Review of robotics in foregut and bariatric surgery

Comparing the Efficacy of Robotic Versus Laparoscopic Sleeve Gastrectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has emerged as the predominant metabolic bariatric surgery. With a growing number of studies evaluating the feasibility of robotic sleeve gastrectomy (RSG), it becomes imperative to ascertain whether the outcomes of both techniques are comparable. This study endeavors to synthesize existing evidence and juxtapose the surgical outcomes of LSG and RSG.

METHODS

We collected articles comparing LSG and RSG published between 2011 and 2024. The compiled data included author names, study duration, sample size, average age, gender distribution, geographical location, preoperative body mass index (BMI), bougie diameter, duration of hospitalization, surgical duration, readmission rates, conversion rates, costs, postoperative percentage of excess weight loss (%EWL), postoperative BMI, mortality rates, and complications.

RESULTS

We incorporated 21 articles. Both the RSG and LSG cohorts exhibited comparable rates of readmission, conversion, mortality, and incidence of complications (p > 0.05). Moreover, the efficacy of weight loss was similar between RSG and LSG. Nonetheless, RSG was linked to longer operative duration (WMD, -27.50 minutes; 95% confidence interval [CI], -28.82 to -26.18; p < 0.0001), prolonged hospitalization (WMD, -0.15 days; 95% CI, -0.25 to -0.04; p = 0.006), and elevated expenses (WMD, -5830.9 dollars; 95% CI, -8075.98 to -3585.81; p < 0.0001).

CONCLUSIONS

While both RSG and LSG demonstrated positive postoperative clinical outcomes, RSG patients experienced extended hospital stays, longer operative times, and increased hospitalization costs compared to LSG patients. Using the robotic platform for sleeve gastrectomy (SG) in patients with obesity did not appear to offer any clear benefits.

A Retrospective Analysis of Short-Term Outcomes of Robotic and Laparoscopic Cholecystectomy: An Indian Tertiary Care Comparative Experience

Background There has been a gradual adoption of general surgery robotic programs in India. However, we still do not have a single comparative study reporting the initial experience of robotic cholecystectomy (RC) compared to laparoscopic cholecystectomy (LC). This retrospective study is aimed at addressing this clinical data gap. Methods This is a retrospective medical chart review where data related to patient demographics, and intraoperative and postoperative outcomes were collected. All patients underwent either RC or LC for gallstone disease, performed by a single surgeon from January 2020 to September 2023. The surgeon had passed the learning curve for RC and this data collection reflects his post-learning curve experience. Results A total of 100 cases (RC: 50; LC: 50) were collected. Baseline parameters such as age, sex, BMI, and comorbidities were comparable. There were no conversions from the planned procedure in either of the groups (0% vs 0%). There were no intraoperative complications such as bleeding or common bile duct injury (0% vs 0%). The rates of surgical site infections (SSIs) were numerically lower in the robotic group, 2% vs 6% (p = 0.3099). There were no postoperative complications in the robotic group, whereas one patient in the laparoscopic group experienced port side bleeding (0% vs 2%, p = 0.3173). The mean length of hospital stay was one day in both groups. The mean pain score 24- hours after the surgery was 1.78 ± 0.68 in the robotic group and 3.3 ± 1.2 in the laparoscopic group (p = <0.001). None of the patients required opioid analgesics in the robotic group, whereas 20% of patients in the laparoscopic group needed at least one dose of opioid analgesics (p = 0.0009). There were no reoperations reported in the robotic group, whereas the laparoscopic group reported 1 case. The 30-day mortality was nil in both groups. Conclusion RC is feasible in Indian settings. Compared to LC, it does not increase morbidity. The improvement in acute postoperative pain can potentially allow early ambulation and recovery. A larger multicentric study, comparing RC to LC in India will validate our initial experience.

Robotics vs Laparoscopy in Foregut Surgery: Systematic Review and Meta-Analysis Analyzing Hiatal Hernia Repair and Heller Myotomy

BACKGROUND

Laparoscopic surgery remains the mainstay of treating foregut pathologies. Several studies have shown improved outcomes with the robotic approach. A systematic review and meta-analysis comparing outcomes of robotic and laparoscopic hiatal hernia repairs (HHR) and Heller myotomy (HM) repairs is needed.

STUDY DESIGN

PubMed, EMBASE, and SCOPUS databases were searched for studies published between January 2010 and November 2022. The risk of bias was assessed using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions tool. Assessed outcomes included intra- and postoperative outcomes. We pooled the dichotomous data using the Mantel-Haenszel random-effects model to report odds ratio (OR) and 95% CIs and continuous data to report mean difference and 95% CIs.

RESULTS

Twenty-two comparative studies enrolling 196,339 patients were included. Thirteen (13,426 robotic and 168,335 laparoscopic patients) studies assessed HHR outcomes, whereas 9 (2,384 robotic and 12,225 laparoscopic patients) assessed HM outcomes. Robotic HHR had a nonsignificantly shorter length of hospital stay (LOS) (mean difference -0.41, 95% CI -0.87 to -0.05), fewer conversions to open (OR 0.22, 95% CI 0.03 to 1.49), and lower morbidity rates (OR 0.76, 95% CI 0.47 to 1.23). Robotic HM led to significantly fewer esophageal perforations (OR 0.36, 95% CI 0.15 to 0.83), reinterventions (OR 0.18, 95% CI 0.07 to 0.47) a nonsignificantly shorter LOS (mean difference -0.31, 95% CI -0.62 to 0.00). Both robotic HM and HHR had significantly longer operative times.

CONCLUSIONS

Laparoscopic and robotic HHR and HM repairs have similar safety profiles and perioperative outcomes. Randomized controlled trials are warranted to compare the 2 methods, given the low-to-moderate quality of included studies.

Primary Robotic Versus Conventional Laparoscopic Roux-en-Y Gastric Bypass in Morbidly Obese Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Robotic Roux-en-Y gastric bypass (RRYGB) and conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) are commonly performed as primary bariatric procedures. The aim of this article was to assess the role of RRYGB in patients undergoing primary bariatric procedures.

METHODS

All of the qualified studies were selected from the PubMed, Embase, and Web of Science databases, etc. We mainly compared the outcomes and safety between RRYGB and LRYGB. The outcomes evaluation included surgical effect and surgical safety.

RESULT

In total, 35 studies containing 426,463 patients were selected. The mortalities of patients adopting these 2 bariatric procedures were similar (RRYGB: 59/28,023, 0.21%; LRYGB: 612/397,945, 0.15%). We found no significant difference between RRYGB and LRYGB in the incidence of postoperative complications (30-day: OR=1.06, P =0.18; 1-y: OR=1.06, P =0.92). The incidence of 30-day readmission after the operation was higher in RRYGB patients (OR=1.24, P =0.003). However, we found that the RRYGB group had a lower incidence of anastomotic stricture 1 year after the operation when compared with LRYGB (OR=0.35, P =0.0004). The 1-year %EBMIL of these 2 groups was similar (78.53% vs. 76.02%). There was no significant difference in length of hospital stay (LOS) (WMD=-0.03d, P =0.59), conversion rate (OR=0.84, P =0.75), or anastomotic leak (OR=1.00, P =0.99) between these 2 groups. The mean hospital charges were higher in the RRYGB group ($11234.75 vs. $9468.58).

CONCLUSION

This systematic review and meta-analysis showed no significant advantage of RRYGB in surgical effect or reduction of intraoperative complications. RRYGB may reduce the incidence of some postoperative long-term complications. The mean hospital charges of RRYGB were higher.

Impact of Intraoperative Nefopam on Postoperative Pain, Opioid Use, and Recovery Quality with Parietal Pain Block in Single-Port Robotic Cholecystectomy: A Prospective Randomized Controlled Trial

Background and Objectives: This study explored how nefopam, a non-opioid analgesic in a multimodal regimen, impacts postoperative pain, opioid use, and recovery quality in single-port robot-assisted laparoscopic cholecystectomy (RALC) patients with a parietal pain block, addressing challenges in postoperative pain management. Materials and Methods: Forty patients scheduled for elective single-port RALC were enrolled and randomized to receive either nefopam or normal saline intravenously. Parietal pain relief was provided through a rectus sheath block (RSB). Postoperative pain was assessed using a numeric rating scale (NRS) in the right upper quadrant (RUQ) of the abdomen, at the umbilicus, and at the shoulder. Opioid consumption and recovery quality, measured using the QoR-15K questionnaire, were also recorded. Results: The 40 patients had a mean age of 48.3 years and an average body mass index (BMI) of 26.2 kg/m2. There were no significant differences in the pre- or intraoperative variables between groups. Patients receiving nefopam reported significantly lower RUQ pain scores compared to the controls, while the umbilicus and shoulder pain scores were similar. Rescue fentanyl requirements were lower in the nefopam group in both the PACU and ward. The QoR-15K questionnaire scores for nausea and vomiting were better in the nefopam group, but the overall recovery quality scores were comparable between the groups. Conclusions: Nefopam reduces RUQ pain and opioid use post-single-port RALC with a parietal pain block without markedly boosting RSB's effect on umbilicus or shoulder pain. It may also better manage postoperative nausea and vomiting, underscoring its role in analgesia strategies for this surgery.

Perceptions of theatre team members to robotic assisted surgery and the aid of technology in colorectal surgery

The implementation of robotic assisted surgery (RAS) has brought in a change to the perception and roles of theatre staff, as well as the dynamics of the operative environment and team. This study aims to identify and describe current perceptions of theatre staff in the context of RAS. 12 semi-structured interviews were conducted in a tertiary level university hospital, where RAS is utilised in selected elective settings. Interviews were conducted by an experienced research nurse to staff of the colorectal department operating theatre (nursing, surgical and anaesthetics) with some experience in operating within open, laparoscopic and RAS surgical settings. Thematic analysis on all interviews was performed, with formation of preliminary themes. Respondents all discussed advantages of all modes of operating. All respondents appreciated the benefits of minimally invasive surgery, in the reduced physiological insult to patients. However, interviewees remarked on the current perceived limitations of RAS in terms of logistics. Some voiced apprehension and anxieties about the safety if an operation needs to be converted to open. An overarching theme with participants of all levels and backgrounds was the 'Teamwork' and the concept of the [robotic] team. The physical differences of RAS changes the traditional methods of communication, with the loss of face-to-face contact and the physical 'separation' of the surgeon from the rest of the operating team impacting theatre dynamics. It is vital to understand the staff cultures, concerns and perception to the use of this relatively new technology in colorectal surgery.

Robotic Magnetic Sphincter Augmentation Device Removal

Although most patients with reflux can be managed with medical therapy, some require surgical intervention to manage their disease. Newer technologies, such as magnetic sphincter augmentation (MSA), have been promoted as the replacement of fundoplication. However, as time has elapsed, our institution noticed the need for the removal of MSA devices. Although a few reports have described MSA device removals, we provide a deeper explanation of how to perform a robotic device removal. Our article describes the technical steps and includes a video to demonstrate how to complete the surgery robotically.

Use of targeted educational resources to improve robotic bariatric surgery training

BACKGROUND

Evidence for how to best train surgical residents for robotic bariatric procedures is lacking. We developed targeted educational resources to promote progression on the robotic bariatric learning curve. This study aimed to characterize the effect of resources on resident participation in robotic bariatric procedures.

METHODS

Performance metrics from the da Vinci Surgical System were retrospectively reviewed for sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cases involving general surgery trainees with a single robotic bariatric surgeon. Pictorial case guides and narrated operative videos were developed for these procedures and disseminated to trainees. Percent active control time (%ACT)-amount of trainee console time spent in active instrument manipulations over total active time from both consoles-was the primary outcome measure following dissemination. One-way ANOVA, Student's t-tests, and Pearson correlations were applied.

RESULTS

From September 2020 to July 2021, 50 cases (54% SG, 46% RYGB) involving 14 unique trainees (PGY1-PGY5) were included. From November 2021 to May 2022 following dissemination, 29 cases (34% SG, 66% RYGB) involving 8 unique trainees were included. Mean %ACT significantly increased across most trainee groups following resource distribution: 21% versus 38% for PGY3s (p = 0.087), 32% versus 45% for PGY4s (p = 0.0009), and 38% versus 57% for PGY5s (p = 0.0015) and remained significant when stratified by case type. Progressive trainee %ACT was not associated with total active time for SG cases before or after intervention (pre r = - 0.0019, p = 0.9; post r = - 0.039, p = 0.9). It was moderately positively associated with total active time for RYGB cases before dissemination (r = 0.46, p = 0.027) but lost this association following intervention (r = 0.16, p = 0.5).

CONCLUSION

Use of targeted educational resources promoted increases in trainee participation in robotic bariatric procedures with more time spent actively operating at the console. As educators continue to develop robotic training curricula, efforts should include high-quality resource development for other sub-specialty procedures. Future work will examine the impact of increased trainee participation on clinical and patient outcomes.

Systematic review: robot-assisted versus conventional laparoscopic multiport cholecystectomy

Laparoscopic cholecystectomy has become the standard of care for the treatment of symptomatic gallstone disease. In the context of the increasing uptake of robotic surgery, robotic cholecystectomy has seen a substantial growth over the past decades. Despite this, a formal assessment of the evidence for this practice remains elusive and a randomised controlled trial is yet to be performed. This paper reviews the evidence to date for robotic multiport cholecystectomy compared to conventional multiport cholecystectomy. This systematic review was performed conducted using the Medline, Embase and Cochrane databases; in line with the PRISMA guideline. All articles that compared robotic and conventional laparoscopic cholecystectomy were included. The studies were assessed with regards to operative outcomes, postoperative recovery and complications. Fourteen studies were included, describing a total of 3002 patients. There was no difference in operative blood loss, complication rates, incidence of bile duct injury or length of hospital stay between the robotic and laparoscopic groups. The operative time for robotic cholecystectomy was longer, whereas the risk of conversion to open surgery was lower. There was marked variation in definitions of measured outcomes, and most studies lacked data on training and quality assessment, leading to substantial heterogeneity of the data. Available evidence on multiport robotic cholecystectomy compared to conventional laparoscopic cholecystectomy is scarce and the quality of the available studies is generally poor. Results suggest longer operating time for robotic cholecystectomy, although many studies included the learning curve period. Postoperative recovery and complications were similar in both groups.

Introducing the E100: will the improvement make a significant difference? Financial analysis based on sleeve gastrectomy

Robotic-assisted surgery has been shown to offer significant benefits for both patients and surgeons. However, the high cost of the equipment remains a major barrier to its widespread adoption in the medical field. To ensure cost-effectiveness of these procedures, it is important to implement strategies that can help reduce the costs involved. One potential strategy to reduce costs is to compare the performance of different generators used in these procedures. In this study, we compared the performance of two generators: the E100 (Intuitive Surgical, Inc.) and the ERBE VIO dV 2.0 (Elektromedizin GmbH). The analysis focused on several key metrics, including the number of times the generators were activated, the average time per seal, total sealing time, and console time. The financial impact of transitioning to the E100 was also evaluated based on annual volume. We analyzed a total of 1457 sleeve gastrectomies, with 746 performed using the ERBE generator and 711 performed using the E100. There were no significant differences in preoperative BMI or bleeding complication rates between the two groups. The average activation of the generator per case was similar in both groups. However, the sealing time was 42.3% lower, and the average console time was 8 min shorter in cases where the E100 was used. Based on our financial analysis, transitioning to the E100 generator would result in cost savings of approximately $33-$34 K per year. This suggests that introducing the new generator is a successful strategy for reducing costs associated with robotic-assisted procedures.

Defining benchmarks for fellowship training in foregut surgery: a 10-year review of fellowship council index cases

INTRODUCTION

Surgical treatment of foregut disease is a complex field that demands advanced expertise to ensure favorable outcomes for patients. To address the growing need for foregut surgeons, leaders within several national societies have become interested in developing a foregut fellowship. The aim of this study was to develop data-driven benchmarks that will aid in defining appropriate accreditation criteria for these fellowships.

METHODS

We obtained case log data for Fellowship Council fellows trained from 2009-2019. We identified 78 complex foregut (non-bariatric) case codes and divided them into 5 index case categories including (1) hiatal/paraoesophageal hernia repair, (2) fundoplication, (3) esophageal myotomy, (4) major organ resection, and (5) minor organ resection. Median volumes in each index category were compared over time using Kruskall-Wallis tests. The share of cases done using open, laparoscopic, or robotic approaches were analyzed using linear regression analysis.

RESULTS

For the 10 years analyzed, 1362 fellows logged 82,889 operations and 111,799 endoscopies. Median foregut cases per fellow grew significantly from 42 (IQR = 24-74) cases in 2010 to 69 (IQR = 33-106) cases in 2019. Median endoscopy volumes also grew significantly from 42 (IQR = 7-88) in 2010 to 69 (IQR 32-123) in 2019.The volume of hiatal/paraoesophageal hernia repairs increased significantly over time while volumes in the remaining 4 index categories remained stable. The share of robotic cases exhibited near perfect linear growth from 2.2% of all foregut cases in 2010 to 14.4% in 2019 (R = 0.99, p < 0.0001). Open cases exhibited linear decay from 7.2% of cases in 2010 to 4.7% of cases in 2019 (R = 0.92, p = 0.0001). Laparoscopic/thoracoscopic cases also exhibited linear decay from 90.6% of cases in 2010 to 80.9% of cases in 2019 (R = 0.98, p < 0.00001).

CONCLUSIONS

FC fellows are exposed to robust volumes of foregut cases. This rich data set provides an evidence-based guide for establishing criteria for potential foregut fellowships.

Is development in bariatric surgery in Germany compatible with international standards? A review of 16 years of data

Bariatric surgery has expanded tremendously internationally over the past decade. In recent years, bariatric surgery has experienced a significant growth in Germany. However, the question arises as to whether this development is in line with international developments or whether there is still room for improvement that could be challenged. 63,990 primary bariatric procedures recorded in the German Bariatric Surgery Registry (GBSR) were analyzed from 2005 to April 2021. The distribution of procedures according to different variants was analyzed and presented. In the last 16 years, 17 different procedures have been performed. The most common surgical procedure was sleeve gastrectomy (SG), followed by Roux-Y gastric bypass (RYGB) (42%). Adjustable gastric banding (AGB) has declined over time, from 23.5% in the first 5 years to 0.2% in recent years. In comparison, omega-loop gastric bypass has increased over the past 5 years (from 0.4% in the first 5 years to 5.9% in the last 5 years). Laparoscopic procedures have accounted for 96.4% of all bariatric surgeries in recent years. The frequency of some procedures has decreased and some bariatric procedures have lost significance. Overall, bariatric surgery in Germany has developed positively compared to the international trend. Nevertheless, there is one area that needs to be optimized: the development of robotic bariatric surgery, which crawls behind in Germany compared to other countries. To establish the technology in bariatric surgery in a timely manner, a balance must be found between cost neutrality and patient-oriented applications.

Impact of Robotic Approach on Post-Anastomotic Leaks After Esophagectomy for Esophageal Cancer

INTRODUCTION

Although mortality rates after esophagectomy have decreased over the last 30 years, anastomotic leaks still commonly persist and portend significant morbidity. Previous studies have analyzed patient and perio-perative risk factors for leaks, yet data describing the association of leaks and an open or minimally invasive approach are lacking. The purpose of this study was to evaluate the impact of operative approach on leak rates and subsequent management of the leaks.

METHODS

We queried the Procedure-Targeted National Surgical Quality Improvement Program Database for patients undergoing esophagectomy for cancer in the years from 2016 to 2019. Patient demographics, disease-related information, peri-operative data, and short-term outcomes were reviewed. Multivariable, stepwise logistic regression analysis was performed to investigate factors associated with post-operative anastomotic leaks.

RESULTS

Of the 2696 patients who underwent esophagectomy for cancer, anastomotic leaks occurred in 374 (14%). Based on approach, 13% of open, 14% of laparoscopic, and 18% of robotic cases were complicated by leak (P = .123). Multivariable analysis identified the following significant risk factors for leak: diabetes (OR 1.32, P = .047), hypertension (OR 1.32, P = .022), and longer operative time (OR 1.61, P < .001). The percentage of leaks requiring endoscopic or operative intervention was 75% for open, 79% for laparoscopic, and 54% for robotic cases (P = .004).

CONCLUSIONS

Anastomotic leaks after esophagectomy for cancer occur frequently regardless of surgical approach. Furthermore, these leaks are managed differently after an open, laparoscopic, or robotic approach. Robotic esophagectomies complicated by anastomotic leak required less invasive management.

Heller myotomy perforation: robotic visualization decreases perforation rate and revisional surgery is a perforation risk

Minimally invasive surgery (MIS) has improved surgical access to the foregut. While the benefits of MIS versus open surgery are well accepted, the relative benefits of laparoscopic versus robotic approaches continue to be debated. Procedure-specific comparisons are difficult to obtain for Heller myotomy, due to the relative rarity of the procedure in most practices. A retrospective review of prospectively collected perioperative data of a single surgical practice from 2001 to 2019 was conducted for the rate of perforation during Heller myotomy laparoscopically compared to robotically. From 2001 through February 2012, a laparoscopic approach was employed and from October 2008 to 2019, a robotic approach was employed. All perforations were recorded, as well as secondary outcomes of perforation location (gastric or esophageal), postoperative imaging for evidence of leak, length of stay, and complications. Chi-square and simple t test were employed for data analysis. During the 11 years of laparoscopic Heller myotomy, 14 cases resulted in 7 instances of perforation (50%). During the 11 years of robotic Heller myotomy, 45 cases resulted in 11 instances of perforation (24%) (p value = 0.06). All perforations in both groups were tiny, recognized, and repaired immediately. The length of stay (LOS) was longer in the laparoscopic perforation group (3.4 days) compared to the laparoscopic non-perforation group (1.2 days) (p value = 0.06). LOS for robotic was not significantly longer in the perforation group (2.8 days) compared to the robotic non-perforation group (1.5 days) (p value = 0.18). First time Heller myotomies showed a higher rate of perforation with laparoscopic (50%) vs robotic (14%) (p value = 0.009) approach. In subgroup analysis of revisional procedures, all ten were performed robotically (p value < 0.001) with a 60% perforation rate (p value = 0.001) and one associated, radiographically confirmed leak. Primary laparoscopic Heller myotomy related to more than four times the frequency of perforation than did primary robotic myotomy. We propose that the robotic platform provided the surgeon with superior ability to avoid perforation. Interestingly, the robotic group in this study dealt with more complex redo cases. In fact, reoperation in the area of the hiatus was a separate risk factor for perforation during robotic Heller myotomy. We recommend further prospective trials be done to better evaluate the benefits of robotic platform in regard to revisional foregut surgery.

Robot-assisted hiatal hernia repair demonstrates favorable short-term outcomes compared to laparoscopic hiatal hernia repair

BACKGROUND

We postulated that the use of robotics may improve outcomes in hiatal hernia repair.

METHODS

We performed a retrospective analysis of a prospectively collected Society of Thoracic Surgery database at a single institution of patients who underwent elective hiatal hernia repair from 2012 to 2017 using either laparoscopy or the da Vinci Xi robot. We compared patient characteristics and outcomes and then performed univariate and multivariate logistic regression modeling to determine the factors associated with postoperative morbidity.

RESULTS

There were 293 consecutive patients who underwent elective hiatal hernia repair using either a laparoscopic (n = 151) or a robotic (n = 142) technique. There were no significant differences in age, gender, BMI, smoking history, presence of comorbidity, or hiatal hernia type. Seventy percent of the cases were a repair of either type III or type IV hiatal hernia. There were significantly higher ASA III and IV (7.9% vs. 4.2%, P = 0.03), higher Toupet fundoplication (83.4% vs. 44.4%, P < 0.001), and lower redo-repair (7.3% vs. 20.4%, P = 0.001) in the laparoscopic group compared to the robotic group. The hospital length of stay was significantly shorter (1.3 ± 1.8 vs. 1.8 ± 1.5 days, P = 0.003) and there were significantly lower rates of complications (6.3 vs. 19.2%, P = 0.001) after robotic compared to laparoscopic hiatal hernia repair. There was no difference in readmission rate and mortality. Multiple logistic regression analysis showed that older age and laparoscopic technique were associated with higher complications after surgery.

CONCLUSION

The use of the Da Vinci Xi robot in our institution was associated with improved outcomes compared to laparoscopic hiatal hernia repair despite a higher incidence of re-operative cases in the robotic group. Thus, short-term outcomes of Da Vinci Xi robot-assisted hiatal hernia repair are not inferior to laparoscopic hiatal hernia repair. Further studies are needed to determine if Da Vinci Xi robot provides superior short-term and long-term outcome in treatment of symptomatic hiatal hernia.

First Experience with the Use of "Micro Hand S" Surgical Robot in Sleeve Gastrectomy

Background: The Chinese minimally invasive surgical robot system "Micro Hand S" was developed in 2013. However, there was no bariatric surgery performed with the "Micro Hand S" surgical robot. We first aim to report our experience with the "Micro Hand S" robotic-assisted sleeve gastrectomy and evaluate the safety and feasibility of the "Micro Hand S" surgical robot. Methods: Between March 2018 and November 2019, sleeve gastrectomies were performed with the "Micro Hand S" robotic system on 7 consecutive patients by a trained surgeon-assistant team. Preoperative, intraoperative, and postoperative clinical data were collected. A questionnaire was used to investigate surgeons' satisfaction with the "Micro Hand S" robot platform. Results: All the patients underwent successful operations. There were no cases of perioperative mortality and complications. The intraoperative blood loss was 20.8 ± 3.6 mL. The average overall operating time was 166.4 ± 16.1 minutes. The weight, body mass index, waist circumference, and hip circumference decreased significantly at 3 months (all P < .01) and 6 months (all P < .01) postoperatively. The percentage excess weight loss was 62.6% ± 10.3% and 85.9% ± 13.3% at 3 and 6 months postoperatively. Surgeons were satisfied with the "Micro Hand S" surgical robot performance in sleeve gastrectomy. Eighty percent of surgeons would incline to use it again. Conclusions: The first use of the "Micro Hand S" robotic surgical platform in sleeve gastrectomy was carried out successfully. The perioperative outcomes are satisfying. Further comparative and large-sample studies are warranted to verify our preliminary outcomes.

Feasibility and safety of robot-assisted bariatric conversions and revisions

BACKGROUND

Conversions and revisions after bariatric procedures are inevitable and associated with longer operative time and higher complication rates. Because robot-assisted procedures allow better dissection, robotic conversions and revisions may be more beneficial to the patients than laparoscopic ones.

OBJECTIVES

This study aimed to compare the feasibility and safety of robot-assisted conversions and revisions to laparoscopic procedures.

SETTING

Academic Hospital, United States.

METHODS

A retrospective chart review was performed on 94 consecutive patients who underwent a bariatric conversion or revision (revision of gastrojejunostomy, conversions of vertical sleeve gastrectomy to Roux-en-Y gastric bypass, adjustable gastric banding to sleeve gastrectomy, Roux-en-Y gastric bypass to sleeve gastrectomy, adjustable gastric banding to Roux-en-Y gastric bypass, Roux-en-Y gastric bypass to duodenal switch, and adjustable gastric banding to duodenal switch) between January 1, 2017, and February 28, 2019. Of these, 30 underwent a robot-assisted conversion or revision.

RESULTS

Patients who underwent a robot-assisted approach were more likely to be older (45.4-versus 38.8-yr old) and lighter (44.6 versus 50.3 kg/m²) than patients who underwent a laparoscopic approach. The mean operative time was longer in the robot-assisted group (155.5 min) than in the laparoscopic group (113.3 min). No difference was observed between the 2 groups in the mean length of hospital stay, 30-day readmission rate, or 30-day reoperation rate. Results were similar when the baseline difference in age and body mass index were accounted for.

CONCLUSIONS

Robot-assisted conversions and revisions were as feasible and safe as laparoscopic procedures. However, operative time was longer in robot-assisted conversions.

Comparative analysis of robotic versus laparoscopic revisional bariatric surgery: perioperative outcomes from the MBSAQIP database

BACKGROUND

There are limited data evaluating the role of robotics in revisional bariatric surgery (RBS) compared with laparoscopy.

OBJECTIVE

The purpose of this study was to compare perioperative outcomes of laparoscopic and robotic RBS.

SETTING

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

METHODS

The 2015 to 2017 MBSAQIP database was queried for patients undergoing revisional robotic and laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Multivariate logistic regression was used to compare outcomes between robotic and laparoscopic approaches, adjusting for demographic characteristics, co-morbidities, and operative time.

RESULTS

A total of 17,012 patients underwent revisional SG with 15,935 (93.7%) laparoscopic and 1077 (6.3%) robotic, and 12,442 patients underwent revisional RYGB with 11,212 (90.1%) laparoscopic and 1230 (9.9%) robotic. Overall morbidity was higher in robotic SG compared with laparoscopic SG (6.7% versus 4.5%; adjusted odds ratio 1.51; P < .01) which was not the case after adjustment for operative time. Robotic RYGB was associated with comparable overall morbidity to laparoscopic (9.3% versus 11.6%; adjusted odds ratio .83; P = .07) although respiratory complications, pneumonia, superficial surgical site infections, and postoperative bleeding were lower with robotic RYGB. The robotic approach with both procedures was associated with longer operative time (P < .01). Length of stay was longer in the robotic group for SG (P < .01) but was not different for RYGB (P = .91).

CONCLUSIONS

Robotic RBS has an increased complication profile compared with the laparoscopic approach for SG and decreased for RYGB. Further analysis is needed regarding variability in surgeon technique and operative experience to determine what factors contribute to these differences.

Initial Experience With a New Robotic Surgical System for Cholecystectomy

Background. Laparoscopic cholecystectomy has been the gold standard treatment for symptomatic cholelithiasis for more than 3 decades. Robotic techniques are gaining traction in surgery, and recently, the Senhance^™ robotic system was introduced. The system offers advantages over other robotic systems such as improved ergonomics, haptic feedback, eye tracking, and usability of standard laparoscopic trocars and reusable instruments. The Senhance was evaluated to understand the feasibility, benefits, and drawbacks of its use in cholecystectomy. Study Design. A prospectively maintained database of the first 20 patients undergoing cholecystectomy with the Senhance was reviewed at a single hospital. Data including operative time, console time, set up time, and adverse events were collected, with clinical outcome and operative time as primary outcome measures. A cohort of 20 patients having laparoscopic cholecystectomy performed by the same surgeon was used as a comparator group. Results. The 2 groups had comparable demographic data (age, sex, and body mass index). In the Senhance group, 19 of the 20 procedures (95%) were completed robotically. The median (interquartile range) total operating, docking, and console times were 86.5 (60.5-106.5), 11.5 (9-13), and 30.8 (23.5-35) minutes, respectively. In the laparoscopic group, the median (interquartile range) operating time was 31.5 (26-41) minutes. Postoperatively, only one patient had a surgical complication, namely a wound infection treated with antibiotics. Conclusion. Our results suggest that Senhance-assisted cholecystectomy is safe, feasible, and effective, but currently has longer operative times. Further prospective and randomized trials are required to determine whether this approach can offer any other benefits over other minimally invasive surgical techniques.

Perioperative Outcomes of Laparoscopic and Robotic Revisional Bariatric Surgery in a Complex Patient Population

BACKGROUND

Utilization of the robotic platform has become more common in bariatric applications. We aim to show that robotic revisional bariatric surgery (RRBS) can be safely performed in a complex patient population with perioperative outcomes equivalent to laparoscopic revisional bariatric surgery (LRBS).

METHODS

Retrospective review was conducted of adult patients undergoing laparoscopic revisional bariatric surgery (LRBS) or robotic revisional bariatric surgery (RRBS) at our institution from September 2007 to December 2016. Patients undergoing planned two-stage bariatric procedures were excluded.

RESULTS

A total of 84 patients who underwent LRBS (n = 66) or RRBS (n = 18) were included. The index operation was adjustable gastric banding (AGB) in 39/84 (46%), sleeve gastrectomy (VSG) in 23/84 (27%), Roux-en-Y gastric bypass (RYGB) in 13/84 (16%), and vertical banded gastroplasty (VBG) in 9/84 (11%). For patients undergoing conversion from AGB (n = 39), there was no difference in operative time, length of stay, or complications by surgical approach. For patients undergoing conversion from a stapled procedure (n = 45), the robotic approach was associated with a shorter length of stay (5.8 ± 3.3 vs 3.7 ± 1.7 days, p = 0.04) with equivalent operative time and post-operative complications. There were three leaks in the LRBS group and none in the RRBS group (p = 0.36). Major complications occurred in 3/39 (8%) of patients undergoing conversion from AGB and 2/45 (4%) of patients undergoing conversion from a stapled procedure (p = 0.53) with no difference by surgical approach.

CONCLUSIONS

RRBS is associated with a shorter length of stay than LRBS in complex procedures and has at least an equivalent safety profile. Long-term follow-up data is needed.

Robotic-Assisted Roux-en-Y Gastric Bypass: Learning Curve Assessment Using Cumulative Sum and Literature Review

Purpose: Robotic-assisted Roux-en-Y gastric bypass (RARYGB) is a procedure that is used with increasing frequency in the United States. Among other bariatric procedures, RARYGB is a good model for the robotic platform because it allows hand-sewn suturing and energy devices application. The aim of this study was to conduct a literature review of robotic approach in RARYGB, its learning curve using the cumulative sum (CUSUM) method, and our experience as Center of Excellence recognized by the American Society for Metabolic and Bariatric Surgery (ASMBS). Methods: A total of 67 patients were included. Results revealed that the learning curve was achieved after case 11. Eighteen studies were included in the pooled analysis. Results: An increase in the operative time was noted at case 46, in which a second phase was identified. A significant difference between these two phases was found only related to previous bariatric surgery. The outcomes of this series were comparable with the ones available in the literature. Conclusions: The robotic platform is increasing its role in complex procedures such as RARYGB. The hand-sewn technique may offer important advantages in terms of shorter learning curve, reduced conversion rate, and lower leakage rate.

Factors supporting and constraining the implementation of robot-assisted surgery: a realist interview study

OBJECTIVE

To capture stakeholders' theories concerning how and in what contexts robot-assisted surgery becomes integrated into routine practice.

DESIGN

A literature review provided tentative theories that were revised through a realist interview study. Literature-based theories were presented to the interviewees, who were asked to describe to what extent and in what ways those theories reflected their experience. Analysis focused on identifying mechanisms through which robot-assisted surgery becomes integrated into practice and contexts in which those mechanisms are triggered.

SETTING

Nine hospitals in England where robot-assisted surgery is used for colorectal operations.

PARTICIPANTS

Forty-four theatre staff with experience of robot-assisted colorectal surgery, including surgeons, surgical trainees, theatre nurses, operating department practitioners and anaesthetists.

RESULTS

Interviewees emphasised the importance of support from hospital management, team leaders and surgical colleagues. Training together as a team was seen as beneficial, increasing trust in each other's knowledge and supporting team bonding, in turn leading to improved teamwork. When first introducing robot-assisted surgery, it is beneficial to have a handpicked dedicated robotic team who are able to quickly gain experience and confidence. A suitably sized operating theatre can reduce operation duration and the risk of de-sterilisation. Motivation among team members to persist with robot-assisted surgery can be achieved without involvement in the initial decision to purchase a robot, but training that enables team members to feel confident as they take on the new tasks is essential.

CONCLUSIONS

We captured accounts of how robot-assisted surgery has been introduced into a range of hospitals. Using a realist approach, we were also able to capture perceptions of the factors that support and constrain the integration of robot-assisted surgery into routine practice. We have translated these into recommendations that can inform future implementations of robot-assisted surgery.

Robotic Surgery is More Expensive with Similar Outcomes in Sleeve Gastrectomy: Analysis of the NIS Database

The aim of this study was to compare postoperative outcomes after robotic-assisted and laparoscopic bariatric sleeve gastrectomy (SG). Sleeve gastrectomy is traditionally performed using laparoscopic techniques. Robotic-assisted surgery enables surgeons to perform minimally invasive SG, but with unknown benefits. Using a national database, we compared postoperative outcomes after laparoscopic SG and robotic-assisted SG. National data from individuals undergoing elective SG in the National Inpatient Sample database between 2011 and 2013 were analyzed. Propensity score matching was used to match robotic and laparoscopic groups by demographics, comorbidities, and hospital characteristics. The matching cohorts were compared. A total of 26,195 patients who underwent elective SG for morbid obesity were included. Of these, 25,391 (96.9%) were completed via laparoscopy, whereas 804 (3.1%) were performed with robotic assistance. There were no significant differences in demographics and subsequent postoperative complications. The inhospital mortality was similar. Length of hospital stay was statistically different, with a mean of 1.88 in laparoscopic versus 2.08 days in robotic (P < 0.001). Higher total hospital charges were noted in the robotic-assisted SG group (median US$38,569 vs US$54,658, P < 0.001). These differences were evident even after adjusting for confounding factors: wound infection, atelectasis, bowel obstruction, pneumonia, and bowel obstruction (P < 0.001).

Outcomes after Robotic Ventral Hernia Repair: A Study of 21,565 Patients in the State of New York

The purpose of our study is to assess outcomes following robotic ventral hernia (RVH) repair. The New York Statewide Planning and Research Cooperative System administrative database was used to identify all patients undergoing laparoscopic ventral hernia (LVH) and RVH between 2010 and 2013. Outcome measures including complications, hospital length of stay (HLOS), 30-day readmissions, and 30-day emergency department (ED) visits were compared. Propensity score (PS) analysis was used to estimate the adjusted marginal differences between patients who underwent robotic-assisted and laparoscopic procedures. There were 20,896 LVH and 679 (3.2%) RVH repairs. Initial univariate analysis demonstrated that patients undergoing RVH had worse outcomes in terms of complications (20.18% vs 10.56%, P < 0.0001), longer HLOS (4.32 vs 2.19 days, P = 0.0023), higher rates in 30-day readmissions (9.28% vs 5.06%, P < 0.0001), and 30-day ED visits (14.43% vs 10.46%, P < 0.0001). Following PS analysis, which accounts for all patient associated variables, there was no difference found in 30-day readmission or 30-day ED visits between RVH and LVH (P = 0.2760 and 0.2043, respectively). Patients undergoing RVH had a significantly shorter HLOS (P < 0.0001) and lower rate of complications (P = 0.0134). Following PS analysis, this study demonstrates that RVH may be associated with shorter HLOS and lower complication rate. Further studies are necessary to compare laparoscopic and robotic approaches for ventral hernia.

The Results of 100 Robotic Versus 100 Laparoscopic Gastric Bypass Procedures: a Single High Volume Centre Experience

BACKGROUND

The introduction of robotics in bariatric surgery is a novel development since the beginning of this century. The aim of this study is to compare surgical outcome of the robotic gastric bypass with the laparoscopic counterpart.

METHODS

A retrospective study was conducted to compare the results of 100 fully robotic gastric bypasses (RGB) and 100 laparoscopic gastric bypasses (LGB) performed by a single surgeon. Surgical outcome was analysed by evaluating operation room time and surgical time, morbidity and mortality, and length of hospital stay.

RESULTS

In the RGB and LGB group, respectively, 92 and 80 % of operated patients were female (p = 0.024). Mean age was 39 (range 20-62, SD 10.21) and 42 years (range 18-65, SD 11.87), respectively (p = 0.158). Mean BMI was 40 (range 35-47, SD 2.66) and 42 (range 35-56, SD 4.75), respectively (p < 0.05). Mean surgical time was 67 (range 39-210, SD 22.46) and 31 min (range 18-62, SD 9.12), respectively (p < 0.05). Mean operation room time was 117 (range 80-257, SD 30.13) and 66 min (range 38-101, SD 12.68), respectively (p < 0.05). The surgery-related 30-day morbidity rate was 5 % in both groups. Major morbidity (Clavien-Dindo class 3-4) was 3 and 1 %, respectively (p = 0.62). There was no mortality. Median hospital stay was two postoperative days in both groups. A learning curve developed after 25 procedures.

CONCLUSIONS

The RGB is a feasible procedure. Although more time is needed, a standardized technique results in fair operation times in the hands of an experienced surgeon.

Robotic vs. Laparoscopic Sleeve Gastrectomy in Adolescents; Reality or Hype

BACKGROUND

The rising prevalence of childhood obesity and concomitant increase in comorbid disease pose significant challenges for the health care system. While mounting evidence demonstrates the safety and efficacy of bariatric surgery for severely obese adolescents, the potential role of robotic technology has not been well defined.

OBJECTIVE

The aim of this study was to establish the safety and efficacy of robotic-assisted laparoscopic sleeve gastrectomy (RSG) in treating severe adolescent obesity. In addition, 30-day outcomes and hospital charges were compared to subjects undergoing RSG versus laparoscopic sleeve gastrectomy (LSG).

METHODS

A retrospective analysis of 28 subjects (14 LSG vs. 14 RSG) at a single institution was conducted. Data collection included demographics, body mass index, comorbidities, hospital length of stay (LOS), operative time, 30-day outcomes, and hospital charges. Analysis was performed using chi-square, Fisher's exact, and nonparametric Wilcoxon rank sum tests.

RESULTS

There were no differences in subject demographics or comorbidities. While median operative time was longer for RSG vs. LSG (132 vs. 100 min, p = 0.0002), the median LOS for RSG compared to LSG was shorter (69.6 vs. 75.9 h, p = 0.0094). In addition, RSG-related hospital charges were higher ($56,646 vs. $49,498, p = 0.0366). No significant differences in post-operative outcomes or complications were observed.

CONCLUSIONS

RSG is equally safe and efficacious when compared to LSG among adolescents. Similar to studies in adults, LOS is shortened while hospital charges are higher. Larger prospective studies are needed to gain insight regarding cost benefit ratios.

Savings from reducing low-value general surgical interventions

Background

Finding opportunities for improving efficiency is important, given the pressure on national health budgets. Identifying and reducing low-value interventions that deliver little benefit is key. A systematic literature evaluation was done to identify low-value interventions in general surgery, with further assessment of their cost.

Methods

A multiplatform method of identifying low value interventions was undertaken, including a broad literature search, a targeted database search, and opportunistic sampling. The results were then stratified by impact, assessing both frequency and cost.

Results

Seventy-one low-value general surgical procedures were identified, of which five were of high frequency and high cost (highest impact), 22 were of high cost and low frequency, 23 were of low cost and high frequency, and 21 were of low cost and low frequency (lowest impact). Highest impact interventions included inguinal hernia repair in minimally symptomatic patients, inappropriate gastroscopy, interval cholecystectomy, CT to diagnose appendicitis and routine endoscopy in those who had CT-confirmed diverticulitis. Their estimated cost was €153 383 953.

Conclusion

Low-value services place a burden on health budgets. Stopping only five high-volume, high-cost general surgical procedures could save the National Health Service €153 million per annum.

A realist process evaluation of robot-assisted surgery: integration into routine practice and impacts on communication, collaboration and decision-making

Background

The implementation of robot-assisted surgery (RAS) can be challenging, with reports of surgical robots being underused. This raises questions about differences compared with open and laparoscopic surgery and how best to integrate RAS into practice.

Objectives

To (1) contribute to reporting of the ROLARR (RObotic versus LAparoscopic Resection for Rectal cancer) trial, by investigating how variations in the implementation of RAS and the context impact outcomes; (2) produce guidance on factors likely to facilitate successful implementation; (3) produce guidance on how to ensure effective teamwork; and (4) provide data to inform the development of tools for RAS.

Design

Realist process evaluation alongside ROLARR. Phase 1 – a literature review identified theories concerning how RAS becomes embedded into practice and impacts on teamwork and decision-making. These were refined through interviews across nine NHS trusts with theatre teams. Phase 2 – a multisite case study was conducted across four trusts to test the theories. Data were collected using observation, video recording, interviews and questionnaires. Phase 3 – interviews were conducted in other surgical disciplines to assess the generalisability of the findings.

Findings

The introduction of RAS is surgeon led but dependent on support at multiple levels. There is significant variation in the training provided to theatre teams. Contextual factors supporting the integration of RAS include the provision of whole-team training, the presence of handpicked dedicated teams and the availability of suitably sized operating theatres. RAS introduces challenges for teamwork that can impact operation duration, but, over time, teams develop strategies to overcome these challenges. Working with an experienced assistant supports teamwork, but experience of the procedure is insufficient for competence in RAS and experienced scrub practitioners are important in supporting inexperienced assistants. RAS can result in reduced distraction and increased concentration for the surgeon when he or she is supported by an experienced assistant or scrub practitioner.

Conclusions

Our research suggests a need to pay greater attention to the training and skill mix of the team. To support effective teamwork, our research suggests that it is beneficial for surgeons to (1) encourage the team to communicate actions and concerns; (2) alert the attention of the assistant before issuing a request; and (3) acknowledge the scrub practitioner’s role in supporting inexperienced assistants. It is beneficial for the team to provide oral responses to the surgeon’s requests.

Limitations

This study started after the trial, limiting impact on analysis of the trial. The small number of operations observed may mean that less frequent impacts of RAS were missed.

Future work

Future research should include (1) exploring the transferability of guidance for effective teamwork to other surgical domains in which technology leads to the physical or perceptual separation of surgeon and team; (2) exploring the benefits and challenges of including realist methods in feasibility and pilot studies; (3) assessing the feasibility of using routine data to understand the impact of RAS on rare end points associated with patient safety; (4) developing and evaluating methods for whole-team training; and (5) evaluating the impact of different physical configurations of the robotic console and team members on teamwork.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Early Australian experience in robotic sleeve gastrectomy: a single site series

BACKGROUND

The use of robotic platforms in bariatric surgery has recently gained relevance. With an increased use of this technology come concerns regarding learning curve effects during the initial implementation phase. The sleeve gastrectomy though may represent an ideal training procedure for introducing the robot into bariatric surgical practice. The present review of the first 10 consecutive robotic sleeve gastrectomy procedures performed in an Australian bariatric programme by a single surgeon describes the evolution of the technique, learning curve and initial patient outcomes.

METHODS

Between 2014 and 2015, robotic sleeve gastrectomies were performed as primary and revisional procedures by a consistent surgeon-assistant team. Technique evolution and theatre set-up were documented. Patient demographics, operative time (robot docking and total operation time), additional operative procedures performed, operative and post-operative complications at 1, 3 and 6 months post-procedure and weight loss achieved at 6 months were retrospectively reviewed from a prospectively maintained database.

RESULTS

Ten robotic sleeve gastrectomies were performed without significant operative complications. One patient was treated as an outpatient with oral antibiotics for a superficial wound infection. The median total operative time was 123 min (interquartile range (IQR) 108.8-142.5), with a median incision to docking time of 19 min (IQR 15.0-31.8). Length of stay in hospital was 2-3 days. Median excess weight loss achieved at 6 months was 50% (IQR 33.9-66.5).

CONCLUSION

This study describes a method of safely introducing the da Vinci robot into bariatric surgical practice.

General surgery training and robotics: Are residents improving their skills?

BACKGROUND

While robotic-assisted operations have become more prevalent, many general surgery residencies do not have a formal robotic training curriculum. We sought to ascertain how well current general surgery training permits acquisition of robotic skills by comparing robotic simulation performance across various training levels.

STUDY DESIGN

Thirty-six participants were categorized by level of surgical training: eight medical students (MS), ten junior residents (JR), ten mid-level residents (MLR), and eight senior residents (SR). Participants performed three simulation tasks on the da Vinci (®) Skills Simulator (MatchBoard, EnergyDissection, SutureSponge). Each task's scores (0-100) and cumulative scores (0-300) were compared between groups.

RESULTS

There were no differences in sex, hand dominance, video gaming history, or prior robotic experience between groups; however, SR was the oldest (p < 0.001). The median overall scores did not differ: 188 (84-201) for MS, 183 (91-234) for JR, 197 (153-218) for MLR, and 205 (169-229) for SR (p = 0.14). The median SutureSponge score was highest for SR (61, range 39-81) compared to MS (43, range 26-61), JR (43, range 11-72), and MLR (55, range 36-68) (p = 0.039). However, there were no significant differences in MatchBoard (p = 0.27) or EnergyDissection (p = 0.99) scores between groups. There was a positive correlation between SutureSponge score and number of laparoscopic cases logged (p = 0.005, r(2) = 0.21), but this correlation did not exist for the MatchBoard or EnergyDissection tasks. Lastly, there was no correlation between total lifetime hours of video gaming and overall score (p = 0.89, R(2) = 0.0006).

CONCLUSIONS

Robotic skillsets acquired during general surgery residency show minimal improvement during the course of training, although laparoscopic experience is correlated with advanced robotic task performance. Changes in residency curricula or pursuit of fellowship training may be warranted for surgeons seeking proficiency.

Review of contemporary role of robotics in bariatric surgery

With the rise in a number of bariatric procedures, surgeons are facing more complex and technically demanding surgical situations. Robotic digital platforms potentially provide a solution to better address these challenges. This review examines the published literature on the outcomes and complications of bariatric surgery using a robotic platform. Use of robotics to perform adjustable gastric banding, sleeve gastrectomy, roux-en-y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch and revisional bariatric procedures (RBP) is assessed. A search on PubMed was performed for the most relevant articles in robotic bariatric surgery. A total of 23 articles was selected and reviewed in this article. The review showed that the use of robotics led to similar or lower complication rate in bariatric surgery when compared with laparoscopy. Two studies found a significantly lower leak rate for robotic gastric bypass when compared to laparoscopic method. The learning curve for RYGB seems to be shorter for robotic technique. Three studies revealed a significantly shorter operative time, while four studies found a longer operative time for robotic technique of gastric bypass. As for the outcomes of RBP, one study found a lower complication rate in robotic arm versus laparoscopic and open arms. Most authors stated that the use of robotics provides superior visualisation, more degrees of freedom and better ergonomics. The application of robotics in bariatric surgery seems to be a safe and feasible option. Use of robotics may provide specific advantages in some situations, and overcome limitations of laparoscopic surgery. Large and well-designed randomised clinical trials with long follow-up are needed to further define the role of digital platforms in bariatric surgery.