Does Robotic Roux-en-Y Gastric Bypass Provide Outcome Advantages over Standard Laparoscopic Approaches?

Robotic bariatric surgery: the Italian point of view to go beyond

Italian robotic community discussed critical issues about data of robotic bariatric surgery activity in Italy. A working group of Italian bariatric surgeon evaluated the current evidence on robotic use discussed its limits, advantages and future perspective in bariatric field. The chair of the working group (MR) and a group of participants (G.F., B.P., G.N.) reported results of Italian SICOB Registry data and discussed about future perspective on the behalf of the Italian Working Group on Robotic Bariatric Surgery (IGRoBS).

MATERIAL

Database of SICOB Italian Registry was analysed since 2014. All procedures were categorized by years from 2014 to October 2024 and evaluated compared than total bariatric procedures (robotic rate). Type of procedures was classified: Roux-en-Y gastric bypass (RYGB), One-anastomosis gastric bypass (OAGB), Sleeve Gastrectomy (SG), Single anastomosis duodenal-ileal bypass (SADIS), Gastric Plication (GP), Gastric Banding (GB) .

RESULTS

168.309 bariatric procedures from 2014 to October 2024 was recorded in SICOB Registry. 1086 procedures (0.64%) were recorded as robotic approach. Robotic bariatric procedures increased by years from 19 robotic procedures in 2014 to 344 procedures in the first 10 months in 2024. Robotic bariatric rate increased in the last years from 0,2% in 2014 to 3,7% in 2024. Robotic procedure types were RYGB 549, SG 433, OAGB 73, SADIS 21, GP 10, GB 5. In the last year, robotic SG was more widespread than other procedures (174 SG versus 147 RYGB).

CONCLUSION

Data showed an increased robotic activity in Italy. Literature reported that more complex procedures, such as revisional procedures, bariatric procedures combined with hiatal hernia repair, and complex cases, including superobese patients and procedures requiring manual anastomosis are promising areas for validating the use of robotic surgery. Future prospective could be resume in three answer: could robotic platforms be more useful than laparoscopy for achieving a safe and efficient learning curve? Could it offer a viable path toward solo-surgery? Could it value for AI applications, and for training and proctoring of new users?

Robotic Surgery in Safety-Net Hospitals: Addressing Health Disparities and Improving Access to Care

Minimally invasive surgery (MIS) has demonstrated significant clinical and economic benefits that have been consistently validated and reproduced in practice and the literature for the past few decades. These benefits include improved patient outcomes, reduced complications, shorter hospital stays, decreased narcotic use, quicker recovery times, and lower rates of wound infections. However, safety-net hospitals, which historically serve a larger percentage of underserved and marginalized populations, often lack the resources to invest in high capital equipment. This limitation decreases access for these marginalized groups to the advantages of MIS, particularly robotic surgery and a wider range of surgical operations. This disparity in access to care highlights a critical shortfall in the delivery of health care for these patients and other vulnerable populations.

Gastric bypass performed with different surgical platforms during different periods

Robotic gastric bypass (RGB) continues to increase. However, conflicting data remain on its impact on patient-reported outcomes. We utilized the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBSAQIP) databases. Gastric bypass cases performed with laparoscopy (LGB) or robotic assistance (RGB) between 2015 and 2021 were analyzed. A 1:1 matched analysis compared outcomes between LGB and RGB performed at different time intervals (2015-2018 vs. 2091-2021). 286,531 RYGB cases (87% LGB, 13% RGB) were analyzed, yielding 25,594 matched LGB and RGB cases. Mortality was low (0.1%) and comparable between cohorts. Surgical site infection (SSI) (0.9% vs. 1.3%, p < 0.001) and bleeding (0.3% vs. 0.4%, p = 0.04) were lower with RGB; however, readmission (5.8% vs. 4.9%, p < 0.001), reoperation (2.2% vs. 1.85%, p = 0.005), and morbidity (7.6% vs. 6.8%, p < 0.001) were higher. Operative length (OL) was longer for RGB (p < 0.001). In the early cohort, SSI and bleeding (p = 0.002 and p = 0.039) were lower for RGB; however, operative duration and LOS (p < 0.001) were more extended. In the later cohort, SSI (p = 0.006) and bleeding (p = 0.046) remained lower with RGB, while morbidity was higher (p = 0.005). Mean OL narrowed but remained longer for RGB (p < 0.001), while LOS was comparable. Both RGB and LGB demonstrate safety profiles with low mortality and morbidity. With increased robotic utilization, RGB was associated with a persistently reduced incidence of SSI and bleeding but longer OL.

Comparison between DaVinci® and Hugo™-RAS Roux-en-Y Gastric Bypass in bariatric surgery

The application of a robotic platform in the bariatric surgical field is intended to enhance the already established advantages of minimally invasive surgery in terms of both technical and clinical outcomes. These advantages are especially relevant for technically challenging multiquadrant operations such as Roux-en-Y Gastric Bypass (RYGB). Consequently, robotic-assisted surgery has emerged as a possible application for bariatric surgeries. The study attempts to assess feasibility and safety of the Hugo™-Robotic-Assisted Surgery System (Hugo™-RAS) platform compared to the DaVinci® Surgical System (DaVinci®-SS) with a focus on complication rates and operative times. We retrospectively reviewed bariatric procedures performed from January 2013 until December 2023. We included all robotic RYGBs performed using Hugo™-RAS and DaVinci®-SS platforms. The study utilized Propensity Score Matching (PSM) analysis to address bias in selection, matching patients based on age, gender, body mass index, comorbidities and past abdominal operations. One hundred thirty-five patients were identified: 90 DaVinci®-SS and 45 Hugo™-RAS procedures. After PSM, each group consisted of 45 patients. There was no discernible disparity observed in relation to early (≤ 30 days) postoperative complications rate (p = 1), mean operative time (for docking time, console time and total operative time: p = 0.176, p = 0.678, p = 0.229, respectively) and postoperative hospital stay (p = 0.052) between DaVinci®-RSS and Hugo™-RAS procedures. Our results suggest that application of both Hugo™-RAS and DaVinci®-SS robotic platforms to RYGB is related to comparable safety profiles. Although DaVinci®-SS remains the most widely adopted platform in clinical practice, this study underscores the potential role of the Hugo™-RAS to provide effective solutions in robotic bariatric procedures.

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.

A Systematic Review to Summarise and Appraise the Reporting of Surgical Innovation: a Case Study in Robotic Roux-en-Y Gastric Bypass

Robotic Roux-en-Y gastric bypass (RRYGB) is an innovative alternative to traditional laparoscopic approaches. Literature has been published investigating its safety/efficacy; however, the quality of reporting is uncertain. This systematic review used the Idea, Development, Exploration, Assessment and Long-term follow-up (IDEAL) framework to assess the reporting quality of available literature. A narrative summary was formulated, assessing how comprehensively governance/ethics, patient selection, demographics, surgeon expertise/training, technique description and outcomes were reported. Forty-seven studies published between 2005 and 2024 were included. There was incomplete/inconsistent reporting of governance/ethics, patient selection, surgeon expertise/training and technique description, with heterogenous outcome reporting. RRYGB reporting was poor and did not align with IDEAL guidance. Robust prospective studies reporting findings using IDEAL/other guidance are required to facilitate safe widespread adoption of RRYGB and other surgical innovations.

The Trajectory of Revisional Bariatric Surgery: Open to Laparoscopic to Robotic

Metabolic and bariatric surgery (MBS) is the most effective therapeutic intervention for patients with obesity, with sleeve gastrectomy (SG) being the most commonly performed primary MBS procedure. Long-term studies have demonstrated that 15-20% of patients require revisional bariatric surgery (RBS) due to weight-related issues or surgical complications. Despite the gold standard being laparoscopic revision, there are other available approaches such as open or robotic-assisted. An extensive literature review was performed for articles from their inception to February 2024. A descriptive review of MBS procedures (SG, Roux-en-Y gastric bypass (RYGB), single anastomosis duodeno-ileostomy (SADI) and biliopancreatic diversion-duodenal switch (BPD-DS)) was carried out to report and compare outcomes between primary and revisional bariatric surgery. A similar review was conducted to compare outcomes of revisional approaches (open, laparoscopic, robotic). RYGB remains the dominant RBS with a similar safety profile compared to revisional SADI and BPD-DS. In terms of the RBS surgical approach, all three options showed comparable short and long-term outcomes, with robotic RBS being associated with longer operative time and variable length of stay. Additional long-term studies are required to further validate our conclusions.

Global benchmarks in primary robotic bariatric surgery redefine quality standards for Roux-en-Y gastric bypass and sleeve gastrectomy

BACKGROUND

Whether the benefits of the robotic platform in bariatric surgery translate into superior surgical outcomes remains unclear. The aim of this retrospective study was to establish the 'best possible' outcomes for robotic bariatric surgery and compare them with the established laparoscopic benchmarks.

METHODS

Benchmark cut-offs were established for consecutive primary robotic bariatric surgery patients of 17 centres across four continents (13 expert centres and 4 learning phase centres) using the 75th percentile of the median outcome values until 90 days after surgery. The benchmark patients had no previous laparotomy, diabetes, sleep apnoea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI greater than 50 kg/m2, or age greater than 65 years.

RESULTS

A total of 9097 patients were included, who were mainly female (75.5%) and who had a mean(s.d.) age of 44.7(11.5) years and a mean(s.d.) baseline BMI of 44.6(7.7) kg/m2. In expert centres, 13.74% of the 3020 patients who underwent primary robotic Roux-en-Y gastric bypass and 5.9% of the 4078 patients who underwent primary robotic sleeve gastrectomy presented with greater than or equal to one complication within 90 postoperative days. No patient died and 1.1% of patients had adverse events related to the robotic platform. When compared with laparoscopic benchmarks, robotic Roux-en-Y gastric bypass had lower benchmark cut-offs for hospital stay, postoperative bleeding, and marginal ulceration, but the duration of the operation was 42 min longer. For most surgical outcomes, robotic sleeve gastrectomy outperformed laparoscopic sleeve gastrectomy with a comparable duration of the operation. In robotic learning phase centres, outcomes were within the established benchmarks only for low-risk robotic Roux-en-Y gastric bypass.

CONCLUSION

The newly established benchmarks suggest that robotic bariatric surgery may enhance surgical safety compared with laparoscopic bariatric surgery; however, the duration of the operation for robotic Roux-en-Y gastric bypass is longer.

Robotic versus laparoscopic gastric bypass in bariatric surgery: a systematic review and meta-analysis on perioperative outcomes

BACKGROUND

Robotic-assisted surgery has emerged as a compelling approach to bariatric surgery. However, current literature has not consistently demonstrated superior outcomes to laparoscopic bariatric surgery to justify its higher cost. With its mechanical advantages, the potential gains from the robotic surgical platform are likely to be apparent in more complex cases such as gastric bypass, especially revisional cases.

OBJECTIVE

This systematic review and meta-analysis aimed to summarize the literature and evaluate the peri-operative outcomes of patients with obesity undergoing robotic gastric bypass versus laparoscopic gastric bypass surgery.

SETTING

Systematic review.

METHODS

A literature search of Embase, Medline, Pubmed, Cochrane library, and Google Scholar was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing outcomes of robotic and laparoscopic gastric bypass for obesity were included.

RESULTS

Twenty-eight eligible studies comprised a total of 82,155 patients; 9051 robotic bypass surgery (RBS) versus 73,104 laparoscopic bypass surgery (LBS) were included. All included studies compared Roux-en-Y gastric bypass. RBS was noted to have higher reoperation rate within 30 days (4.4% versus 3.4%; odds ratio 1.31 [95% CI, 1.04-1.66]; P = .027; I2 = 43.5%) than LBS. All other endpoints measured (complication rate, anastomotic leak, anastomotic stricture, surgical site infections, hospital readmission, length of stay, operative time, conversion rate and mortality) did not show any difference between RBS and LBS.

CONCLUSION

This systematic review and meta-analysis showed that there was no significant difference in key outcome measures in robotic versus laparoscopic gastric bypass. RBS was associated with a slightly higher reoperation rate and there was no reduction in overall complication rate with the use of robotic platform.

Outcomes of totally robotic Roux-en-Y gastric bypass in patients with BMI ≥ 50 kg/m2: can the robot level out "traditional" risk factors?

Roux-en-Y gastric bypass (RYGB) in patients with body mass index (BMI) ≥ 50 kg/m2 is a challenging procedure and BMI ≥ 50 kg/m2 has been identified as independent risk factor for postoperative complications and increased morbidity in previous studies. The objective of the present study was to assess whether a BMI ≥ 50 kg/m2 and various established risk factors maintain their significance in patients undergoing fully robotic RYGB (rRYGB). A single-center analysis of prospectively collected data of 113 consecutive patients undergoing standardized rRYGB with robotic stapling technique and hand-sewn gastrojejunostomy using the daVinci Xi system. Surgical outcomes were analyzed considering a number of individual perioperative risk factors including BMI ≥ 50 kg/m2. The mean BMI of the total cohort was 50.6 ± 5.5 kg/m2 and 63.7% of patients had a BMI ≥ 50 kg/m2. There were no major surgical and perioperative complications in patients with BMI ≥ 50 kg/m2 as well as in those with BMI < 50 kg/m2 after rRYGB. We identified female sex and surgeon experience but neither body weight, BMI, metabolic disorders, ASA nor EOSS scores as independent factors for shorter operation times (OT) in multivariate analyses. Complication rates and length of hospital stay (LOS) did not significantly differ between patients with potential risk factors and those without. rRYGB is a safe procedure in both, patients with BMI ≥ 50 kg/m2 and with BMI < 50 kg/m2. Higher body weight and BMI did affect neither OT nor LOS. A fully robotic approach for RYGB might help to overcome "traditional" risk factors identified in conventional laparoscopic bariatric surgery. However, larger and prospective studies are necessary to confirm these results.

Robotic Surgery: A Comprehensive Review of the Literature and Current Trends

Robotic surgery (RS) is an evolution of minimally invasive surgery that combines medical science, robotics, and engineering. The first robots approved by the Food and Drug Administration (FDA) were the Da Vinci Surgical System and the ZEUS Robotic Surgical System, which have been improving over time. Through the decades, the equipment applied to RS had undergone a wide transformation as a response to the development of new techniques and facilities for the assembly and implementation of the own. RS has revolutionized the field of urology, enabling surgeons to perform complex procedures with greater precision and accuracy, and many other surgical specialties such as gynecology, general surgery, otolaryngology, cardiothoracic surgery, and neurosurgery. Several benefits, such as a better approach to the surgical site, a three-dimensional image that improves depth perception, and smaller scars, enhance range of motion, allowing the surgeon to conduct more complicated surgical operations, and reduced postoperative complications have made robotic-assisted surgery an increasingly popular approach. However, some points like the cost of surgical procedures, equipment-instrument, and maintenance are important aspects to consider. Machine learning will likely have a role to play in surgical training shortly through "automated performance metrics," where algorithms observe and "learn" individual surgeons' techniques, assess performance, and anticipate surgical outcomes with the potential to individualize surgical training and aid decision-making in real time.

Robotic-Assisted Bariatric Surgery Is Associated with Increased Postoperative Complications Compared to Laparoscopic: a Nationwide Readmissions Database Study

PURPOSE

Robotic-assisted (RA) bariatric surgery has been increasingly used without consistent benefit over a laparoscopic approach (LA). We compared intra- and post-operative complications and 30- and 90-day all-cause readmissions between RA and LA using the Nationwide Readmissions Database (NRD).

MATERIALS AND METHODS

We identified hospitalizations with adult patients who underwent RA or LA bariatric surgery from 2010 to 2019. Primary outcomes included intra- and post-operative complications and 30- and 90-day all-cause readmissions. Secondary outcomes included in-hospital death, length of stay (LOS), cost, and cause-specific readmissions. Multivariable regression models were estimated; analyses accounted for the NRD sampling design.

RESULTS

A total of 1,371,778 hospitalizations met inclusion criteria with 7.1% using RA. Patient demographic and clinical characteristics were mostly similar between groups. Adjusted odds of complication were 13% higher for RA (adjusted odds ratio [aOR]: 1.13, 95% CI: 1.03-1.23 p = .008); aORs differed across bariatric procedures. The most common complications included nausea/vomiting, acute blood loss anemia, incisional hernia, and transfusion. Adjusted odds of 30- and 90-day readmission were 10% higher for RA (aOR: 1.10, 95% CI: 1.04-1.17, p = .001 and aOR: 1.10, 95% CI: 1.04-1.16, p <.001, respectively). LOS was similar (1.6 vs. 1.6 days, p = .253); although, hospital costs were 31.1% higher for RA ($15,806 vs. $12,056, p < .001).

CONCLUSION

RA bariatric surgery is associated with 13% higher odds of complication, 10% higher odds of readmission, and 31% hospital costs. Subsequent studies are required using databases that can include additional patient-, facility-, surgery-, and surgeon-specific characteristics.

Establishing robotic bariatric surgery at an academic tertiary hospital: a learning curve analysis for totally robotic Roux-en-Y gastric bypass

The use of robotic systems in bariatric surgery has constantly increased over the last years. However, beside its technical advantages in morbidly obese patients the conclusive role of robotics in bariatric and metabolic surgery is still under controversial debate. This is an analysis of prospectively collected data of consecutive patients undergoing fully robotic Roux-en-Y gastric bypasses (TR-RYGB) during the first year after implementation of a robotic bariatric program at a tertiary university hospital. All patients were operated by a previously untrained robotic but experienced laparoscopic bariatric surgeon using the daVinci Xi system (Intuitive Surgical, Sarl). Data recording included patient characteristics, operative and functional outcomes, complications and learning curves for surgeon and assistants. In total, 80 patients underwent primary or revisional robotic bariatric surgery. Seventy-two patients (90%) received a TR-RYGB. There were no major complications, re-interventions or readmissions. The overall complication rate was 2.5% (Clavien-Dindo grade I and II). The overall operation time was 140.7 ± 24.6 min and decreased significantly from the first to the last decade of procedures (procedure 1-10: 171.2 ± 26.3 min versus procedure 63-72: 116.0 ± 10.9 min, p < 0.0001). A stabilization of the learning curve was observed after 30 procedures for the surgeon and after five procedures for the bedside assistant. With immediate effect, TR-RYGB is a safe procedure with low complication rates for an experienced laparoscopic bariatric surgeon without prior robotic skills. Learning curves are steep and operation times can be effectively decreased by increasing the experience of the surgeon.

A fully stapled technique for gastrojejunal anastomosis creation in robotic Roux-en-Y gastric bypass

PURPOSE

The purpose of this paper is to showcase a fully stapled approach to creating a gastrojejunostomy during a robot-assisted Roux-en-Y gastric bypass.

METHODS

We utilize two robotic 12-mm ports, two robotic 8-mm ports, and one 8-mm assistant port. The tools used are a fenestrated bipolar forceps, vessel sealer, cadiere grasper, needle driver, and a robotic stapler. After the partial gastrectomy, the roux limb is brought up to the gastric pouch where monopolar scissors are used to create a gastrotomy and enterotomy. The gastrotomy is made just above the staple line of the gastric pouch. The enterotomy is created 2 cm distal to the roux limb's staple line. The stapler is inserted into both the gastrotomy and enterotomy to create the common channel. A 2-0 vicryl suture is used to place four interrupted sutures across the remaining enterotomy in full thickness bites. An endoscope or Visigi bougie is advanced across the anastomosis into the roux limb before the final suture. The tails of the most lateral and medial sutures are grasped and lifted towards the abdominal wall. The stapler is advanced over the approximated enterostomy while holding tension with the suture tails. The stapler is fired transversely across the suture line to seal the gastrojejunostomy. The staple line may be oversewn with silk sutures. A leak test is performed prior to completing the reconstruction with the jejunojejunostomy.

CONCLUSIONS

A fully stapled technique of anastomosis creation may reduce operative time, standardizes the process for reproducibility, and increases consistency across operators and patients.

Operative Time and 30-Day Outcomes in Bariatric Surgery: Comparison between Robotic and Laparoscopic Approach: 4-Year MBSAQIP Database Analysis

BACKGROUND

The main criticism of robotic surgery is longer operative time (OT). The aim of this study was to examine the variables that determine OT, the association between OT and 30-day outcomes, and the effect of the robotic approach in bariatric surgery.

STUDY DESIGN

MBSAQIP data for 2016 to 2019 were queried. Logistic regression was performed to examine the association between OT and outcomes for each surgical approach while adjusting for patients' characteristics. The results of each fitted logistic regression model were reported as odds ratio and the associated 95% CI.

RESULTS

A total of 666,182 patients underwent robotic sleeve gastrectomy (R-SG), laparoscopic sleeve gastrectomy, robotic Roux-en-Y gastric bypass (R-RYGB), laparoscopic Roux-en-Y gastric bypass, robotic duodenal switch (R-DS), and laparoscopic duodenal switch). More patients underwent laparoscopic surgery (89.7%) than robotic surgery (10.3%). OT for robotic cases was longer than for laparoscopic cases (p < 0.0001). Longer OT was associated with increased odds of adverse 30-day outcomes irrespective of the surgical approach. The association between OT and adverse outcomes was stronger in the laparoscopic cohort. There was no significant difference in postoperative outcomes when comparing the laparoscopic and robotic approaches after adjusting for OT, except a lower reoperation rate for R-SG (p = 0.03) and readmission rates in R-RYGB and R-DS (p < 0.01). The variability of OT was higher in the laparoscopic group and was more affected by the first assistant.

CONCLUSIONS

The outcomes in robotic bariatric surgery were comparable with the laparoscopic approach despite longer OT. Use of robotic surgery decreased the variability in OT.

Racial disparity in causes for readmission following bariatric surgery

BACKGROUND

Readmission after bariatric surgery is not cost-effective and is a preventable quality metric within standardized practices. However, reasons for readmission among racial/ethnic bariatric cohorts are less explored and understood.

OBJECTIVE

Our study objective was designed to compare reasons for readmission among racial/ethnic cohorts of bariatric patients.

SETTING

Academic hospital.

METHODS

We performed a retrospective analysis of the 2015-2018 MBSAQIP databases to identify Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases. Regression analyses determined predictors of all-cause and bariatric-related readmissions. Reasons for readmission were compared between racial/ethnic cohorts using propensity score matching.

RESULTS

More than 550 000 RYGB and SG cases were analyzed. The readmission rate was 3%-4%. Black race, RYGB, robot-assisted approach, and numerous co-morbidities were independently associated with readmission (P <.05). In RYGB cases, black (versus white) patients were at decreased odds of leak-related (P < .001) and cardiovascular-related (P < .001) readmissions but at increased odds of readmissions related to renal complications (P < .001). Hispanic (versus white) patients had a higher likelihood of venous thromboembolism-related readmissions (P < .001). In SG cases, black (versus white) patients had a similar lower likelihood of readmission related to leaks or cardiovascular complications but higher odds of readmission related to renal complications (P < .001). Hispanic (versus black) patients had a higher likelihood of leak-related readmissions (P < .001).

CONCLUSION

Readmission reasons after bariatric surgery vary by race/ethnicity. Perioperative pathways to mitigate complications, including readmissions, should consider these disparate findings.

Sugammadex, the Guardian of Deep Muscle Relaxation During Conventional and Robot-Assisted Laparoscopic Surgery: A Narrative Review

High intra-abdominal pressure induced by artificial pneumoperitoneum can obviously impair respiratory and circulatory functions and has a negative effect on the prognosis of patients undergoing conventional and robot-assisted laparoscopic surgery. The application of deep neuromuscular blockade during the operation is reported to lower the intra-abdominal pressure and improve patients’ outcome. However, concern lies in the risks of postoperative residual muscular paralysis with the use of deep neuromuscular blockade. Sugammadex, a specific antagonist for aminosteroids muscle relaxants, can effectively and rapidly reverse rocuronium and vecuronium induced neuromuscular blockade of different depths. Thus, sugammadex allows the ability to safeguard the application of deep neuromuscular blockade in laparoscopic operations and helps to alleviate the adverse complications associated with pneumoperitoneum. Here, we review the application of deep neuromuscular blockade in different laparoscopic surgeries and discuss the benefits and possible risks of sugammadex administration in the reversal of deep neuromuscular blockade in these operations.

Long-term Emergency Department Visits and Readmissions After Laparoscopic Roux-en-Y Gastric Bypass: a Systematic Review

PURPOSE

There is considerable evidence on short-term outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB), but data on long-term outcome is scarce, especially on postoperative emergency department (ED) visits and readmissions. We aim to systematically review evidence on the incidence, indications, and risk factors of ED visits and readmissions beyond 30 days after LRYGB.

MATERIALS AND METHODS

A systematic search in PubMed, Scopus, Embase.com , Cochrane Library, and PsycINFO was performed. All studies reporting ED visits and readmissions > 30 days after LRYGB, with ≥ 50 patients, were included. PRISMA statement was used and the Newcastle-Ottawa Scale for quality assessment.

RESULTS

Twenty articles were included. Six studies reported on ED visits (n = 2818) and 19 on readmissions (n = 276,543). The rate of patients with an ED visit within 90 days after surgery ranged from 3.9 to 32.6%. ED visits at 1, 2, and 3 years occurred in 25.6%, 30.0%, and 31.1% of patients. Readmissions within 90 days and at 1-year follow-up ranged from 4.1 to 20.5% and 4.75 to 16.6%, respectively. Readmission was 29% at 2 years and 23.9% at 4.2 years of follow-up. The most common reason for ED visits and readmissions was abdominal pain.

CONCLUSION

Emergency department visits and readmissions have been reported in up to almost one in three patients on the long-term after LRYGB. Both are mainly indicated for abdominal pain. The report on indications and risk factors is very concise. A better understanding of ED visits and readmissions after LRYGB is warranted to improve long-term care, in particular for patients with abdominal pains.

The Impact of Robotics in Learning Roux-en-Y Gastric Bypass: a Retrospective Analysis of 214 Laparoscopic and Robotic Procedures : Robotic Vs. Laparoscopic RYGB

BACKGROUND

Proximal Roux-en-Y gastric bypass is commonly used to manage obesity, performed using laparoscopic or robot-assisted minimally invasive surgery. As the prevalence of robotic bariatric surgery increases, further data is required to justify its use.

METHODS

This was a large, retrospective analysis of prospectively recorded data for Roux-en-Y gastric bypass (RYGB) procedures performed using laparoscopic (LRYGB) or robotic (RRYGB; da Vinci Xi system, Intuitive Surgical Sàrl) surgery between January 2016 and March 2019. The surgical techniques did not differ apart from different trocar placements. Data collected included patient characteristics before and after RYGB, operative outcomes and complications.

RESULTS

In total, 114 RRYGB and 108 LRYGB primary surgeries were performed. There were no significant differences between the groups, apart from a significantly shorter duration of surgery (116.9 vs. 128.9 min, respectively), lower C-reactive protein values at days 1 (31.1 vs. 44.1 mg/l) and 2 (50.3 vs. 77.8 mg/l) after the intervention, and overall complication rate (4.4 vs. 12.0%, Clavien-Dindo classification II-V) with RRYGB compared with LRYGB. There was a lower hemoglobin value in the postoperative course after RRYGB (12.1 vs. 12.6 g/dl, day 2).

CONCLUSIONS

In our experience, robotic RYGB has proven to be safe and efficient, with a shorter duration of surgery and lower rate of complications than laparoscopic RYGB. RRYGB is easier to learn and seems safer in less experienced centers. Increasing experience with the robotic system can reduce the duration of surgery over time. Further studies with higher evidence level are necessary to confirm our results.

Clinical outcomes and functional analysis of third space robotic and endoscopic cooperative surgery versus laparoscopic wedge resection for gastric submucosal tumours: a propensity score-matched study

Third space robotic and endoscopic cooperative surgery (TS-RECS) is a novel minimally invasive surgery for resecting gastric submucosal tumours (GSMTs), which could accomplish the completely oncological curability and maximal functional preservation. This study investigated the clinical outcomes and gastrointestinal function after TS-RECS versus laparoscopic wedge resection (LWR) for GSMTs. This was a single-centre retrospective study that included 130 patients with GSMTs who underwent LWR or TS-RECS from 2013 to 2019. To overcome selection biases, we performed propensity score matching (1:1) using seven covariates that could impact the group assignment and outcomes. Then, the clinical outcomes and gastrointestinal function in the LWR and TS-RECS groups were compared in a matched cohort. Among the 130 enrolled patients, 96 patients underwent LWR, and 34 underwent TS-RECS and were matched into 30 patients for each group. There was no significant difference in the operation time between the two groups (P = 0.543). However, the TS-RECS group had significantly less blood loss (20,5–100 vs 95,10–310 ml, P < 0.0001) and better postoperative recovery in terms of time to oral intake (2,2–4 vs 3,2–6 days, P < 0.0001) and postoperative hospital stay (5,4–10 vs 8.5,5–16 days, P < 0.0001) than the LWR group. The severity and frequency scores of postoperative gastrointestinal symptoms in the TS-RECS group were significantly lower than those in the LWR group. The median follow-up period was 24 months (10–60 months) in the LWR group and 18 months (10–27 months) in the TS-RECS group, and there was in total a single recurrence in the LWR group. TS-RECS appears to be a technically safe and effective surgery with preservation of gastrointestinal function for resection of GSMT resection.

Role of Robotic Surgery in Complex Revisional Bariatric Procedures

PURPOSE

Revisional bariatric surgery (RBS) is becoming more common, with an estimated increase of more than 300% from 2017 to 2018. For these complex procedures, the role of robotics is still debated. The purpose of our study is to report the safety and effectiveness of robotic-assisted RBSs.

MATERIALS AND METHODS

A retrospective review of electronic medical records was conducted for robotic-assisted RBSs performed at the Mayo Clinic in Florida, between January 1, 2016, and January 1, 2020. Peri- and postoperative data were analyzed, reviewing patient characteristics, indications for surgery, and outcomes.

RESULTS

From 160 RBSs performed during the study period, 67 were robotic-assisted and met inclusion criteria. Primary procedures included sleeve gastrectomy (26 [38.8%]), adjustable gastric band (24 [35.8%]), Roux-en-Y gastric bypass (14 [20.9%]), vertical-banded gastroplasty (2 [3.0%]), and duodenal switch (1 [1.5%]). RBSs performed were Roux-en-Y gastric bypass (49 [73.1%]), redo gastrojejunostomy (14 [20.9%]), and duodenal switch (4 [6.0%]). Rate of conversion to open procedure and rate of readmission 1 month after surgery were 6.0% and 7.5%, respectively. Rate of 30-day Clavien-Dindo grade III or higher adverse events was 4.5%. No anastomotic leaks were documented. Fifty-two patients presented with preoperative symptoms, and 69.2% reported improvement after RBS. Mean (SD) excess weight loss was 57.62% (23.80) 12 months after RBS.

CONCLUSION

Robotic-assisted RBSs are safe with low major adverse event rates. Symptom resolution and weight loss outcomes are acceptable.

Comparative analysis of robotic versus laparoscopic Roux-en-Y gastric bypass in severely obese patients

Benefits of robotic surgery for Roux-en-Y gastric bypass (RYGB) are still debated. We aimed to compare conventional laparoscopic (L-RYGB) to robotic RYGB (R-RYGB) and evaluate safety, efficacy, advantages and drawbacks of each procedure. A prospective cohort study with a retrospective review approach was conducted to analyze results of L-RYGB and R-RYGB performed at a bariatric center of excellence. Patient demographics, perioperative data, weight loss, comorbidities evolution and cost were assessed. One hundred and sixty-one severely obese patients underwent R-RYGB and L-RYGB, respectively. Patient's characteristics were similar between groups. Intraoperative blood loss was similar (p = 0.91), with no requirement for blood transfusion. Median operative time was significantly reduced for R-RYGB (127 vs 160 min; p < 0.001). Seven patients (11.4%) in the L-RYGB group and 15 patients (15%) in the R-RYGB group had early postoperative complications (p = 0.63), with more anastomotic leaks and stenosis for R-RYGB during initial learning curve (p = NS). Mortality was null. Median length of hospital stay was similar (6 days; p = 0.20). Mean hospital cost was non-significantly increased for R-RYGB ($5730 vs. $4879; p = 0.34). Two years after surgery, median BMI and mean EWL% were similar for both groups (26.1 vs 26.5 kg/m² and 89.9% vs 90.9% for L-RYGB and R-RYGB groups, respectively; p = 0.71 and 0.85, respectively), with no statistically significant difference in comorbidities between the two groups (p = 0.80). R-RYGB is feasible and safe within the reach of every laparoscopic surgeon. In our series, it was associated with shorter operative time and equivalent length of stay and weight loss outcomes compared to L-RYGB. Further well-designed randomized studies are necessary to draw safe conclusions.

Robotic Duodenal Switch Is Associated with Outcomes Comparable to those of Laparoscopic Approach

Introduction/Purpose

This study evaluates the outcomes of robotic duodenal switch (RDS) when compared to conventional laparoscopy (LDS).

Materials and Methods

Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), patients who underwent RDS were compared to those of LDS (2015–2018) for perioperative characteristics and thirty-day postoperative outcomes. Operative complexity, complications, and resource utilization trends were plotted over the included years for the two approaches. Multivariable analysis was conducted to characterize the impact of each approach on these outcomes.

Results

Of 7235 minimally invasive operations, 5720 (79.1%) were LDS while 1515 (20.9%) were RDS. Intraoperative endoscopy, anastomosis testing, and shorter operative duration were associated with LDS. RDS group had more concomitant procedures with less attending assistance. The odds ratios of organ space infection and sepsis were equivalent. RDS increased the odds ratios for venous thromboembolism [VTE] (odds ratio [OR] = 2.3, 95% confidence interval [CI] = 1.1–4.8, p = 0.02) and early discharge (OR = 7.3, CI = 4.9–10.9, p < 0.01). The difference in wound infection between LDS and RDS has been decreasing (1.5% and 1.5% in 2018 from 2.3% and 4.1% in 2015, respectively) over the years. Similarly, the decreasing trends were noted for systemic infections.

Conclusion

While the development of VTE after RDS was higher, most of the other complications were comparable between LDS and RDS in this study. RDS may reduce the need for advanced intraoperative assistance and minimize hospital stay in select cases, without increasing morbidity. The recent trends suggest a gradual decrease in the variations between LDS and RDS outcomes over time.

Robotic Revisional Bariatric Surgery: a High-Volume Center Experience

PURPOSE

The number of bariatric revisional procedures is growing. Scarce evidence is available regarding the role and postoperative outcomes of robotic-assisted revisional bariatric surgery (RRBS). The aim of this study is to evaluate the safety and postoperative outcomes of RRBS.

MATERIALS AND METHODS

A retrospective analysis of a prospectively collected database of patients who underwent RRBS between 2012 and 2019 was performed. Primary outcomes of interest were 30-day major morbidity, mortality, length of hospital stay (LOS), urgent reoperation rates, and percentage of total weight loss (%TWL).

RESULTS

RRBS was performed in 76 patients; among these 60 (78.9%) underwent conversion to Roux-en-Y gastric bypass (C-RYGB). Failed weight loss (76%) and gastroesophageal reflux (9.2%) were the main indications for revision. Primary bariatric procedures included gastric band (LAGB) (50%), sleeve gastrectomy (SG) (40.8%), and RYGB (6.6%). Major morbidity and mortality rates were 3.9% and 1.3%, respectively. Mean LOS was 2.1 days, and 3 patients (3.9%) required urgent reoperation. The %TWL at 3, 6, 12, and 24 months was 10.2%, 16.6%, 18.3%, and 22.4% respectively. Comparative analysis of C-RYGB after failed LAGB and SG showed similar morbidity. Higher readmission rates (SG: 22.2% vs. LAGB: 0%, p = 0.007) and lower %EWL at 3, 6, 12, and 24 months were found in C-RYGB after SG.

CONCLUSION

This is one of the largest single-center series of RRBS published in the literature; the data indicate that robotic approach for revisional bariatric surgery is safe and helps achieving further weight loss. RRBS outcomes might be influenced by the primary procedure.

Comparison Between Robotic and Laparoscopic or Open Anastomoses: A Systematic Review and Meta-Analysis

INTRODUCTION

Robotic surgery has been increasingly used in fashioning various surgical anastomoses. Our aim was to collect and analyze outcomes related to anastomoses performed using a robotic approach and compare them with those done using laparoscopic or open approaches through meta-analysis.

METHODS

A systematic review was conducted for articles comparing robotic with laparoscopic and/or open operations (colectomy, low anterior resection, gastrectomy, Roux-en-Y gastric bypass (RYGB), pancreaticoduodenectomy, radical cystectomy, pyeloplasty, radical prostatectomy, renal transplant) published up to June 2019 searching Medline, Scopus, Google Scholar, Clinical Trials and the Cochrane Central Register of Controlled Trials. Studies containing information about outcomes related to hand-sewn anastomoses were included for meta-analysis. Studies with stapled anastomoses or without relevant information about the anastomotic technique were excluded. We also excluded studies in which the anastomoses were performed extracorporeally in laparoscopic or robotic operations.

RESULTS

We included 83 studies referring to the aforementioned operations (4 randomized controlled and 79 non-randomized, 10 prospective and 69 retrospective) apart from colectomy and low anterior resection. Anastomoses done using robotic instruments provided similar results to those done using laparoscopic or open approach in regards to anastomotic leak or stricture. However, there were lower rates of stenosis in robotic than in laparoscopic RYGB (p=0.01) and in robotic than in open radical prostatectomy (p<0.00001). Moreover, all anastomoses needed more time to be performed using the robotic rather than the open approach in renal transplant (p≤0.001).

CONCLUSION

Robotic anastomoses provide equal outcomes with laparoscopic and open ones in most operations, with a few notable exceptions.

Outcomes in conventional laparoscopic versus robotic-assisted primary bariatric surgery: a retrospective, case-controlled study of the MBSAQIP database

Introduction

Robotic-assisted bariatric surgery is increasingly performed. There remains controversy about the overall benefit of robotic-assisted (RBS) compared to conventional laparoscopic (LBS) bariatric surgery. In this study, we used a large national risk-stratified bariatric clinical database to compare outcomes between robotic and laparoscopic gastric bypass (RNYGB) and sleeve gastrectomy (SG).

Methods

A retrospective analysis of the 2015 and 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use Data File (PUF) was performed. Primary robotic and laparoscopic RYNGB and SG were analyzed. Descriptive analysis was performed of the unmatched cohorts, followed by 1:3 case-controlled matching. Cases and controls were matched by patient demographics and pre-operative comorbidities, and peri-operative outcomes compared.

Results

77,991 Roux-en-Y gastric bypass (RnYGB) (7.5% robotic-assisted) and 189,503 SG (6.8% robotic-assisted) cases were identified. Operative length was significantly higher in both the robotic-assisted RnYGB and SG cohorts (p < 0.0001). Outcomes were similar between the robotic-assisted and laparoscopic RnYGB cohorts, except a lower mortality rate (p = 0.05), transfusion requirement (p = 0.005), aggregate bleeding (p = 0.04), and surgical site infections (SSI) (p = 0.006) in the robotic-assisted cohort. Outcomes were also similar between robotic-assisted and laparoscopic SG, except for a longer length of stay (p < 0.0001) and higher rates of conversion (p < 0.0001), 30-day intervention (p = 0.01), operative drain present (p < 0.0001), sepsis (p = 0.01), and organ space SSI (p = 0.0002) in the robotic cohort. Bleeding was lower in the robotic SG cohort and mortality was similar.

Conclusion

Both robotic-assisted and laparoscopic RnYGB and SG are overall very safe. Robotic-assisted gastric bypass is associated with a lower mortality and morbidity; however, a clear benefit for robotic-assisted SG compared to laparoscopic SG was not seen. Given the longer operative and hospital duration, robotic SG is not cost-effective.

Electronic supplementary material

The online version of this article (10.1007/s00464-019-06915-7) contains supplementary material, which is available to authorized users.