a double-layered technique with a flexible wound retractor and specimen bag to prevent any possible tumor seeding. We hope this video provides new insight and considerations for continued improvement in surgical and anastomotic techniques in colorectal surgery.