Robotic-assisted surgery enhances the learning curve while maintaining quality outcomes in sleeve gastrectomy: a preliminary, multicenter study

Evaluation of hemorrhage risk and the volume-outcome relationship following vertical sleeve gastrectomy amidst robotic-assisted surgery adoption

BACKGROUND

Robotic-assisted surgery (RAS) holds promise for maintaining bariatric outcomes, while offering a shorter adoption learning curve relative to conventional laparoscopy. However, low RAS procedure volume relative to a laparoscopic approach has limited our understanding of its impact, and the transition from laparoscopic to RAS entails a volume-outcome relationship that is not fully characterized.

METHODS

This is a retrospective cohort study in a MBSAQIP accredited, bariatric surgery program. The incidence of hemorrhage following vertical sleeve gastrectomy (VSG) was observed from 2020 to 2023. This period was divided into an early adoption period (RAS 31% of cases) and a late adoption period (RAS 82% of cases).

RESULTS

A total of 1250 patients underwent VSG over the study period. Laparoscopic VSG (L-VSG) and robotic-assisted VSG (RA-VSG) groups were similar in age, sex, and risk factors for postoperative bleeding. They differed in race (P < 0.0001) and ASA category (P = 0.007). The overall postoperative hemorrhage rate was 1.04% (n = 13). Hyperlipidemia was predictive of hemorrhage on univariate analysis (P = 0.045). The relative risk of hemorrhage in the robotic group dropped from 4.38 (CI 0.577-3.24) during the early adoption period to 0.28 (CI 0.083-0.96, P = 0.063) during the late adoption period. This shift with respect to hemorrhage risk was not associated with a significant reduction of hemorrhage in the RA-VSG approach (1.5% vs. 0.98%; P = 0.636), but with an increase in L-VSG risk (0.35% vs. 3.5%, P = 0.0245).

CONCLUSION

As RA-VSG became the more frequently utilized approach within a single program, the risk of hemorrhage with L-VSG significantly increased. This suggests an unanticipated risk associated with a transition to the robotic approach. Specifically, the risk of complication increased when performing L-VSG in a practice dominated by RA-VSG.

Thirty day outcomes for laparoscopic versus robotic sleeve gastrectomy: Does the stapler matter?

BACKGROUND

Sleeve gastrectomy (SG) remains a safe and effective treatment for severe obesity. The number of robotic SG (RSG) has steadily increased from 2015 to 2021. Prior studies have shown higher rates of some adverse outcomes with RSG but have not accounted for staplers used.

OBJECTIVE

The aim of this study is to compare outcomes for RSG compared to laparoscopic sleeve gastrectomy (LSG), accounting for stapler type used.

SETTING

National hospital derived administrative data.

METHODS

The PINC AI Healthcare Database was used for the current study. Analyzed cohort included elective LSG or RSG performed between January 1, 2019, and December 31, 2021. Patient, hospital, billing, provider, insurance, and operative data were captured. Bleeding, leak, and other outcomes were identified by ICD-10-CM diagnosis codes. Propensity score matching (PSM) compared outcomes between RSG with SureForm stapler vs. LSG with powered stapler.

RESULTS

56,013 LSG and 13,832 RSG were analyzed. RSG increased from 15 % in 2019 to 25 % in 2021 with an absolute 27 ​% increase in robotic stapler utilization for RSG. PSM analysis compared, 5434 RSG with SureForm Stapler vs. 5434 LSG with powered staplers showed equivalent complication rates, shorter LOS, but longer operative time with RSG.

CONCLUSIONS

When stapler type used is accounted for, patient outcomes following RSG and LSG are equivalent.

The training pathway for residents: 'Robotic Curriculum for young Surgeons' (RoCS) does not impair patient outcome during implementation into clinical routine

The "Robotic Curriculum for young Surgeons" (RoCS) was launched 03/2020 to address the increasing importance of robotics in surgical training. It aims to provide residents with foundational robotic skills by involving them early in their training. This study evaluated the impact of RoCS' integration into clinical routine on patient outcomes. Two cohorts were compared regarding the implementation of RoCS: Cohort 1 (before RoCS) included all robot-assisted procedures between 2017 and 03/2020 (n = 174 adults) retrospectively; Cohort 2 (after RoCS) included all adults (n = 177) who underwent robotic procedures between 03/2020 and 2021 prospectively. Statistical analysis covered demographics, perioperative parameters, and follow-up data, including mortality and morbidity. Subgroup analysis for both cohorts was organ-related (upper gastrointestinal tract (UGI), colorectal (CR), hepatopancreaticobiliary system (HPB)). Sixteen procedures were excluded due to heterogeneity. In-hospital, 30-, 90-day morbidity and mortality showed no significant differences between both cohorts, including organ-related subgroups. For UGI, no significant intraoperative parameter changes were observed. Surgery duration decreased significantly in CR and HPB procedures (p = 0.018 and p < 0.001). Estimated blood loss significantly decreased for CR operations (p = 0.001). The conversion rate decreased for HPB operations (p = 0.005). Length of hospitalization decreased for CR (p = 0.015) and HPB (p = 0.006) procedures. Oncologic quality, measured by histopathologic R0-resections, showed no significant changes. RoCS can be safely integrated into clinical practice without compromising patient safety or oncologic quality. It serves as an effective training pathway to guide robotic novices through their first steps in robotic surgery, offering promising potential for skill acquisition and career advancement.

Characteristics of the learning curve in robotic thoracic surgery in an emerging country

It is not established which factors impact the learning curve (LC) in robotic thoracic surgery (RTS), especially in emerging countries. The aim of this study is to analyze LC in RTS in Brazil and identify factors that can accelerate LC. We selected the first cases of two Brazilian surgeons who started their LC. We used CUSUM and the Lowess technique to measure LC for each surgeon and Poisson regression to assess factors associated with shorter console time (CT). 58 patients were operated by each surgeon and included in the analysis. Surgeries performed were different: Surgeon I (SI) performed 54 lobectomies (93.11%), whereas Surgeon II (SII) had a varied mix of cases. SI was proctored in his first 10 cases (17.24%), while SII in his first 41 cases (70.68%). The mean interval between surgeries was 8 days for SI and 16 days for SII. There were differences in the LC phases of the two surgeons, mainly regarding complications and conversions. There was shorter CT by 30% in the presence of a proctor, and by 20% with the Da Vinci Xi. Mix of cases did not seem to contribute to faster LC. Higher frequency between surgeries seems to be associated with a faster curve. Presence of proctor and use of bolder technologies reduced console time. We wonder if in phase 3 it is necessary to keep a proctor on complex cases to avoid serious complications. More studies are necessary to understand which factors impact the LC.

Supporting laparoscopic general surgery training with digital technology: The United Kingdom and Ireland paradigm

Surgical training in the UK and Ireland has faced challenges following the implementation of the European Working Time Directive and postgraduate training reform. The health services are undergoing a digital transformation; digital technology is remodelling the delivery of surgical care and surgical training. This review aims to critically evaluate key issues in laparoscopic general surgical training and the digital technology such as virtual and augmented reality, telementoring and automated workflow analysis and surgical skills assessment. We include pre-clinical, proof of concept research and commercial systems that are being developed to provide solutions. Digital surgical technology is evolving through interdisciplinary collaboration to provide widespread access to high-quality laparoscopic general surgery training and assessment. In the future this could lead to integrated, context-aware systems that support surgical teams in providing safer surgical care.