V68 - Robotic NICE J-pouch: A Natural Orifice-Assisted Approach for Completion Proctectomy and Ileal Pouch-Anal Anastomosis

CME Eligible

Purpose/Background: Ileal pouch-anal anastomosis (IPAA) is one of the most technically demanding operations in colorectal surgery. Minimally invasive approaches reduce postoperative pain and morbidity compared with open surgery. However, even when performed laparoscopically or robotically, pouch construction is often still performed extracorporeally through a separate suprapubic incision or the ileostomy site, and this decreases the benefits by necessitating a larger incision. The Natural orifice-assisted IntraCorporeal anastomosis and specimen Extraction (NICE) technique can bypass this limitation. While NICE is increasingly used for left-sided colectomy, its application in restorative proctocolectomy remains rare. We describe a robotic completion proctectomy and IPAA using the NICE approach.

Methods/Interventions: A 30-year-old female with congenital extrahepatic portosystemic shunt requiring multiple laparotomies and several other prior abdominal operations (cholecystectomy, left ovarian cystectomy, incisional hernia repair, appendectomy, and PEG-J placement for gastroparesis) underwent total abdominal colectomy with end ileostomy for medically refractory indeterminate proctocolitis in January 2025. After counseling regarding the potential for Crohn's disease and associated pouch failure risk, she elected to pursue restoration of intestinal continuity.

Following the robotic completion proctectomy, the rectum was divided at the anorectal ring and extracted transanally. The ileal J-pouch was created intracorporeally with three 60mm linear stapler firings transanally. A 25 mm EEA stapler anvil was introduced transanally and secured at the pouch apex using both an absorbable purse-string suture and endoloop. The anal cuff was closed around the stapler spike using a double purse-string technique. Perfusion was confirmed with indocyanine green angiography, and flexible endoscopy confirmed an intact, airtight anastomosis. A diverting loop ileostomy was created.

Results/Outcomes: At two months, pouchoscopy and CT with transanal contrast showed no evidence of anastomotic leak, stricture, or pouchitis. The patient recovered well and underwent ileostomy reversal at 11 weeks post-operatively.

Conclusion/Discussion: IPAA remains a technically challenging procedure, and even in laparoscopic or robotic cases, pouch construction is typically performed open. This case demonstrates the feasibility of fully intracorporeal J-pouch creation and anastomosis using the NICE approach. The natural alignment of the intra-abdominal anal opening and the pouch apex facilitates accurate reach estimation, ergonomic transanal intracorporeal stapling, and eliminates the need for an additional incision or ileostomy site enlargement for specimen extraction and pouch construction. We believe this technique broadens the spectrum of complex, minimally invasive restorative proctocolectomy and represents a meaningful advance in robotic colorectal surgery.