The Economy of Motion of the Totally Robotic Gastric Bypass: Technique, Learning Curve, and Outcomes of a Fellowship-Trained, Robotic Bariatric Surgeon

Racial disparities in the utilization and outcomes of robotic bariatric surgery: an 8-year analysis of Metabolic and Bariatric Surgery Accreditation Quality Improvement Program data

BACKGROUND

Robotic surgery utilization has been increasing across surgical specialties; however, racial disparities in patient access to care and outcomes have been reported.

OBJECTIVES

In this study, we examined racial disparities in the utilization and outcomes of robotic bariatric surgery over an 8-year period.

SETTING

Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP) centers of excellence across the United States.

METHODS

The MBSAQIP database was used to identify adult patients who underwent robotic bariatric surgery between 2015 and 2022. Patients were stratified according to race and ethnicity into non-Hispanic White, non-Hispanic Black or African American (AA), Indigenous, Asian, and Hispanic patients. Multivariable analyses were used to assess predictors of robotic surgery use, odds of minor and major complications, prolonged length of stay (prolonged length of stay (pLOS): ≥3 days), readmissions, reoperations, and mortality within 30 days.

RESULTS

Out of 1,288,359 patients included, robotic surgery was utilized in 196,314 patients (15.2%), with a mean age of 44 ± 12 years and 80.6% females. Rates of robotic surgery increased to 30% by 2022. Compared to White patients, Black/AA patients were more likely to undergo robotic surgery (adjusted odds ratio (aOR) = 1.22, 95% confidence interval (CI) = 1.21-1.24, P < .001). The safety of robotic bariatric surgery improved for both White and Black patients with decreased odds of major complications, readmissions, reoperations, and pLOS over the study period. However, Black/AA patients were more likely to experience minor and major complications, readmissions and have pLOS compared with White patients in 2022 (aOR:1.26, 95% CI:1.19-1.34, P < .001; aOR:1.22, 95% CI:1.06-1.41, P = .006; aOR:1.44, 95% CI:1.28-1.62, P < .001; aOR:2.26, 95% CI:2.06-2.47, P < .001, respectively).

CONCLUSION

The utilization of robotic bariatric surgery has increased significantly over the past 8 years with continued improvements in its safety profile. While Black/AA patients have improved access to robotic surgery, their clinical outcomes continue to be worse than those of White patients. Efforts to address racial disparities in bariatric surgery outcomes must remain a priority to achieve health equity.

American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass

BACKGROUND

Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB).

OBJECTIVE

This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU).

METHODS

PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee.

RESULTS

Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures.

CONCLUSIONS

This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.

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.

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.

Use of targeted educational resources to improve robotic bariatric surgery training

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Roux-en-Y Gastrojejunostomy: is it an effective treatment for complex Hiatal hernias in the morbidly obese?

BACKGROUND

Primary repair failure rates for hiatal hernias (HH) can reach up to 40%, this is especially high in the morbidly obese patient. There is no clear data on how to manage this patient subset. This paper evaluates the efficacy of Roux-N-Y Gastrojejunostomy (RNY GJ) for treatment of symptomatic HH.

METHODS

A retrospective analysis of all patients who received a Roux-en-Y Gastrojejunostomy (RNY GJ) for HH at our institution between January 2016 and January 2021 was performed. Patient demographics, symptoms, and post-operative outcomes were recorded and univariate analysis was performed between preoperative and postoperative symptoms.

RESULTS

Thirty-seven patients with a mean age of 56.9 years (SD 11.8) underwent RNY GJ. Patients were mostly female (81.1%) with a mean BMI of 36.8 (SD 8.4). An 78.4% reduction in symptoms of either heartburn, dysphagia, or regurgitation was noted at follow up (p < 0.001).

CONCLUSIONS

RNY GJ represents a safe procedure for morbidly obese patients with hiatal hernias with no mortalities amongst our patient cohort along with a significant reduction in pre-operative symptoms and no symptomatic recurrences. RNY GJ should be considered as the operation of choice for repair for this patient population.

Technical aspects and standardization of the totally robotic Roux-en-Y gastric bypass. Results of a single surgeon experience with a 5-year follow-up

INTRODUCTION

The use of robotics in bariatric surgery is increasing worldwide, with as main objective reducing complications and optimising surgical outcome. This study presents the results of a single surgeon 8-year experience with a totally robotic Roux-en-Y gastric bypass (RYGB).

METHODS

A total of 183 consecutive patients underwent a robotic bariatric procedure. A retrospective analysis was performed of all patient files to obtain patient characteristics, weight loss results and per- and postoperative morbidity. For long-term follow-up all patients were contacted one by one.

RESULTS

In 155/183 patients, a primary RYGB was performed, 23 procedures were revisional cases and in 5 other procedures were performed. Mean initial weight was 112.07 (±20.5) kg, mean start BMI was 40.8 (±5.36) kg/m². There were no conversions and no major intraoperative complications. In the early postoperative period we note two revisions; one postoperative bleeding and one missed iatrogenic enterotomy. Mean length of stay in the hospital was 3.50 (±1.20) days. After a mean follow-up of 62.06 (±32.76) months, mean BMI was 28.07 (±4.88) kg/m² with an % excess body mass index loss of 84.02 (±31.64) %. Patient satisfaction was high, with 95.1% of the patients being happy. The main complaint in the remaining patients was weight regain.

CONCLUSION

The robotic RYGB is a safe and reproducible approach to treat morbid obesity. A secure hand-sewn gastrojejunal anastomosis, quick recovery and better ergonomics are the main advantages of this technique.

Adopt or Abandon? Surgeon-Specific Trends in Robotic Bariatric Surgery Utilization Between 2010 and 2019

Background: It is unknown if surgeons are more likely to adopt or abandon robotic techniques given that bariatric procedures are already performed by surgeons with advanced laparoscopic skills. Methods: We used a statewide bariatric-specific data registry to evaluate surgeon-specific volumes of robotic bariatric cases between 2010 and 2019. Operative volume, procedure type, and patient characteristics were compared between the highest utilizers of robotic bariatric procedures (adopters) and surgeons who stopped performing robotic cases, despite demonstrating prior use (abandoners). Results: A total of 44 surgeons performed 3149 robotic bariatric procedures in Michigan between 2010 and 2019. Robotic utilization peaked in 2019, representing 7.24% of all bariatric cases. We identified 7 surgeons (16%) who performed 95% of the total number of robotic cases (adopters) and 12 surgeons (27%) who stopped performing bariatric cases during the study period (abandoners). Adopters performed a higher proportion of gastric bypass both robotically (22.9% versus 3.1%, P < .001) and laparoscopically (27.5% versus 15.1%, P < .001), when compared with abandoners. Surgeon experience (no. of years in practice), type of practice (teaching versus nonteaching hospital), and patient populations were similar between groups. Conclusions: Robotic bariatric utilization increased during the study period. The majority of robotic cases were performed by a small number of surgeons who were more likely to perform more complex cases such as gastric bypass in their own practice. Robotic adoption may be influenced by surgeon-specific preferences based upon procedure-specific volumes and may play a greater role in performing more complex surgical procedures in the future.

The Longitudinal Efficiency of Robotic Surgery: an MBSAQIP Propensity Matched 4-Year Comparison of Robotic and Laparoscopic Bariatric Surgery

BACKGROUND

The objective of this study was to examine the MBSAQIP database to assess efficiency trends and perioperative outcomes in robotic bariatric surgery.

METHODS

Robotic (RA) and laparoscopic (L) sleeve gastrectomy (SG) and gastric bypass (RYGB) were compared using the 2015-2018 MBSAQIP Participant Use Data Files. Patients were propensity matched 1:1 based on sex, body mass index, assistant, and previous obesity or foregut surgery. A total of 93,802 patients were included.

RESULTS

Median operative times were significantly longer for both RA-SG (89 vs. 62 min; p < 0.0001) and RA-RYGB (141 vs. 105 min; p < 0.0001) compared with laparoscopic. Over the 4-year period, the difference in operative times (OR delta) between RA-SG and L-SG was unchanged while the difference in operative times between RA-RYGB and L-RYGB increased. Both robotic groups were significantly more likely to be readmitted (RA-SG p = 0.001, RA-RYGB p = 0.006). Robotic SG was more likely to have a reintervention (p = 0.018) and extended length of stay (LOS) (> 4 days) compared with laparoscopic (p = < 0.0002). No significant differences were noted in morbidity and mortality by approach.

CONCLUSIONS

Operative times were 30% longer for RA-SG and 25% longer for RA-RYGB when compared with laparoscopic. There was no significant improvement in OR delta for either RA-SG or RA-RYGB over the four years. Readmission rates were higher for both RA-SG and RA-RYGB. Robotic SG had a greater percentage of patients with extended LOS compared with laparoscopic. No evidence of improved efficiency for robotic bariatric surgery as defined by operative time or clinical outcomes was identified.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Surgical trainee impact on bariatric surgery safety

BACKGROUND

Roux-en-Y-gastric bypass (RYGB) and sleeve gastrectomy (SG) are commonly performed bariatric procedures that are associated with a significant learning curve. The effect of surgeon experience on perioperative outcomes and safety is established, but the effect of trainee participation remains unclear. The purpose of this study was to assess the impact of trainees on early perioperative safety of bariatric surgery.

METHODS

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for 2015 was used to identify non-revisional laparoscopic and robotic RYGB and SG procedures. Comparisons were made based on assistant level. Multivariable logistic and linear regression methodology was used to compare clinical outcomes.

RESULTS

There were 35,354 laparoscopic RYGB, 2896 robotic RYGB, 79,717 laparoscopic SG, and 5449 robotic SG procedures examined. 21,257 (17%) and 11,322 (9%) of all procedures were performed with a resident or fellow, respectively. Fellow presence was independently associated with the development of complications for all procedure types except robotic SG when compared to non-trainee [odds ratio (OR) 1.31, 2.20, 1.28 for laparoscopic RYGB, robotic RYGB, and laparoscopic SG, respectively]. The most common events were urinary tract and superficial surgical site infections. This negative impact of fellow on overall complications was eliminated after accounting for operative duration. In laparoscopic SG, resident participation was associated with higher leak rate (OR 1.61), readmission (OR 1.18), re-intervention (OR 1.4), and complication rate (OR 1.32) compared to non-trainee, even after accounting for procedural duration. In robotic SG, there was no impact of trainee on outcomes.

CONCLUSIONS

Although fellow training is associated with higher overall complication rate, there is no such impact on major safety benchmarks, including leak rate and re-operation. In contrast, the impact of resident trainees on SG outcomes is substantial. Operative involvement of trainees in bariatric surgery leads to different outcomes based on trainee level and should be judiciously considered during the programmatic design of bariatric educational curricula.

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

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

What is the Learning Curve for Laparoscopic Major Hepatectomy?

BACKGROUND

Laparoscopic liver resection is rapidly expanding with more than 9500 cases performed worldwide. While initial series reported non-anatomic resection of benign peripheral hepatic lesions, approximately 50-65 % of laparoscopic liver resections are now being done for malignant tumors, primarily hepatocellular carcinoma (HCC) or colorectal cancer liver metastases (mCRC).

METHODS

We performed a literature review of published studies evaluating outcomes of major laparoscopic liver resection, defined as three or more Couinaud segments.

RESULTS

Initial fears of adverse oncologic outcomes or tumor seeding have not been demonstrated, and dozens of studies have reported comparable 5-year disease-free and overall survival between laparoscopic and open resection of HCC or mCRC in case-cohort and propensity score-matched analyses. Increased experience has led to laparoscopic anatomic liver resections including laparoscopic major hepatectomy. A steep learning curve of 45-60 cases is evident for laparoscopic hepatic resection.

CONCLUSION

Laparoscopic major hepatectomy is safe and effective in the treatment of benign and malignant liver tumors when performed in specialized centers with dedicated teams. Comparable to other complex laparoscopic surgeries, laparoscopic major hepatectomy has a learning curve of 45-60 cases.