Understanding the Current Role of Robotic-Assisted Bariatric Surgery

Inpatient opioid use and pain control after robotic versus laparoscopic sleeve gastrectomy

BACKGROUND

During the past decade, the proportion of bariatric surgery performed robotically has been rising. However, the clinical benefits of the robotic approach over laparoscopy are uncertain. One area in need of further investigation is pain control after robotic versus laparoscopic bariatric surgery.

METHODS

A retrospective cohort study was conducted of bariatric surgery patients undergoing laparoscopic or robotic sleeve gastrectomy at a single institution from October 2019 to August 2022. Inpatient opioid use was measured in morphine milliequivalents. Pain scores were collected by the nursing staff.

RESULTS

A total of 368 patients were included: 286 laparoscopic and 82 robotic surgery patients. The groups shared similar demographics. For the entire cohort, the mean age was 42 years, the body mass index was 50 kg/m2, and 79% were female. Mean operative time was significantly lower for laparoscopic surgeries (87.5 ± 47.3 minutes vs 109.3 ± 30.3 minutes; P < .01). The median total inpatient morphine milligram equivalents used was similar for both groups: 52.3 (31.5-77.0) for the laparoscopic group versus 40 (24-74.5) for robotic (P = .13). Mean postoperative pain scores (scale out of 10) were not significantly different between groups: 5.2 ± 1.7 (postoperative day 0) and 4.5 ± 1.7 (day 1) for laparoscopic patients versus 5.1 ± 2.0 (day 0) and 4.4 ± 1.8 (day 1) for robotic. The proportion of patients prescribed opioids at discharge was significantly higher for the laparoscopic group (75.2% vs 62.2%; P = .02). Other clinical outcomes, including duration of stay, 30-day readmissions, and visits to the emergency department, were not significantly different.

CONCLUSION

There is no difference in inpatient opioid use or pain scores between patients undergoing laparoscopic and robotic sleeve gastrectomy.

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.

Cost Variation in Bariatric Surgery Across the United States

BACKGROUND

High costs have been cited as a barrier to utilization of bariatric surgery despite the increasing prevalence of obesity in the United States. The present work characterizes the center-level variation and risk factors for increased hospitalization costs following bariatric operations.

STUDY DESIGN

The 2016-2019 Nationwide Readmissions Database was queried to identify all adults undergoing elective laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). Random effects were estimated using Bayesian methodology and used to rank hospitals by increasing risk-adjusted center-level costs.

RESULTS

Of an estimated 687,866 patients at an annual 2435 hospitals, 69.9% underwent SG and 30.1% RYGB, with median costs of $10,900 (interquartile range: 8600-14,000) and $13,600 (10,300-18,000), respectively. Hospitals in the highest tertile of annual SG and RYGB volume were associated with a $1500 (95% CI - 2,100, -800) and $3400 reduction in costs (95% CI -4,200, -2600). Approximately 37.2% (95% CI 35.8-38.6) of variation in hospitalization costs was attributable to the hospital. Hospitals in the top decile of center-level costs were associated with increased odds of developing complications (AOR 1.22, 95% CI 1.05-1.40) but not mortality.

CONCLUSION

The present work identified significant interhospital variation in the costs of bariatric operations. Further efforts to standardize costs may enhance the value of bariatric surgical care in the US.

Totally robotic Roux-en-Y gastric bypass in a morbidly obese patient in Korea: a case report

Robotic bariatric surgery renders it unnecessary for surgeons to manually apply torque while simplifying intracorporeal suturing. Surgeons can comfortably manipulate instruments. Also, the three-dimensional operative field is very clear. Unfortunately, robotic bariatric surgery is still not the first choice for morbidly obese patients in Korea because it currently is not covered by the National Healthcare Insurance system. In this video, we show the totally robotic Roux-en-Y gastric bypass conducted using robotic staplers, in a morbidly obese patient with diabetes mellitus and private medical insurance.

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.

Current Status of Robot-Assisted Revisional Bariatric Surgery

Bariatric surgery has been demonstrated to be effective in achieving significant weight loss and remission of obesity-related comorbidities. However, a percentage of patients fail to lose enough weight, regain weight, or experience postoperative complications, requiring additional interventions. Revisional bariatric surgeries (RBS) involve the wide spectrum of procedures that aim to treat complications of the index operation or achieve further weight loss. These are technically challenging procedures due to adhesions of the internal organs, reduced working space, and a distorted anatomy. Indications, timing, and type of operation for RBS are not standardized, and there is no consensus on the best surgical approach. Some authors claim a robotic platform could be advantageous in these types of procedures that are performed in reduced, deep operating fields, or those requiring precision and accuracy. This review examines the most current and representative literature on the outcomes of robot-assisted RBS. Included studies demonstrate the safety and feasibility of the robotic approach for RBS. However, long operative times and high costs remain major drawbacks of the device. Finally, if we consider that many centers have not yet completed the learning curve for robot-assisted RBS, the potential for improved outcomes seems promising.

Robot-assisted versus laparoscopic approach to concurrent bariatric surgery and hiatal hernia repair: propensity score matching analysis using the 2015-2018 MBSAQIP

BACKGROUND

Up to 37% of class three obesity patients have a Hiatal Hernia (HH). Most of the existent HHs get repaired at the time of bariatric surgery. Although the robotic platform might offer potential technical advantages over traditional laparoscopy, the clinical outcomes of the concurrent bariatric surgery and HH repair comparing robotic vs laparoscopic approaches have not been reported.

METHODS

Using the 2015-2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, patients between 18 and 65 year old who underwent Sleeve gastrectomy (SG) or Roux en-Y Gastric Bypass (RYGB) with concurrent HH repair were identified. Demographic, operative, and 30-day postoperative outcomes data were compared between laparoscopic and robotic groups. To adjust for potential confounders, 1:1 propensity score matching was performed using 22 preoperative characteristics.

RESULTS

75,034 patients underwent SG (n = 61,458) or RYGB (n = 13,576) with concurrent HH repair. The operative time was significantly longer in the Robotic-assisted compared to the laparoscopic approach both for SG (102.31 ± 44 vs. 75.27 ± 37; P < 0.001) and for RYGB (163.48 ± 65 vs. 132.87 ± 57; P < 0.001). In the SG cohort (4639 matched cases), the robotic approach showed similar results in 30 day outcomes as in the laparoscopic approach, with no statistical difference. Conversely, for the RYGB cohort (1502 matched cases), the robotic approach showed significantly fewer requirements for blood transfusions (0.3% vs. 1.7%; P = 0.001), fewer anastomotic leaks (0.2% vs. 0.8%; P = 0.035), and less postoperative bleeding (0.4% vs. 1.1%; P = 0.049).

CONCLUSION

Robotic concurrent bariatric surgery and HH repair leads to similar overall clinical outcomes as the laparoscopic approach despite longer operative times. Furthermore, the robotic approach is associated with reduced blood transfusion and anastomotic leak incidence in the RYGB group.

Robotic Roux-en-Y Gastric Bypass: A Single Surgeon's Experience with 527 Consecutive Patients

Background and Objectives

Robotic bariatric surgery is increasingly adopted by surgeons. We present the surgical results of 527 consecutive patients who underwent robotic Roux-en-Y gastric bypass (RYGB) using the standard technique.

Methods

A retrospective analysis of a prospectively maintained database was performed including 527 consecutive patients who underwent robotic RYGB between January 1, 2018 and December 31, 2021.

Results

The mean age of the patients was 41 years, with a male/female sex distribution of 143/384 (27.1%/72.9%). Type 2 diabetes in the pre-operative period was diagnosed in 31% of patients. The median pre-operative body mass index (BMI) was 44.6 kg/m² (range, 35-64). The mean operation time was 134 min for robotic RYGB, including the docking process. Early (< 30 days) complications included ileus (0.2%), atelectasis (0.2%), thromboembolic (0.2%) events, and surgical-site infection (0.2%). No leakage or bleeding of the gastrojejunal and jejunojejunal anastomoses were recorded. Oral food intake was begun at 1.8 days on average. The average hospital stay was 2 days. Despite a range of BMI values, operation times and gastrojejunal anastomosis times did not show significant differences. There were no significant differences in mean operation time or mean gastrojejunal anastomosis time over the years.

Conclusions

The robotic approach is effective and safe for patients undergoing RYGB. This technique provides satisfactory results with short-term surgical outcomes. However, the real benefits of robotic RYGB should be further evaluated by well-conducted randomized trials. Even in difficult cases with higher BMI values, optimal operation times and similar operative efficiency can be obtained if a standard operation technique is applied.