How long do we need to reach sufficient expertise with the avatera® robotic system?

PURPOSE

To investigate the learning curve in four basic surgical skills in laparoscopic and robotic surgeries, and evaluate the approximate time needed to reach sufficient expertise in performing these tasks with the avatera® system.

METHODS

Twenty urology residents with no previous experience in dry-lab and robotic surgery were asked to complete four basic laparoscopic tasks (peg transfer, circle cutting, needle guidance, and suturing) laparoscopically and robotically. All participants were asked to complete the tasks first after watching the Uroweb educational material and, second, after undertaking a 2-hour training in robotic and laparoscopic dry-lab. Thereafter, all trainees continued to undertake 2-hour training programs until being able to complete the tasks with the avatera® robot at the desired time. Paired t test and one-way ANOVA test were used to analyze time differences between the groups.

RESULTS

Time needed to complete all tasks either robotically or laparoscopically was significantly less in the second compared to the first attempt for all Groups in each Task. In the robotic dry-lab, time needed to complete the tasks was significantly less than in the laparoscopic dry-lab. A significant effect of previous laparoscopic experience of the participants on the training time needed to achieve most of the goal times was detected.

CONCLUSION

The results of the study highlight the role of previous laparoscopic experience in the training time needed to achieve the performance time goals and demonstrate that the learning curve of basic surgical skills using the avatera® system is steeper than the laparoscopic one.

A novel miniature flexible robotic system for endoscopic mucosal dissection: an animal experimental study

Endoscopic submucosal dissection (ESD) is a standard treatment for early gastrointestinal cancer due to its higher rate of en-bloc resection and lower recurrence rate. However, the technical challenges lead to long learning curve and high risks of adverse events. A gastrointestinal flexible robotic-tool system (GIFTS) was proposed to reduce the difficulty and shorten the learning curve of novices. This is an animal study to evaluate the feasibility of GIFTS in ESD. The GIFTS provides a total of 13 degrees of freedom within 10 mm in diameter and variable stiffness function to achieve endoscopic intervention and submucosal dissection with the cooperation of two flexible robotic instruments. One esophageal and four colorectal ESDs in five porcine models were performed. In all five ESD procedures, the GIFTS was successfully intubated and submucosal dissection was completed without perforation or significant bleeding, and there was no system fault. The mean operative time was 99 min, and the mean size of the specimen was 151 mm2. The fifth experiment showed significantly better results than the first one. In vivo animal experiments confirmed the feasibility of GIFTS in performing ESD. The control of GIFTS is friendly to inexperienced beginners, which will help reduce the technical challenges of ESD and shorten the learning curve of endoscopists.

Minimally invasive enucleation of pancreatic tumors: The main pancreatic duct is no longer a restricted area

Background

Tumors involving the main pancreatic duct (MPD) used to be a contraindication for enucleation.

Methods

Clinical data of consecutive patients with pancreatic tumors who received laparoscopic or robotic enucleation (LEN or REN) between January 2019 and December 2021 at Fudan University Shanghai Cancer Center were analyzed.

Results

Ninety-six patients were included in the analysis, with 55 in the LEN group and 41 in the REN group, and no conversion to laparotomy. Most tumors were located in the head of pancreas (71.9 %). The tumor diameter (3.1 vs. 1.9 cm) was larger, and more cystic tumors (92.7 % vs. 56.4 %) and more tumors involving the MPD (34.1 % vs. 3.6 %) were observed in the REN group. MPD support tube insertion was performed in 15 cases, with 11 in the REN group and 4 in the LEN group. The incidence of biochemical and grade B postoperative pancreatic fistula (POPF) was both 46.9 %, and no grade C POPF occurred. Among the 45 patients with grade B POPF, 28 cases (62.2 %) were due to carrying drainage tube >3 weeks without additional treatment, and only 4 cases required invasive treatment. For patients with MPD support tube implantation (n = 15), support tube fall-offs were observed in 12 cases, 2 patients had MPD dilatation, and no MPD stricture, stone formation or pancreatic atrophy was observed during follow-up.

Conclusions

The incidence of POPF was high but still controllable without serious complications after minimally invasive enucleation. The MPD is no longer a restricted area, and the robotic system has advantages in handling complex enucleations.

Fixed-time neural network control of a robotic manipulator with input deadzone

In this paper, a fixed-time control method is proposed for an uncertain robotic system with actuator saturation and constraints that occur a period of time after the system operation. A model-based control and a neural network-based learning approach are proposed under the framework of fixed-time convergence, respectively. We use neural networks to handle the uncertainty, and design an adaptive law driven by approximation errors to compensate the input deadzone. In addition, a new structure of stabilizing function combining with an error shifting function is introduced to demonstrate the robotic system stability and the boundedness of all error signals. It is proved that all the tracking errors converge into the compact sets near zero in fixed-time according to the Lyapunov stability theory. Simulations on a two-joint robot manipulator and experiments on a six-joint robot manipulator verified the effectiveness of the proposed fixed-time control algorithm.

Robot-Assisted Percutaneous Lag Screw Osteosynthesis for C1 Lateral Mass Fractures: Case Series and Technical Note

BACKGROUND

C1 lateral mass fractures (LMF) cause abnormal alignment of the upper cervical joints. Conservatively treated cases can develop into late cock-robin junction, requiring a reconstructive surgical procedure of the occipitocervical junction. Partial coronal C1 LMF could be effectively fixed with lag screws. Navigation and robot-assisted techniques have made percutaneous fixation possible and are gradually being used in the upper cervical spine.

METHODS

Five consecutive patients with C1 LMF who underwent percutaneous lag screw osteosynthesis under the guidance of a new robotic system were reviewed retrospectively. Preoperative and postoperative computed tomography scans were used to specify the fracture types and to assess the efficacy of fracture reduction. The medical records were reviewed.

RESULTS

Among the 5 patients, 4 underwent percutaneous lag screw reduction and fixation with the assistance of the robotic system through a posterior approach and 1 patient underwent a transoral approach. No intraoperative complications, such as screw malposition, neurologic deficit, and vertebral artery injury, occurred. Satisfactory fracture reduction and bone healing were achieved at postoperative follow-up.

CONCLUSIONS

Robot-assisted percutaneous lag screw osteosynthesis is a viable option for C1 LMF. Different approaches can be selected according to the distribution of the fracture lines. With the posterior approach, the guidewire tends to deviate from the entry point because of skiving, and the technical problems need to be further solved. Screw implant by a transoral approach is comparatively easy to achieve, but the possibly of infection exists and should be monitored.

Clinical implementation of the Versius robotic surgical system in visceral surgery-A single centre experience and review of the first 175 patients

BACKGROUND

Robotic surgical systems introduce new opportunities for the minimal accessed surgeon. The combination of three-dimensional magnified vision and articulated instruments with seven degrees of freedom provide a good and safe alternative to laparoscopic surgery. Indeed some of these features may support the case that robotic surgery may be better than conventional surgery. In this study, we report our experience of robotic surgery by using the first open console, modular robotic platform in Germany, the Versius Surgical System®.

METHODS

We implemented the Versius Surgical System® in April 2021 at our centre. Since then, 175 patients received robotic assisted surgery. All patients were included in this study. Data were analysed by using the SPSS (IBM Statistics) Software.

RESULTS

175 patients underwent robotic surgery. We started the implementation of the system by performing cholecystectomy. After the first 50 successful operations, we began to perform robotic assisted oncological resections. We saw a learning curve with improvements in total operative time and console time until reaching a standard similar to conventional laparoscopic surgery. The perioperative complication-ratio was equivalent for operations matched the histopathological outcome (MERCURY graduation, R0-staus) at oncological resections. However, four patients had to be revised because of secondary bleeding. Interestingly the total hospital stay for right sided hemicolectomy and oesophagus-resection was shorter than in laparoscopic surgery. In our opinion, the Versius Surgical System® seems to be a good, promising system and a safe alternative to other robotic systems, although any comparison is still missing. The open design enabling a better communication between console surgeon and bedside-unit assistant as well as the mobile bedside units are very interesting and allow more flexibility. Nevertheless, there are limitations of the system that require a direct comparison with other robotic systems as well as continuous advancement.

Two-dimensional C-arm robotic navigation system (i-Navi) in spine surgery: a pilot study

PURPOSE

Pedicle screws placement is very common procedure in spinal surgery. Robotic assisted surgery has been widely used in this operation. We assessed the accuracy of thoracolumbar spine trans-pedicle screws (TPS) implantation utilizing a noval robotic navigation system (i-Navi robotic navigation system) by planning with two-dimensional (2-D) C-arm.

METHODS

This study was approved by the Institutional Review Board of the Cathay General Hospital on June 21, 2018 (IRB number: CGH-P 106,092), and written informed consents were obtained from all the patients. There are 18 patients were enrolled in the study. All the patients received the posterior fusion with TPS insertion under the assistant of our robotic navigation system.

RESULTS

There are 18 patients were included into our study, there are 2 patients were quitted from the study due to the equipment setup was not complete. Other 16 patients completed the entire procedure successfully. There is total 88 pedicle screws were inserted through i-Navi robotic navigation system. There are 79 of 88 screws were graded A, and 9 screws were graded B; no screws were graded C or D. No vascular or nerve injuries were noted after the operations.

CONCLUSION

We present our i-Navi robotic navigation system, by planning with 2-D C-arm imaging and pre-operative CT scans. According to the results of study, we think it can provide a reliable and easy tool to perform the TPS in thoracic lumbar spine surgery.

Automatic system for high-throughput and high-sensitivity diagnosis of SARS-CoV-2

The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had severe consequences for health and the global economy. To control the transmission, there is an urgent demand for early diagnosis and treatment in the general population. In the present study, an automatic system for SARS-CoV-2 diagnosis is designed and built to deliver high specification, high sensitivity, and high throughput with minimal workforce involvement. The system, set up with cross-priming amplification (CPA) rather than conventional reverse transcription-polymerase chain reaction (RT-PCR), was evaluated using more than 1000 real-world samples for direct comparison. This fully automated robotic system performed SARS‐CoV‐2 nucleic acid-based diagnosis with 192 samples in under 180 min at 100 copies per reaction in a “specimen in data out” manner. This throughput translates to a daily screening capacity of 800–1000 in an assembly-line manner with limited workforce involvement. The sensitivity of this device could be further improved using a CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats)-based assay, which opens the door to mixed samples, potentially include SARS-CoV-2 variants screening in extensively scaled testing for fighting COVID-19.

Balance and visual reliance in post-COVID syndrome patients assessed with a robotic system: a multi-sensory integration deficit

The symptoms of SARS-CoV-2 infection are not limited to the acute phase, with vertigo, peripheral neuropathies, headache, fatigue, memory loss, and depression being the most common post-acute clinical manifestations. Such post-COVID syndrome is a new clinically relevant challenge for diagnosis and therapy. Our goal was to quantify deficit in balance and proprioception related to post-COVID syndrome and, in this sense, we prospectively analyzed data of 66 post-COVID-19 outpatients (mean age 47.3 ± 11.1 years, 50 females, 25 hospitalized), evaluated using the robotic device hunova. The dynamic balance was assessed with open (OE) and closed eyes (CE) and three indexes, proportional to subject instability, were measured: the sway path and two oscillation ranges. Hospitalized group showed the worst performance with respect to non-hospitalized patients and normality range in both visual conditions for the sway path and the oscillation ranges, with the worst performance being with CE. When compared to normality ranges, post-COVID patients were significantly more distant from normality in the OE condition compared to the CE condition. These results suggest that independently from the severity of the disease experienced, post-COVID syndrome makes the elastic balance test performances more distant from the normality when the subject integrates vision, somatosensory information, and vestibular information. In the absence of visual feedback, patients seem to implement compensatory strategies, presumably seeking more significant feedback from the lower limbs, which improve their performance. These data suggest a new mechanism of the post-COVID syndrome that deserves further investigation for its potential impact on activities of daily living.

Thoracic vertebra interbody fusion surgery with robotic assisted system in a swine model

Minimally invasive procedures have been increasing in spine surgery, and interest in robotic systems has inclined. In this study, we aimed to evaluate feasibility of a robotic-assisted thoracic spine interbody fusion in a swine model. Neurosurgeons performed the surgical procedures with robotic surgery certificates on the Da Vinci Xi Surgical System. Surgical approaches were applied using four ports while the swine was in the left lateral position. The surgical procedure was accomplished in 70 min including positioning and preparation of robotic system (20 min), placement of ports and thoracic dissection and confirmation of level with the C-arm system (10 min), discectomy and cage insertion (15 min), control of cage position via the C-arm system and closure (10 min). This study showed the anterior thoracic approach with robotic surgery is safe and feasible with providing a wide working area and high image quality.

Evaluation of the automated micro-solid phase extraction clean-up system for the analysis of pesticide residues in cereals by gas chromatography-Orbitrap mass spectrometry

Food analysis is a tremendously broad field that is constantly evolving. New methods have emerged to increase productivity, such as modern miniaturized and robotic analytical techniques. In this paper, a micro-solid-phase extraction system (µ-SPE) for clean-up was combined with a robotic autosampler to yield ready-to-analyze extracts. The system was evaluated for its applicability in routine laboratories. The new, automated, high-throughput µ-SPE clean-up method was applied to acetonitrile extracts and was developed for the analysis of pesticide residues in cereals by gas chromatography-Orbitrap mass spectrometry (GC-Orbitrap-MS). The µ-SPE clean-up efficiency was demonstrated in the removal of matrix-interfering components and in the recovery of pesticides. The sorbent bed mixture consisted of magnesium sulfate, primary-secondary amine, C₁₈, and CarbonX, and effectively retained matrix components without loss of target analytes. Analysis of five types of cereals (barley, oat, rice, rye, and wheat) by GC-Orbitrap-MS showed that the method removed more than 70% of matrix components. The clean-up method was validated for 170 pesticides in rye, 159 pesticides in wheat, 142 pesticides in barley, 130 pesticides in oat, and 127 pesticides in rice. Spike recovery values were 70-120% for all pesticides and the repeatability, calculated as the relative standard deviation, was less than 20%. The limits of quantitation achieved were 0.005 mg kg^-1 for almost all analytes, ensuring compliance with the maximum residue limits.

Development status of telesurgery robotic system

As an emerging field, telesurgery robotic system is changing the traditional medical mode and can delivery remote surgical treatment anywhere in the world. Advances in telesurgery robotic technology achieve the remote control beyond the current limitation of distance and special medical environment. This review introduces the development history, the current status and the potential in future of the telesurgery robotic system. In addition, it presents the construction of control platform and the application, especially in trauma treatment, as well as the challenge in clinic.

Initial experience of laparoscopic radical nephrectomy using the Senhance® robotic system for renal cell carcinoma

The Senhance^® robotic system (TransEnterix, Morrisville, NC, USA), previously called the TELELAP Alf-X system, is a novel robotic system with a telesurgical concept. We herein describe our initial experience of Senhance^® assisted laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) with detailed figures and videos. Case 1: A left renal tumor was incidentally detected in a 52-year-old female on ultrasonography. Case 2: A right renal tumor was detected in a 67-year-old male with epigastric pain on computed tomography. They were referred for further examination and diagnosed with RCC (clinical T1bN0M0 and clinical T2aN0M0, respectively). Senhance^® assisted LRN was completed without conversion to conventional LRN or open surgery in both cases. The pneumoperitoneum time, console time and estimated blood loss in case 1 and case 2 were 173 min, 143 min and 3 mL, and 154 min, 122 min and 50 mL, respectively. The postoperative course was uneventful. Senhance^® assisted LRN for RCC was safely and precisely performed. Furthermore, the operator was comfortable during the surgery. Although further surgical experience and long-term follow-up are required to assess surgical and oncological outcomes, Senhance^® assisted LRN for RCC may be a promising procedure.

Supplementary information

The online version contains supplementary material available at 10.1007/s13691-021-00487-x.

A preliminary study of a novel robotic system for pedicle screw fixation: A randomised controlled trial

Background and objective

Existing orthopaedic robotic systems are almost restricted to provide guidance for trajectory direction. In the present study, a novel spinal robotic system with automatic drilling power was introduced. The aim of this study is to evaluate the feasibility and safety in pedicle screw ​insertion of posterior lumbar interbody fusion assisted by this novel robotic system.

Methods and materials

A randomised controlled trial was conducted for 17 participants who were required posterior lumbar interbody fusion process. Seven (3 M/4 F) were randomly assigned to the robot-assisted group (RA group), and the other ten (4 M/6 F) were assigned to the conventional technique group (FH group). A novel robotic system was used in the RA group. All measurements were based on postoperative computed tomography (CT) data. Accuracy of screw insertion was determined using the Gertzbein and Robbins Scale. Precision was measured by the entry point deviation distance and the trajectory rotation. Other variables included operation time, radiation time, length of stay, and screw-related complications.

Result

A total of 82 pedicle screws were placed in the 17 participants. In the RA group, 90.6% of screws placed were Grade A, and 9.4% were Grade B. In the FH group, 78.0% of screws were Grade A, 20.0% were Grade B, and 2.0% were Grade C. No statistical difference was found in the operation time, radiation time per case, and length of stay between both groups. The radiation time per screw is significantly lower in the RA group. No screw-related complications or revision occurred in the present study.

Conclusion

The outcome of screw accuracy of this robotic system was comparable with that of experienced surgeons, and no screw-related complication was found in the RA group during hospitalisation. In addition, radiation time per screw in the robotic group was significantly lower than that in the conventional group, which shows the potential to reduce radiation exposure of pedicle screw fixation assisted by this robotic system.

Translational potential

Our study shows that pedicle screw fixation assisted by "Orthbot" system is accurate and safe. It is concluded that this novel robotic system offers a new option for internal implantation in spine surgery.

A novel inspection robot for nuclear station steam generator secondary side with self-localization

Nuclear energy is one of the most important clean energy on earth presently. The steam generator secondary side is the key device of nuclear power station. As an important branch of special robot, nuclear robot is the most convenient and effective mean to inspect the steam generator. This paper describes one robot system which could help users inspecting tubes and locating the robot inside the steam generator. The main part of this system is a climbing robot which can move inside the steam generator carrying a PT or telescopic arm. Four cameras are installed on the robot and PT to send real-time videos back for analysis. Experiments show that this system works stably and the localization is accuracy and effective.

A novel approach to an automated needle insertion in brachytherapy procedures

One of the most challenging phases in interstitial brachytherapy is the placement of the needles. In these medical procedures, the needles are inserted inside the tissue to guide the positioning of the radioactive sources. The low-dose-rate radioactive sources are placed inside the tissue permanently, whereas a radioactive source in the high-dose-rate brachytherapy is temporarily placed in the desired positions so that the delivery of the prescription dose to the clinical targets can be achieved. Consequently, the precise needle placement directly influences the radiation dose delivery and the treatment outcomes of patients. Any deviation from the desired position of the radioactive sources can cause a suboptimal dose distribution and inadequate tumor coverage. Therefore, it is of significant importance to develop a robust and sophisticated tool that can perform the automatic needle placement with a high level of accuracy for different medical procedures and conditions. In this study, we propose a novel concept for the automatic needle insertion using a new miniature automated robotic system. The mathematical model of this system was presented in detail, allowing the implementation of the model predictive control that can be used to govern the mechanism. The purpose of this approach was to minimize the lateral components of the generalized reactive force which is responsible for the tissue displacement and, consequently, for the needle deflection. The proposed approach was designed to predict and to compensate for the unmeasured disturbances, such as needle deflection or tissue resistance and reactive force, and it was capable of correcting them without waiting until the effect appears at the output of the system causing the needle deviation from the desired positions. The extensive simulation of the system was presented to evaluate the feasibility of the method and the parameters of interest including displacements, system errors and system responses to the change in the environmental conditions.

Usability testing of a developed assistive robotic system with virtual assistance for individuals with cerebral palsy: a case study

This paper presents a novel application of an assistive robotic system with virtual assistance to enhance manual performance of individuals with cerebral palsy. Cerebral palsy affects one's voluntary motor movements resulting in limited opportunities to actively engage in physical manipulative activities that require fine motor movements and coordination. Lack of object manipulation and environmental exploration can result in further impairments such as cognitive and social delays. The proposed assistive robotic system has been developed to enhance hand movements of people with disabilities when performing a functional task colouring. This paper presents the usability testing of the effectiveness of the developed system with an individual with cerebral palsy in a set of colouring tasks. Assisted and unassisted approaches were compared and analysed through quantitative and qualitative measures. The robotic-based approach was further compared with the participant's typical alternate access method to perform the same proposed tasks. The robotic system with virtual assistance was clinically validated to be significantly more effective, compared to both unassisted and typical approaches, by increasing the hand controllability, reducing the physical load and increasing the easiness of maintaining movements within the lines. Future studies will inform the use of the system for children with disabilities to provide them with assisted play for functional and playful activities. Implications for rehabilitation Robotic system can enhance manual performance in individuals with disabilities. Participating in a robot-mediated play activity could increase children's motivation and engagement. The developed robotic system can contribute to a basis for clinical and home-based implementation of the technology to promote manual play activities for children with disabilities.

The in situ force in the calcaneofibular ligament and the contribution of this ligament to ankle joint stability

BACKGROUND

Numerous biomechanical studies of the lateral ankle ligaments have been reported; however, the isolated function of the calcaneofibular ligament has not been clarified. We hypothesize that the calcaneofibular ligament would stabilize the ankle joint complex under multidirectional loading, and that the in situ force in the calcaneofibular ligament would change in each flexed position.

METHODS

Using seven fresh frozen cadaveric lower extremities, the motions and forces of the intact ankle under multidirectional loading were recorded using a 6-degree-of-freedom robotic system. On repeating these intact ankle joint complex motions after the calcaneofibular ligament transection, the in situ force in the calcaneofibular ligament and the contribution of the calcaneofibular ligament to ankle joint complex stability were calculated. Finally, the motions of the calcaneofibular ligament-transected ankle joint complex were recorded.

FINDINGS

Under an inversion load, significant increases of inversion angle were observed in all the flexed positions following calcaneofibular ligament transection, and the calcaneofibular ligament accounted for 50%-70% of ankle joint complex stability during inversion. The in situ forces in the calcaneofibular ligament under an anterior force, inversion moment, and external rotation moment were larger in the dorsiflexed position than in the plantarflexed position.

INTERPRETATION

The calcaneofibular ligament plays a role in stabilizing the ankle joint complex to multidirectional loads and the role differs with load directions. The in situ force of the calcaneofibular ligament is larger at the dorsiflexed position. This ligament provides the primary restraint to the inversion ankle stability.

Combination of Hansen Robotic system with cryocatheter in a challenging parahisian accessory pathway ablation

A perceived distinctive feature of cryoablation is the stability (cryoadherence) of the catheter tip during cold temperatures at the desired location, even during tachycardia. We report the case report of a young patient with a parahisian accessory pathway where stability of the ablation catheter was not achieved despite using the cryocatheter with a steerable sheath. Ultimately, stability at the desired location was achieved robotically by means of Hansen system (Hansen Medical, Mountain View, CA, USA).

Robotically-assisted laparoscopic biliopancreatic diversion with duodenal switch: the utility of the robotic system in bariatric surgery

Biliopancreatic diversion with duodenal switch (BPD/DS) is considered the most effective surgical option for morbidly obese patients. Several techniques have been described: open, laparoscopic, and the combination of open and laparoscopic. Only a few centers in the world perform robotically-assisted laparoscopic BPD/DS and the published literature is limited. We describe our experience using this technique as a safe alternative for treatment of morbid obesity. A review of a prospectively maintained database from 2008 to 2011 was conducted. A total of 107 consecutive patients (F:M = 83:24) were included in this series. Average age was 44.76 years (range 20-67), body mass index 49.97 kg/m(2) (range 37-70), and the number of preoperative comorbidities was 6.24 (range 3-11). The mean operative time for a typical BPD/DS with or without an appendectomy was 264 min (range 192-413), which increased to 298 min (range 210-463) when lysis of adhesion or additional procedures were performed. All study cases were completed using a minimally invasive approach. There were no intraoperative or 30-day major postoperative complications. Two patients returned to the operating room: one for endoscopic release of an inadvertently-sutured nasogastric tube during creation of the duodeno-ileal anastomosis and another patient for a port-site infection. Minor postoperative complications included carpal tunnel syndrome exacerbation (n = 1), which did not require surgical intervention. The median length of stay was 3.0 days (range 2-13). Two patients were readmitted within 30 day due to fluid retention and incarcerated umbilical hernia. The percentages of excess body weight loss (EBWL) at 1, 3, 6, 9, 12, and 18 months were 18.9, 36.4, 54.5, 67.4, 73.9, and 82.42 %, respectively. No mortality occurred in this study. Robotically-assisted laparoscopic technique for BPD/DS is a feasible, safe, and effective alternative for weight loss surgery with excellent outcomes.