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

Costs of robotic and laparoscopic bariatric surgery: a systematic review and meta-analysis

BACKGROUND

Bariatric surgery is currently the most effective approach to addressing severe obesity and reducing related health issues. Laparoscopy remains the standard technique, whereas robotic-assisted surgery is increasingly adopted, although its role in bariatric surgery remains debated. The main criticism concerns its higher costs and the lack of evidence demonstrating improved clinical outcomes compared to other treatment methods. We aimed to compare the costs of robotic-assisted and laparoscopic bariatric surgery through a systematic review and meta-analysis.

METHODS

Following PRISMA reporting guidelines, a literature search was conducted in PubMed, Cochrane Library, Web of Science, and Google Scholar for studies comparing robotic-assisted and laparoscopic bariatric surgery. The primary outcome was total hospital costs, with bias assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. Effect sizes were calculated with 95% confidence intervals, and an overall effect was estimated using a random-effects model.

RESULTS

A total of 14 retrospective studies (293 articles screened) were included, with 1,414,357 patients (112,363 robotic; 1,301,994 laparoscopic). Total hospital costs favored laparoscopic surgery (SMD 0.721, 95%CI: 0.555-0.887, p < 0.001, absolute difference USD 3819). Operating room costs also favored laparoscopy (SMD 1.339, 95%CI 0.202-2.476, p = 0.021, absolute difference: USD 9746). Laparoscopy was associated with shorter operative time, while robotic surgery showed a slight advantage in hospital stay and complication rates. Subgroup and sensitivity analyses were consistent with the main findings. The quality of evidence was rated as low due to potential biases.

CONCLUSIONS

Our systematic review and meta-analysis provides the most current and robust evidence indicating that the robotic-assisted approach incurs significantly higher costs than the laparoscopic approach in bariatric surgery. This finding remained consistent across the overall analysis as well as in nearly all subgroup and sensitivity analyses. Randomized controlled trials are warranted to accurately evaluate the cost-effectiveness of the robotic approach in both primary and revisional bariatric procedures.

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.

Learning curves for adoption of robotic bariatric surgery: a systematic review of safety, efficiency and clinical outcomes

Robotic bariatric surgery may overcome challenges associated with laparoscopy, potentially achieving technically superior results. This review aims to summarise current literature reporting on learning curves for surgeons newly adopting robotic bariatrics and implications for safety, efficiency and outcomes. A systematic review was performed in line with the PRISMA guidelines. Electronic databases PubMed and MEDLINE were searched and articles reporting on learning curves in robotic bariatric surgery were identified. Studies that reported changes in outcome over time, or learning curves for surgeons newly adopting robotic bariatric surgery were included in this review. Eleven studies reporting on 1237 patients were included in this review. Most surgeons reported prior bariatric surgical experience. Differences were noted regarding the approach and adoption of robotics. Ten studies found significant reduction in operative time, with the shortest learning curve of 11 cases. Reporting of clinical outcomes was limited. Three studies reported statistically significant improvement in outcomes after the learning curve. Long-term outcomes were in line with current literature, though none assessed differences between learning curve groups. Reported learning curves in robotic bariatric surgery is variable, with limited reporting of clinical outcomes. With appropriate mentorship, surgeons can improve efficiency, safety and clinical outcomes, maximising the benefits of minimally invasive surgery.

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.

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.

Safety and efficacy of Roux-en-Y gastric bypass as revisional bariatric surgery after failed anti-reflux surgery: a systematic review

This systematic review evaluates the safety and efficacy of Roux-en-Y gastric bypass (RYGB) on weight loss and anti-reflux outcomes when used as a revisional bariatric surgical procedure after failed anti-reflux surgery. A systematic literature search next to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed for articles published by 30 Mar 2022. After examining 416 papers, 23 studies were included (n = 874 patients). Primary anti-reflux surgery included mainly Nissen fundoplication (16 studies). Reasons for revisional surgery included predominantly gastroesophageal reflux disease (GERD) (reported by 18 studies), obesity (reported by 6 studies), and hiatal hernia (reported by 6 studies). Interval to surgical revision was 5.58 ± 2.46 years (range, 1.5-9.4 yr). Upper endoscopy at revision was performed for all patients; esophageal manometry and pH monitoring were reported in 6 and 4 studies, respectively. Mean body mass index (BMI) at revision was 37.56 ± 5.02 kg/m2 (range, 31.4-44 kg/m2). Mean excess weight loss was 69.74% reported by 12 studies. Delta BMI reported by 7 studies was 10.41 kg/m2. The rate of perioperative complications was 16.7%, including mostly stenosis, leakage, ventral hernia, and small bowel obstruction. Mean improvement rate of GERD was 92.62% with a mean follow-up of 25.64 ± 16.59 months reported in 20 studies. RYGB seems to be an efficient surgical treatment option in failed anti-reflux procedures, but should be performed in experienced centers for selected patients, since the rate of perioperative and long-term complications must be minimized. Cooperation between bariatric and reflux surgeons is essential to offer patients with obesity and GERD the best long-term outcome.

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.

The Hidden Pandemic: the Cost of Postoperative Complications

Purpose of Review

Population-based increases in ageing and medical co-morbidities are expected to substantially increase the incidence of expensive postoperative complications. This threatens the sustainability of essential surgical care, with negative impacts on patients' health and wellbeing.

Recent Findings

Identification of key high-risk areas, and implementation of proven cost-effective strategies to manage both outcome and cost across the end-to-end journey of the surgical episode of care, is clearly feasible. However, good programme design and formal cost-effectiveness analysis is critical to identify, and implement, true high value change.

Summary

Both outcome and cost need to be a high priority for both fundholders and clinicians in perioperative care, with the focus for both groups on delivering high-quality care, which in itself, is the key to good cost management.