LAUSR

BACKGROUND In 2018, we described a robotic natural orifice assisted left-sided colorectal resection with intracorporeal anastomosis and transrectal extraction of the specimen and termed it the NICE procedure. More recently, we have explored the feasibility, safety, and utility of performing total handsewn intracorporeal anastomosis without the use of a circular stapler device. Our aim is to present a technical video and initial experience depicting the unique steps to accomplish the NICE procedure with colorectal end to end handsewn anastomosis. TECHNIQUE MATERIALS AND METHODS We performed 20 NICE procedures with end-to-end handsewn intracorporeal anastomosis. A video depicting the essential steps with two variations of the handsewn techniques is presented along with the short-term outcomes. RESULTS The most common indication for NICE procedure was complicated diverticulitis followed by rectal cancer and deep infiltrative endometriosis of the rectum. The mean operative time was 235 minutes (99-294 min) and there were no intraoperative complications or conversions. Handsewn end to end intracorporeal anastomosis was successful in all patients. Natural orifice transrectal extraction was successful in 17 of 20 (85%) patients. The mean postoperative length of stay was 2.1 days (± 1.05 SD). There was a total of three major complications. One patient developed a deep surgical site infection, and another patient had an organ space abscess. Both required readmission and were treated with antibiotics alone. One patient, who had a diverting ileostomy performed at the time of the index procedure, developed a 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. CONCLUSION Robotic NICE Procedure and colorectal end to end handsewn anastomosis is feasible and safe in this initial series. This technique can be successfully performed in a total intracorporeal fashion without the need for an abdominal wall extraction incision or any circular stapling devices.