Show notes
Join us as we dissect the use of robotics in bariatric surgery – where precision meets programming, and the scalpel gets a software upgrade.
Video Clip Link: https://app.behindtheknife.org/video/clinical-challenges-in-robotic-bariatric-surgery-the-robot-is-here-to-stay
This videos includes:
- Robotic RYGB
- Robotic Sleeve Gastrectomy
- SADI: Single Anastomosis Duodenoileostomy
Hosts:
- Matthew Martin, trauma and bariatric surgeon at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California)
- Adrian Dan, bariatric and MIS surgeon, program director for the advanced MIS bariatric and foregut fellowship at Summa Health System (Akron, Ohio)
- Crystal Johnson Mann, bariatric and foregut surgeon at the University of Florida (Gainesville, Florida)
- Katherine Cironi, general surgery resident at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California)
Learning objectives:
Strengths of the robot:
Surgical robots are at the forefront of technology and continue to improve with detailed, precision cameras and the ability to remove baseline tremors
Allows for smooth movements, fine dissection, and precise tissue handling
Ergonomics are more advantageous to the surgeon when compared to laparoscopy
Weaknesses of the robot:
The loss of haptic feedback can be challenging for surgeons early in their learning curve
Emphasis on surgical robots means some trainees may be losing exposure to laparoscopic techniques
Longer operative time when working robotically, and more time under anesthesia for the patient
Increased cost for robotic surgery
Outcomes data:
Mixed data from the MBSA QIP database (metabolic and bariatric surgery accreditation and quality improvement program)
The most recent study looked at 824,000 patients from 2015-2022 who had a sleeve gastrectomy or RNY gastric bypass, either laparoscopically (lap sleeve 61%, lap RYGB 24%) or robotically (robo sleeve 11%, robo RYGB 4%).
Robotic sleeves were reported to have higher complication rates compared to laparoscopy, seen as higher overall morbidity and an increased rate of leaks
While the robotic RYGBs have lower overall complications, including decreased morbidity and bleeding. Robotic RYGB can be especially advantageous with revisional surgeries when compared to lap.
Setting up for success
Train your eyes to determine tension on tissue, since there is no haptic feedback
Learn how to assist yourself (manipulating the camera and effectively utilizing the fourth arm)
Understand how techniques of the surgery change when doing it robotically, as compared to laparoscopy
Experienced operating room team
When learning, recommend putting all cases feasible on the robot (including easier cases), to master the straightforward cases before moving to technically challenging revision cases.
Don’t hesitate to add an additional trocar or assistant port when needed
Education in Robotic learning
Learning by observation/mirroring – ex: robotic bilateral inguinal hernia (mirroring the attending/instructor)
Easy for the attending/instructor in the case to switch instruments seamlessly, then give them back intermittently at the appropriate time
Helpful when the attending annotates the screen to depict where to go
Data-driven teaching tools on the Davinci system
Tips for robotic sleeve gastrectomy:
Of the robotic bariatric surgeries, sleeve gastrectomy is most similar to its laparoscopic procedure
30-40 degrees of reverse Trendelenburg
Liver hammock stitch instead of a liver retractor (one less trocar), which makes a total of 4 trocars needed for the case
Green staple load for the first firing, then the rest are typically blue loads
Mixed opinions on reinforced staple loads versus non-reinforced staple loads and oversewing the staple line (discussed cost-benefit)
Tips for robotic gastric bypass:
Watch videos from colleagues to learn what they do
Gastric bypass is a multi-quadrant surgery; thus, you must set yourself up for success so that your arms are not fighting when moving through different quadrants
A size 12 trocar on the left can make the formation of the gastric pouch easier
GJ and JJ anastomosis formed with a linear fire, then a two-layer closure with absorbable barb suture
Don’t forget to close the mesenteric defect (non-absorbable braided suture)
Tips for robotic DS and SADI:
If doing a duodenal anastomosis hand-sewn, then recommend planning the exact number of sutures and locations of each for ease
Hand-sewn anastomosis can have less bleeding and fewer strictures for patients, and is completed in a much more seamless fashion with the robot
Future of Robotics
Haptic feedback
Integrated visual overlays to identify anatomical structures/serve as an intraoperative map
Artificial intelligence integration
Telesurgery – ex, small surgical robot deployed to space
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