Current Trends in the Utilization of a Robotic Approach in the Field of Bariatric Surgery

More procedures, more efficiency: optimizing operating room during the phase of learning curve-experience of first 100 robotic bariatric procedures in a single center

Robotic bariatric surgery (RBS) is increasingly adopted worldwide. This study aims to evaluate the implementation and evolution of RBS at a high volume center over five years, focusing on operative time (OT), operating room (OR) efficiency, and cost outcomes. A prospective analysis was conducted on patients undergoing elective RBS between July 2021 and March 2025 at ARNAS G. Brotzu, Cagliari. Metrics included OT, OR session time, and surgical volume. Variables analyzed included OT, OR session time, and surgical volume. Efficiency metrics such as overall OR efficiency, defined as OR session time/OT (Eff1), and robotic console utilization, defined as OR session time/console time (Eff2) were derived. Cost analysis incorporated OR activation time, surgeon and material costs. Statistical analyses included t-tests, Pearson's correlation, and linear regression. 100 robotic-assisted procedures were recorded. Robotic adoption increased from 4.06% in 2021 to 38.98% in 2025. A learning curve (LC) was identified, with a significant OT reduction after the first 34 Roux-en-Y gastric bypass cases (p = 0.001). Full robotic manual anastomosis showed a notable cost decrease in later cases (p < 0.0001). Increased surgical volume correlated with both reduced OT (r = - 0.58) and improved Eff1 (r = - 0.49, p = 0.005). However, Eff2 changes were not statistically significant (r = - 0.31, p = 0.09), underscoring the need for team-wide coordination. RBS in high-volume centers enhance OR efficiency and cost-effectiveness over time. The LC, surgical volume, and institutional workflows were key factors in optimizing efficiency, highlighting the importance of a collective LC for the entire surgical team.

Robotic bariatric surgery in Australia: early outcomes from a national clinical quality registry with propensity score matched analysis

The robotic approach to metabolic bariatric surgery (MBS) is becoming more popular despite limited data supporting beneficial outcomes. The objective of this study was to evaluate the early outcomes of robotic MBS in Australia. An observational analysis of prospectively maintained data from the Australian arm of the Australia and New Zealand Bariatric Surgery Registry between 2014 to June 2022 were conducted. All patients who underwent robotic MBS (RMBS) were propensity score matched 1:1 to laparoscopic MBS (LMBS) within the Registry. Clinical outcomes were compared using conditional logistic regression analyses. A total of 66,232 patients were included (LMBS n = 65,322; RMBS n = 910) in the analysis. The majority of RMBS were gastric or duodenal-ileal bypasses, significantly higher than the LMBS cohort (49.6 vs 24.3%, p < 0.0001) and more were revisional procedures (26% vs 19.6%, p < 0.0001). On direct comparison, there were significantly more defined adverse events in the RMBS group. When adjusted for cofounders, clinical outcomes of RMBS were comparable to LMBS with no increased risks of defined adverse events or complications.

Indications and Outcomes of Laparoscopic Versus Robotic Conversional Bariatric Surgery: An MBSAQIP Study

BACKGROUND

Conversional bariatric surgeries (CBS) are performed using laparoscopic and robotic techniques, but comprehensive data comparing these approaches remains scarce.

OBJECTIVE

To compare the indications and outcomes of laparoscopic versus robotic CBS.

METHODS

The MBSAQIP database was retrospectively analyzed from 2020 to 2022, comparing laparoscopic and robotic CBS. Primary outcomes were 30-day serious complications and mortality.

RESULTS

Of 72,189 CBS procedures, 75.4% were laparoscopic and 24.6% robotic. Mean age and BMI were similar between groups. The most common indications for both approaches were reflux, weight regain, and inadequate weight loss, with reflux being more prevalent in robotic CBS (38.3% vs 33.2%). Sleeve-to-bypass was the most common procedure in both groups (35.8% laparoscopic, 44.2% robotic). Robotic CBS had longer mean operative times (165.4 vs 121.7 min, p < 0.001) and slightly longer hospital stays (1.7 vs 1.6 days, p < 0.001). The rate of serious complications was slightly higher for robotic CBS, though not statistically significant (6.5% vs 6.1%, p = 0.08). Robotic CBS had higher rates of leak (0.9% vs 0.7%, p = 0.071), reoperation (2.8% vs 2.6%, p = 0.138), and readmission (6.7% vs 5.4%, p < 0.001). Mortality rates were similar (0.1% for both, p = 0.942).

CONCLUSIONS

Both laparoscopic and robotic CBS show similar safety profiles with comparable mortality rates. However, robotic CBS was associated with longer operative times, slightly longer hospital stays, and higher readmission rates. These findings suggest that the choice between approaches should consider individual patient factors and institutional expertise.

Robotic-assisted sleeve gastrectomy: an analysis of cost, peri-operative outcomes and learning curve in a prospective cohort study

Minimally invasive sleeve gastrectomy as a treatment for individuals living with severe obesity remains the most common operation in bariatric and metabolic surgery. With the introduction of robotic-assisted surgery, an increasing proportion of sleeve gastrectomies are performed using the da Vinci robotic surgical platform. To date, the evidence to support or contest this practice is still unclear although meta-analyses have shown safety and feasibility. Here we present a prospective cohort study comparing 101 consecutive patients who had either robotic-assisted or laparoscopic sleeve gastrectomy for obesity. Short-term outcomes, including length of stay and thirty-day complication rates, as well as the total consumable cost for both the laparoscopic and robotic-assisted procedures were collected. We also assessed the learning curve associated with robotic-assisted sleeve gastrectomy. The cohort had similar baseline characteristics in terms of BMI and co-morbidity. The mean operative time, post-operative CRP and complication rates were the same in both groups. Length of stay was statistically shorter for the robotic-assisted cohort in comparison to the laparoscopic cohort; 1.3 days versus 1.9 days, respectively (p < 0.005). The percentage of patients requiring only a single night admission was significantly higher at 82% in the robotic-assisted group, compared to 32% in the laparoscopic group (p < 0.005); in the context of a nurse-led-discharge protocol. Total consumable cost was significantly lower in the robotic group at an average of £2310, compared to £2665 in the laparoscopic group (p < 0.001). The learning curve for the procedure was found to be 26 cases, predominantly driven by the resectional component of the procedure. Robotic-assisted sleeve gastrectomy on the 4th generation da Vinci system utilising robotic advanced energy and Sureform stapling is safe and effective. This cohort study suggests that using the robotic platform is favourable in terms of overall consumable cost and may reduce length of stay. In the context of previous robotic experience, the observed learning curve is relatively short.

Exploring the Impact of the Physical Environment on Robotic-Assisted Surgery Outcomes and Processes: A Scoping Review

ObjectiveThe purpose of this scoping review is to identify physical environmental facilitators and barriers related to performing robotic-assisted surgery (RAS) in operating rooms (ORs).BackgroundAs new robotic surgery technology is developed and brought to market, there is a need to understand how existing and future operating rooms are adapted and designed to support patient safety, surgical workflow, and teamwork. This review will focus on literature related to physical environment factors that impact workflow and communication, as well as the adoption of RAS technology.MethodThe scoping review search was conducted during November 2022, following the PRISMA guidelines. An independent reviewer screened articles for inclusion and exclusion and two independent reviewers completed a quality appraisal was on the included articles.ResultsOf the 9325 texts screened, 28 articles were included for analysis. The primary physical environment and outcome variables were extracted and synthesized under the following categories: RAS process or task-related, environmental features, environmental qualities, and staff or patient outcomes.ConclusionThe physical environment of the OR, such as OR layout, OR size, environmental noise, and dedicated robotic ORs played a significant role in efficiency and workflow outcomes for RAS, as well as workload measures, staff and patient safety, and surgical performance.ApplicationSince there are minimal evidence-based resources available for the application of RAS, this review provides distinct connections between RAS outcomes and specific environmental features for considerations among design researchers, architects, human factors professionals, hospital administrators, and practitioners to aid in decision making during and after implementation of RAS technology.

Robotic sleeve gastrectomy has higher complication rates compared to laparoscopic: 8-year analysis of robotic versus laparoscopic primary bariatric surgery

BACKGROUND

Robotic-assisted bariatric surgery is growing rapidly. The optimal approach to minimize complications remains unclear.

OBJECTIVE

Assess robot utilization and compare 30-day outcomes for laparoscopic and robotic primary sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

SETTING

United States.

METHODS

A retrospective analysis of the MBSAQIP database identified primary SG and RYGB cases from 2015 to 2022. Revisions/conversions, cases converted to another approach, and combined cases other than esophagogastroduodenoscopy were excluded. Outcomes were compared with logistic regression following 1:1 propensity-score matching to adjust for differences in patient demographics/comorbidities and operative variables.

RESULTS

A total of 823,902 cases (591,118 SG; 232,784 RYGB) were included. From 2015 to 2022, the percentage of SG and RYGB performed robotically increased from 6.7% and 6.9% to 29.5% and 31.8%, respectively. Compared to laparoscopic, robotic SG had significantly higher overall morbidity (odds ratio 1.14 [1.07-1.21], P < .001), leak (1.24 [1.05-1.46], P = .03), and bleeding rates (1.34 [1.13-1.58], P < .001). Robotic RYGB had significantly lower overall morbidity (.75 [.70-.81], P < .001) and bleeding (.80 [.68-.94], P < .01) with similar leak rates (.87 [.71-1.07], P = .18). Combined robotic SG and RYGB outcomes were similar to laparoscopic for 2020-2022 cases, except for higher rates of organ/space infection, readmission, and septic shock in the robotic group.

CONCLUSION

Robotic SG has higher complication rates compared to laparoscopic, while robotic RYGB is protective against bleeding complications. Short-term outcomes for robotic surgery have become more similar to laparoscopic, but remain inferior. Further studies are warranted to elucidate the factors driving these findings.

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.

Robotics, money and research: is data or physician payments driving robotic bariatric surgery literature?

INTRODUCTION

Physician payments from Intuitive Surgical have increased from 37 million to over 53 million per year since 2018. The study was completed to determine the accuracy of conflict of interest (COI) statements and the influence of industry payments on the valuation of the robotic platform.

METHODS

PubMed and Medline search for "robotic, robotic assisted" and "bariatric, Gastric Bypass, Sleeve Gastrectomy, Biliopancreatic Diversion, and Single Anastomosis Duodeno-Ileal Bypass". Manuscripts on robotic bariatric surgery with a US author with an electronic publication (EPub) date between 2018 and 2022 were included. Manuscripts were reviewed for disclosure of COI. The manuscripts were reviewed by two reviewers. The Introduction, Results, and Discussion/Conclusion were scored as Robotic Unfavorable, Neutral, or Robotic Favorable. https://OpenPaymentsData.CMS.gov was reviewed for physician payments 1 year prior and 1 year following the EPub date.

RESULTS

Robotic favorable manuscripts were significantly less likely to have an adequate COI. Authors of robotic favorable manuscripts were significantly more likely to have a COI. Authors of robotic favorable manuscripts had significantly a higher Intuitive physician compensation. In addition, authors of robotic favorable manuscripts were significantly more likely to have an increase in the amount of compensation by Intuitive Surgical the following year.

CONCLUSION

Our findings suggest that Intuitive open payments have significantly influenced favorable reports in robotic bariatric literature. The submission of open payments data, to include compensation amounts should be required for manuscript publication or acceptance to surgical conferences.

Metabolic/bariatric surgery optimization: a position statement by Arabic association for the study of diabetes and metabolism (AASD)

For patients considering bariatric surgery, it is essential to have clear answers to common questions to ensure the success of the procedure. Patients should understand that surgery is not a quick fix but a tool that must be complemented by lifestyle changes, including dietary adjustments and regular physical activity. The procedure carries potential risks that should be weighed against the potential benefits. Health authorities play a critical role in ensuring that bariatric surgery is performed under the highest standards of care. Recommendations are provided to determine who is an appropriate candidate for surgery, what preoperative evaluations are necessary, and how to monitor patients postoperatively to maximize outcomes and minimize risks. Additionally, authorities are responsible for ensuring access to follow-up care, including nutritional support and psychological counseling, which are vital for the long-term success of bariatric surgery.Understanding these aspects by both patients and decision-makers is critical before proceeding with bariatric surgery. The following questions guide patients and healthcare professionals in making informed decisions about the procedure and managing the expectations and outcomes associated with bariatric surgery.

First modified Delphi consensus statement on robotic-assisted da Vinci sleeve gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) is the most commonly performed metabolic and bariatric surgery (MBS) procedure. Technical considerations related to the performance of SG are well established and reported in the literature but not in relation to robotic-assisted (RA) SG. We report the results of the first modified Delphi consensus-building exercise addressing technical considerations of RA da Vinci (dV) SG.

OBJECTIVES

Develop best practices for the performance of robotic-assisted da Vinci sleeve gastrectomy.

SETTING

Survey based consensus statement.

METHODS

A consensus building committee (CBC) was created comprising 10 experts in the field of RA surgery and MBS based on strict selection criteria. The CBC developed 49 consensus statements which were then shared with 240 experts in RA surgery. Our stopping criterion was stability in responses (≤15%). The consensus cut point was 70%.

RESULTS

The overall response rate was 49%. In the first round of voting, there was consensus agreement on 25 statements (51%), consensus disagreement on 14 (28%), and no consensus on the remaining statements (21%). In the second round of voting, we reached agreement on 3 additional statements. Experts recommended the use of the number of pauses generated by the stapler to guide choice of staple height (91.2%) and to upsize the staple height when using buttressing (92%). There was also consensus (81.4%) that the use of the closed staple height of 1.00 mm (white) is acceptable and that stapling of the antrum using a 1.5-mm staple (blue load) is also acceptable (73%).

CONCLUSIONS

Collective expert opinion structured through a modified Delphi consensus statement presents a practical guide for surgeons interested in performing dV-SG.

Robotic bariatric surgery reduces morbidity for revisional gastric bypass when compared to laparoscopic: outcome of 8-year MBSAQIP analysis of over 40,000 cases

INTRODUCTION

Robotic-assisted metabolic and bariatric surgery (MBS) is gaining popularity. Revisional MBS is associated with higher perioperative morbidity compared to primary MBS. The optimal surgical approach to minimize complications in these complex cases is unclear. The goal of this study was to assess robot utilization in revisional MBS and compare laparoscopic and robotic revisional MBS outcomes in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

METHODS

A retrospective review of the MBSAQIP database was performed identifying revisional sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cases from 2015 to 2022. Primary MBS, open/emergent cases, cases converted to another approach, and combined cases other than esophagogastroduodenoscopy were excluded. 30-Day outcomes for laparoscopic and robotic cases were compared using multivariate logistic regression adjusting for patient demographics, comorbidities, and operative variables.

RESULTS

41,404 Cases (14,474 SG; 26,930 RYGB) were identified. From 2015 to 2022, the percentage of revisional SG and RYGB cases performed robotically increased from 6.1% and 7.3% to 24.2% and 32.0% respectively. Laparoscopic SG had similar rates of overall morbidity, leak, bleeding, readmission, reoperation, and length of stay compared to robotic. Laparoscopic RYGB had significantly higher rates of overall morbidity (6.2% vs. 4.8%, p < 0.001, AOR 0.80 [0.70-0.93]), blood transfusion (1.5% vs. 1.0%, p < 0.05, AOR 0.74 [0.55-0.99]), superficial incisional SSI (1.2% vs. 0.4%, p < 0.001, AOR 0.30 [0.19-0.47]), and longer length of stay (1.87 vs. 1.76 days, p < 0.001) compared to robotic. Laparoscopic operative times were significantly shorter than robotic (SG: 86.4 ± 45.8 vs. 113.5 ± 51.7 min; RYGB: 130.7 ± 64.7 vs. 165.5 ± 66.8 min, p < 0.001).

CONCLUSION

Robot utilization in revisional bariatric surgery is increasing. Robotic surgery has lower postoperative morbidity and shorter length of stay in revisional RYGB when compared to laparoscopic. Robotic platforms may have the capacity to improve the delivery of care for patients undergoing revisional bariatric surgery.

Scientific production on robotic metabolic and bariatric surgery: a comprehensive bibliometric analysis on its current world status

BACKGROUND

 Robotic metabolic and bariatric surgery (RMBS) has emerged as an innovative approach in the treatment of severe obesity by combining the ergonomic precision of robotic technology and instrumentation with the established benefits of weight loss surgery. This study employs a bibliometric approach to identify local research trends and worldwide patterns in RMBS.

MATERIALS & METHODS

 The research methodology used "robotic" and "metabolic" or "bariatric surgery" to search Web of Science. Articles that were published prior to December 31st, 2023, were included. The analyses were developed using the Rayyan and Bibliometric, in R Studio.

RESULTS

 265 articles from 51 different journals were included. Scientific production of RMBS experienced a significant annual growth rate of 21.96% from 2003 to 2023, resulting in an average of 12.6 papers published per year. A high correlation (R2 = 0.94) was found between the year and number of articles. The mean number of citations per document was 13.25. Approximately 90% of the journals were classified as zone 3, according to the Bradford categorization. International collaboration was identified in 10.57% of cases, with the University of California and the University of Illinois being the most common organizations. The countries with the highest number of corresponding authors, in descending order, were the United States of America, China, and Switzerland.

CONCLUSION

 Scientific production in RMBS has experienced sustained growth since the first original publications in 2003. While it has not yet reached the volume, impact, and international collaboration seen in studies related to non-robotic metabolic and bariatric surgery, RBMS holds potential that remains to be explored.

Six-year analysis of 30-day post-operative leaks for primary sleeve gastrectomy: a MBSAQIP database study

BACKGROUND

Sleeve gastrectomy is the most performed bariatric surgery. Post-operative gastric sleeve leaks, although rare, are dreaded complications. This study aims to perform an updated investigation of the factors associated with sleeve leaks.

METHODS

This retrospective cohort study analyzed 692,554 cases from the MBSAQIP database (2016-2021) with CPT code 43,775 for primary sleeve gastrectomy. We excluded emergency operations, conversions/revisions, endoscopic interventions, patient with prior foregut surgery, and open operations. Multivariate logistic regression analysis (STATA version 15) was performed to identify factors associated with sleeve gastrectomy leaks.

RESULTS

Out of 692,554 patients, 600,910 (86.77%) patients underwent laparoscopic sleeve gastrectomy, and 91,644 (13.23%) patients underwent robotic sleeve gastrectomy. 1179 (0.17%) developed leaks within 30 days; 177(0.19%) were in the robotic group and 1002 (0.17%) in the laparoscopic group with no significant difference in leak rates between two groups on multivariate analysis. Black patients had lower odds of having leaks as compared to white patients (Odds Ratio (OR): 0.68 (0.56-0.82); p < 0.01). Hispanic patients had lower odds of having leak as compared to non-Hispanics. Factors associated with higher leak odds (p < 0.05) included hypertension, GERD, smoking, immunosuppression, increased operating time, and albumin < 3.5 g/dl. Higher odds of leaks were observed in years 2016-2019 vs 2020-2021 (OR: 1.44 (1.25-1.65), p < 0.01). Higher odds of leak in operations with general surgeons compared to bariatric surgeons was found (OR: 1.46 (1.04-2.02), p = 0.02); observed only on robotic group on subgroup analysis (OR: 2.2 (1.2-4.2), p = 0.02). Staple line reinforcement, oversewing, and performance of leak test showed no differences in leak rate. Bougie size and distance from pylorus were not associated with changes in leak rate.

CONCLUSION

This study provides updated insights into the factors associated with sleeve leaks, reinforcing information gained from prior studies. A higher association of leak among general surgeons could represent a learning curve for new robotic general surgeons. The overall decreasing trend for gastric sleeve leak is encouraging and may be a sign of improved techniques.

Laparoscopic versus robotic-assisted primary bariatric-metabolic surgery. Are we still expecting to overcome the learning curve? A propensity score-matched analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database

BACKGROUND

Robotic surgery is becoming increasingly popular in bariatric-metabolic surgery. However, its superiority regarding postoperative outcomes compared with conventional laparoscopy has not been clearly proven. With growing adoption of robotic surgery and improved technologies, benefits should become more evident.

OBJECTIVES

Evaluate readmission and reoperation rates after bariatric-metabolic surgery performed by conventional laparoscopy versus robotic-assisted from 2015 to 2021.

SETTING

Academic institution.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) was reviewed for primary bariatric operations performed with conventional laparoscopy versus robotic-assisted. Postoperative outcomes were compared in a propensity score-matched sample.

RESULTS

Of 1,059,348 cases meeting inclusion criteria, 921,322 (87%) were conventional laparoscopic bariatric-metabolic surgeries, which were matched 1:1 with robotic-assisted cases (138,026). Reoperation (odds ratio [OR] 1.07; 95% confidence interval [CI] 1.00-1.15, P = .0463), postoperative morbidity (OR 1.07; 95% CI 1.01-1.12, P = .0193), readmission (OR 1.14; 95% CI 1.09-1.18, P < .0001), and emergency department visits (OR 1.06; 95% CI 1.03-1.09, P = .0003) at 30 days postoperatively were significantly greater for robotic-assisted cases. Robotic-assisted cases had a similar mortality rate at 30 days postoperatively and length of stay >3 days when compared with conventional laparoscopic cases. Similar results were observed in cases from 2020 to 2021, except for reoperation and emergency department visits, which showed no difference between groups and length of stay >3 days, which was greater in robotic-assisted cases.

CONCLUSIONS

Our results show a greater readmission and reoperation rate and greater morbidity at 30 days postoperatively in robotic-assisted bariatric-metabolic surgery compared with conventional laparoscopy. Analyzing only cases performed between 2020 and 2021, robotic surgery also does not show superiority over conventional laparoscopy.

Predictors and Outcomes Associated with Bariatric Robotic Delivery: An MBSAQIP Analysis of 318,151 Patients

Background: The adoption of robotic bariatric surgery has increased dramatically over the last decade. While outcomes comparing bariatric and laparoscopic approaches are debated, little is known about patient factors responsible for the growing delivery of robotic surgery. A better understanding of these factors will help guide the planning of bariatric delivery and resource allocation. Methods: Data were extracted from the MBSAQIP registry from 2020 to 2021. The patient population was organized into primary robot-assisted sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) versus those who underwent laparoscopic procedures. Bivariate analysis and multivariable logistic regression modeling were conducted to characterize cohort differences and identify independent patient predictors of robotic selection. Results: Of 318,151, 65,951 (20.7%) underwent robot-assisted surgery. Patients undergoing robotic procedures were older (43.4 ± 11.8 vs. 43.1 ± 11.8; p < 0.001) and had higher body mass index (BMI; 45.4 ± 7.9 vs. 45.0 ± 7.6; p < 0.001). Robotic cases had higher rates of medical comorbidities, including sleep apnea, hyperlipidemia, gastroesophageal reflux disease (GERD), and diabetes mellitus. Robotic cases were more likely to undergo RYGB (27.4% vs. 26.4%; p < 0.001). Robotic patients had higher rates of numerous complications, including bleed, reoperation, and reintervention, resulting in higher serious complication rates on multivariate analysis. Independent predictors of robotic selection included increased BMI (aOR 1.02), female sex (aOR 1.04), GERD (aOR 1.12), metabolic dysfunction, RYGB (aOR 1.08), black racial status (aOR 1.11), and lower albumin (aOR 0.84). Conclusions: After adjusting for comorbidities, patients with greater metabolic comorbidities, black racial status, and those undergoing RYGB were more likely to receive robotic surgery. A more comprehensive understanding of patient factors fueling the adoption of robotic delivery, as well as those expected to benefit most, is needed to better guide healthcare resources as the landscape of bariatric surgery continues to evolve.

Robotic Versus Laparoscopic Sleeve Gastrectomy Outcome Trends Over Time: Are We Improving?

BACKGROUND

Sleeve gastrectomy (SG) is an effective treatment option for patients with obesity. Robotic sleeve gastrectomy (RSG) is reported to have worse short-term patient outcomes compared to laparoscopic SG (LSG), but prior studies may not have accounted for evolving technology, including stapler utilization.

OBJECTIVE

This study compared RSG and LSG outcomes over different time periods.

SETTING

Academic Hospital.

MATERIAL AND METHODS

The 2015 to 2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBSAQIP) databases were used. Matched cohort analyses compared adverse outcomes within 30 days for the 2015-2018 and 2019-2021 cohorts. Bivariate and regression models compared cohorts using Stata/MP 17.0.

RESULTS

Seven hundred sixty-eight thousand and sixty-nine SG were analyzed. Over the 7-year study period, all patient outcomes, operation length (OL), and length of stay (LOS) trended downward for RSG, except surgical site infection (SSI). In the 2015-2018 cohort, leak was significantly higher with RSG (OR 1.53), and OL and LOS longer (p < 0.001). In the 2019-2021 cohort which corelated with a significant increase in robotic cases, leak (OR 1.36), SSI (OR 1.46), and morbidity (OR 1.11) were higher with RSG. While the mean difference in OL and LOS decreased between the two time periods, they remain longer for RSG (p < 0.001).

CONCLUSION

While RSG and LSG are safe with similar mortality, RSG continues to be associated with higher rates of morbidity, leak, and SSI, as well as longer OL, hospital LOS, and higher cost. The study is limited by the ability to account for the impact of surgeon experience and stapler utilization on outcomes.

A superior approach? The role of robotic sleeve gastrectomy in patients with super super obesity using the 2019-2022 MBSAQIP database

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) in patients with BMI ≥ 60 presents technical challenges, that might be overcome by robotic surgery, but its effectiveness has not been rigorously evaluated. We compared the 30-day outcomes of LSG and robotic sleeve gastrectomy (RSG) in patients with BMI < 60 versus ≥ 60 and between LSG and RSG in patients with BMI ≥ 60.

METHODS

Patients aged 18-65 years who underwent sleeve gastrectomy were included using the 2019-2022 MBSAQIP database. We performed a Propensity Score Matching analysis, with 21 preoperative characteristics. We compared 30-day postoperative outcomes for patients with BMI < 60 versus ≥ 60 using either a laparoscopic (Analysis 1) or robotic approach (Analysis 2) and compared LSG versus RSG in patients with BMI ≥ 60 (Analysis 3).

RESULTS

297,250 patients underwent LSG and 81,008 RSG. Propensity-matched¸ outcomes in analysis 1 (13,503 matched cases), showed that patients with BMI ≥ 60 had higher rates of mortality (0.1% vs. 0.0%, p = 0.014), staple line leak (0.3% vs. 0.2%, p = 0.035), postoperative bleeding (0.2% vs 0.1%, p = 0.028), readmissions (3.5% vs. 2.4%, p < 0.001), and interventions (0.7% vs. 0.5%, p = 0.028) when compared to patients with BMI < 60. In analysis 2 (4350 matched cases), patients with BMI ≥ 60 demonstrated longer operative times, length of stay, and higher rates of unplanned ICU when compared to patients with BMI < 60. In analysis 3 (4370 matched cases), patients who underwent RSG had fewer readmissions (2.9% vs. 3.7%, p = 0.037), staple line leaks (0.1% vs. 0.3%, p = 0.029), and postoperative bleeding (0.1% vs. 0.3%, p = 0.045), compared to LSG. Conversely, a longer operative time (92.74 ± 38.65 vs. 71.69 ± 37.45 min, p < 0.001) was reported.

CONCLUSION

LSG patients with BMI ≥ 60 have higher rates of complications compared to patients with a BMI < 60. Moreover, some outcomes may be improved with the robotic approach in patients with BMI ≥ 60. These results underscore the importance of considering a robotic approach in this super super obese population.

Updates in Bariatric Surgery

Bariatric surgery is currently the most effective long-term treatment for morbid obesity as well as type-2 diabetes mellitus. The field of metabolic and bariatric surgery has seen tremendous growth over the past decade with dramatically reduced risks. This article aims to provide an update on bariatric surgery, highlighting the latest outcomes, improvements, and challenges in the field. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) released a major update to the indications for bariatric surgery at BMI ≥35 kg/m2 regardless of co-morbidities and 30-34.9 kg/m2 with obesity-related comorbidities. Sleeve gastrectomy has emerged as the most popular bariatric procedure in the last 10 years with its remarkable efficacy and safety profile. The implementation of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and Enhanced Recovery After Surgery (ERAS) protocols have significantly improved the quality of care for all bariatric patients. The recent introduction and FDA approval of Glucagon-Like Peptide-1 (GLP-1) agonists for chronic obesity has garnered significant media coverage and popularity, but no guidelines exist regarding its use in relation to bariatric surgery. This update underscores the need for tailored approaches, ongoing research, and the integration of evidence-based medicine and innovations to enhance patient care.

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-assisted Roux-en-Y gastric bypass with the novel platform HugoTM RAS: preliminary experience in 15 patients

Robotic assisted surgery is a rapidly developing field in bariatric surgery. Its wide diffusion has led to the development and standardisation of robotic assisted approaches for various bariatric operations. However, further application has been limited thus far due to issues of cost-effectiveness and accessibility. The introduction of new robotic platforms may help overcome those obstacles. In this study, we present the first fifteen cases of Roux-en-Y Gastric Bypass (RYGB) operations performed with the new Hugo™ RAS system (Medtronic, Minneapolis, MN, USA). From January to March 2023, consecutive patients scheduled for minimal invasive Roux-en-Y-Bypass were randomly selected and underwent the procedure robotic-assisted with the new platform. No exclusion criteria were applied. Seven female and eight male patients with a median BMI of 42 (range: 36-50) and obesity-related comorbidities in eight cases underwent RYGB. The median docking time was 7 min (range: 6-8.5) and the median console time was 100 min (range: 70-150). Procedures were performed without intraoperative complications and no conversion to laparoscopy or open surgery was noted. Operative times were indicative of a steep learning curve. No early post-operative complications were observed. Based on our initial experience, RYGB with the Hugo™ RAS system is promising and may be integrated in established robotic programmes without requiring a long adaptation period.

Characterization of the robotic surgery experience in minimally invasive surgery fellowships from 2010 to 2021

BACKGROUND

Robotic surgery has experienced exponential growth in the past decade. Few studies have evaluated the impact of robotics within minimally invasive surgery (MIS) fellowship training programs. The purpose of our study was to examine and characterize recent trends in robotic surgery within MIS fellowship training programs.

METHODS

De-identified case log data from the Fellowship Council from 2010 to 2021 were evaluated. Percentage of operations performed with robot assistance over time was assessed and compared to the laparoscopic and open experience. Case logs were further stratified by operative category (e.g., bariatric, hernia, foregut), and robotic experience over time was evaluated for each category. Programs were stratified by percent robot use and the experience over time within each quartile was evaluated.

RESULTS

MIS fellowship training programs with a robotic platform increased from 45.1% (51/113) to 90.4% (123/136) over the study period. The percentage of robotic cases increased from 2.0% (1127/56,033) to 23.2% (16,139/69,496) while laparoscopic cases decreased from 80.2% (44,954/56,033) to 65.3% (45,356/69,496). Hernia and colorectal case categories had the largest increase in robot usage [hernia: 0.7% (62/8614) to 38.4% (4661/12,135); colorectal 4.2% (116/2747) to 31.8% (666/2094)]. When stratified by percentage of robot utilization, current (2020-2021) programs in the > 95th percentile performed 21.8% (3523/16,139) of robotic operations and programs in the > 50th percentile performed 90.0% (14,533/16,139) of all robotic cases. The median number of robotic cases performed per MIS fellow significantly increased from 2010 to 2021 [0 (0-6) to 72.5 (17.8-171.5), p < 0.01].

CONCLUSIONS

Robotic use in MIS fellowship training programs has grown substantially in the past decade, but the laparoscopic and open experience remains robust. There remains an imbalance with the top 50% of busiest robotic programs performing over 90% of robot trainee cases. The experience in MIS programs varies widely and trainees should examine program case logs closely to confirm parallel interests.

A cognitive task analysis of expert surgeons performing the robotic roux-en-y gastric bypass

BACKGROUND

The safe and effective performance of a robotic roux-en-y gastric bypass (RRNY) requires the application of a complex body of knowledge and skills. This qualitative study aims to: (1) define the tasks, subtasks, decision points, and pitfalls in a RRNY; (2) create a framework upon which training and objective evaluation of a RRNY can be based.

METHODS

Hierarchical and cognitive task analyses for a RRNY were performed using semi-structured interviews of expert bariatric surgeons to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed verbatim, supplemented with literary and video resources, coded, and thematically analyzed.

RESULTS

A conceptual framework was synthesized based on three book chapters, three articles, eight online videos, nine field observations, and interviews of four subject matter experts (SME). At the time of the interview, SME had practiced a median of 12.5 years and had completed a median of 424 RRNY cases. They estimated the number of RRNY to achieve competence and expertise were 25 cases and 237.5 cases, respectively. After four rounds of inductive analysis, 83 subtasks, 75 potential errors, 60 technical tips, and 15 decision points were identified and categorized into eight major procedural steps (pre-procedure preparation, abdominal entry & port placement, gastric pouch creation, omega loop creation, gastrojejunal anastomosis, jejunojejunal anastomosis, closure of mesenteric defects, leak test & port closure). Nine cognitive behaviors were elucidated (respect for patient-specific factors, tactical modification, adherence to core surgical principles, task completion, judicious technique & instrument selection, visuospatial awareness, team-based communication, anticipation & forward planning, finessed tissue handling).

CONCLUSION

This study defines the key elements that formed the basis of a conceptual framework used by expert bariatric surgeons to perform the RRNY safely and effectively. This framework has the potential to serve as foundational tool for training novices.

Improving Operating Room Efficiency of Robotic-Assisted Metabolic and Bariatric Surgery Through Standardization

INTRODUCTION

The use of robotic-assisted (RA) surgery in the field of metabolic and bariatric surgery (MBS) is controversial because of cost concerns and issues related to efficiency. The objective of this study is to evaluate the operating room efficiency in performing RA-MBS prior and after the implementation of a standardized surgical approach.

MATERIALS AND METHODS

All MBS cases entered into our database between October 2017 and October 2022 were collected and analyzed before and after the introduction of the standardized approach (SA). The outcome variables consisted of operation time (OT), turnover time (TT), wheels in-wheels out (WW), and console time (CT). Procedures were divided into Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and revisional bariatric surgery (RBS).

RESULTS

For RYGB (n = 185), we found a significant reduction in OT, TT, and WW after SA (129 min vs 139 min; 37 min vs 73 min; 165 min vs 175 min, respectively, p < 0.05). For SG (n = 253), we found a significant reduction in turnover time (TT) after SA. For RBS (n = 201), we also found a significant reduction in OT, TT, WW, and CT after SA ( 157 min vs 177 min; 36 min vs 72 min; 194 min vs 216 min; 119 min vs 134 min, respectively, p < 0.05).

CONCLUSION

Using a standardized surgical approach, we were able to demonstrate improved operation room efficiency as demonstrated by a reduction in operation length, turnover time, and the overall time of the procedure for primary RYGB and revisional procedures and turnover time for primary sleeve procedures.

Feasibility of Roux-en-Y Gastric Bypass with the novel robotic platform HUGO™ RAS

Introduction

Robotic assisted surgery is a rapidly developing field of minimally invasive bariatric surgery in the last 20 years. Its wide diffusion has led to the development and standardization of robotic assisted approaches for bariatric operations. In this study, we present the first four Roux-en-Y Gastric Bypass (RYGB) operations performed with the new Hugo™ RAS system (Medtronic, Minneapolis, MN, USA).

Methods

In January and February 2023, 4 consecutive patients scheduled for minimal invasive Roux-en-Y-Bypass were selected and underwent the procedure robotic-assisted with the new platform. No exclusion criteria were applied.

Results

Four patients, two females and two males, underwent RYGB with a median BMI of 40 Kg/m² (range: 36-46) and diabetes mellitus in two cases. The median docking time was 8 min (range: 7-8.5) and the median console time was 127.5 min (range: 95-150). A description of the operating theatre, robotic arms and docking setup is provided. Procedures were performed without intraoperative complications and no conversion to laparoscopy or open surgery was noted. No additional ports were needed to be placed. System's function and docking were uneventful. No early post-operative complications were observed.

Conclusions

Based on our initial experience, RYGB with the Hugo™ RAS system is feasible. This study provides the configurations necessary to perform RYGB with the Hugo™ RAS system as well as general information and insights from our preliminary experience.

First worldwide report on Hugo RAS™ surgical platform in right and left colectomy

The diffusion of robotic surgery is rapidly and constantly growing in different surgical specialties. Recently, novel robotic platforms have entered into the market. To date, however, most of the reports on their clinical use have specifically focused on gynecological and urological surgery. In this study, we present the first three robotic-assisted colectomies performed with the new Hugo RAS system (Medtronic, Minneapolis, MN, USA). The surgical team had previous robotic experience and completed simulation training and an official 2-day cadaver laboratory session. Operating room setting and trocar layout were planned and two full cadaver procedures were carried out (right and left colectomy). Onsite dry-run sessions were performed before tackling clinical cases. Three patients underwent robotic-assisted colectomies: one left colectomy, two right colectomies with complete mesocolic excision (CME) and high vascular ligation (HVL) at our Institution. Preoperative diagnosis was colonic adenocarcinoma in all cases. A description of the operative room setup, robotic arm configuration and docking angles is provided. Mean docking time and console time were 8 and 259 min, respectively. All the surgical steps were completed without critical surgical errors or high-priority alarms. Neither intraoperative complications nor conversions to open surgery were recorded. Postoperative courses were uneventful with a mean length of stay of 5 days. Further clinical data and experience are required for procedural standardization and potential integration of the system into robotic general surgery and colorectal programs.