The NICE Procedure: Surgical Technique and Technical Considerations

Vollständiger Abstract

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Abstract The NICE (Natural orifice IntraCorporeal anastomosis with transrectal Extraction) procedure represents an evolution in minimally invasive colorectal surgery, combining robotic precision with natural orifice specimen extraction to minimize abdominal wall trauma. The technique involves mesenteric-sparing resection of the diseased segment, transrectal natural orifice specimen extraction, and creation of an end-to-end intracorporeal anastomosis, thereby eliminating the need for an abdominal extraction-site incision and avoiding the intersecting staple lines inherent to a conventional double-stapling technique. Multiple publications have demonstrated the feasibility, reproducibility, and favorable outcomes of this approach, with 100% success rates for intracorporeal anastomosis and 95 to 100% success rates for transrectal extraction in large consecutive series. The NICE procedure has become the standard of care at our institution and has been increasingly adopted by other centers. This article outlines the history, indications, and key technical steps necessary for safe and successful performance of the NICE procedure, presented in a standardized, stepwise manner to provide surgeons with a reproducible and practical framework for adopting the technique in the management of diverticular disease. Foundational principles include mesenteric-sparing resection with division above the superior rectal artery, systematic mobilization of the pararectal and anterior rectal reflections to straighten and elongate the rectum, and protection of the rectal cuff during extraction using an Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA). An end-to-end anastomosis is preferred to avoid intersecting staple lines and is achieved through purse-string suture placement on the proximal colon and secure closure of the rectal cuff. In select cases involving thickened mesentery from chronic diverticular disease, a mesenteric-shaving technique may be used to permit safe extraction of a bulky specimen. Compared with conventional minimally invasive approaches that require a mini-laparotomy extraction site, the NICE procedure is associated with an earlier return of bowel function, a shorter length of stay, reduced postoperative pain and opioid consumption, and fewer wound-related complications, without an increase in operative time or overall complication rates.