Robotic gastric bypass may lead to fewer complications compared with laparoscopy

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.

Do advances in technology translate to improved outcomes? Comparing robotic bariatric surgery outcomes over two-time intervals utilizing the MBSAQIP database

BACKGROUND

This study aims to compare outcomes and utilization of robotics in bariatric procedures across two-time intervals, chosen because they correspond to drastic changes in technology utilization-namely, a new platform and a new stapling device. Outcomes of robotic Roux-en-Y gastric bypass (rRYGB) and robotic sleeve gastrectomy (rSG) across this changing landscape have not been well studied, despite increasing popularity.

METHODS

The MBSAQIP database was analyzed over early (2015-2016) and late (2019-2020) time intervals. Patients who underwent rSG and rRYGB were identified, and the cohorts were matched for 26 preoperative characteristics using Propensity Score Matching Analysis. We then compared 30-day outcomes and bariatric-specific complications between the early and late time frames for rSG and rRYGB.

RESULTS

49,442 rSG were identified: 13,526 cases in the early time frame and 35,916 in the late time frame. The matched cohorts were 13,526 for the two groups. 30-day outcomes showed that in the late time frame, rSG was associated with lower rates of pulmonary complications (0.1% vs 0.3%, p < 0.001), readmissions (2.5% vs 3.6%, p < 0.001), interventions (0.6% vs 1.4%, p < 0.001), reoperations (0.7% vs 1.0%, p = 0.024), length of stay (1.36 ± 1.01 days vs 1.76 ± 1.79 days, p < 0.001), operative time (92.47 ± 41.70 min vs102.76 ± 45.67 min p < 0.001), staple line leaks (0.2% vs 0.4%, p = 0.001) and strictures (0.0% vs 0.2%, p < 0.001). Similarly, 21,933 rRYGB were found: 6,514 cases were identified in the early time frame and 15,419 in the late time frame. The matched cohorts were 6,513 for the two groups. 30-day outcomes revealed that the late time fame rRYGB was associated with lower rates of pulmonary complications (0.1% vs 0.3%, p = 0.012), readmissions (6.3% vs 7.2%, p = 0.050), interventions (2.0% vs 3.1%, p < 0.001), length of stay (1.69 ± 1.46 days vs 2.13 ± 2.12 days p < 0.001), postoperative bleeding (0.4% vs 0.7%, p = 0.001), stricture (0.4% vs 0.8%, p < 0.001) and anastomotic ulcer (0.2% vs 0.4%, p = 0.013).

CONCLUSION

Compared to early robotic bariatric surgery outcomes, a significant reduction in pulmonary complications, readmissions, reoperations, interventions and length of stay were seen in 2019-20 after rSG and rRYGB. Potential contributing factors include increased surgical experience and advances in the robotic platform. A significant recent reduction in staple line leaks with faster operative times associated with rSG suggests that stapling technology has had a positive impact on patient outcomes.

ROBOTIC VERSUS LAPAROSCOPIC ROUX-EN-Y-GASTRIC BYPASS: A RETROSPECTIVE STUDY IN A SINGLE CENTER

BACKGROUND

Bariatric surgery is the best treatment option for patients with obesity. As a result of the advancement of technology, the robotic gastric bypass presents promising results, despite its still high costs.

AIMS

The aim of this study was to compare patients submitted to a robotic versus a laparoscopic gastric bypass at a single center by a single surgeon.

METHODS

This retrospective study collected data from the medical records of 221 patients (121 laparoscopic procedures versus 100 with daVinci platform). The variables analyzed were sex, age, body mass index, comorbidities, surgical time, length of stay, and complications.

RESULTS

The mean surgical time for patients in the robotic group was shorter (102.41±39.44 min versus 113.86±39.03 min, p=0.018). The length of hospital stay in robotic patients was shorter (34.12±20.59 h versus 34.93±11.74 h, p=0.007). There were no serious complications.

CONCLUSIONS

The group submitted to the robotic method had a shorter surgical time and a shorter hospital stay. No difference was found regarding strictures, bleeding, or leakage.

Selection of Robotic Bariatric Surgery Candidates: a Nationwide Analysis

INTRODUCTION

This study aims to identify risk factors associated with 30-day major complications, readmission, and delayed discharge for patients undergoing robotic bariatric surgery.

METHODS

From the metabolic and bariatric surgery and accreditation quality improvement program (2015-2018) datasets, adult patients who underwent elective robotic bariatric operations were included. Predictors for 30-day major complications, readmission, and delayed discharge (hospital stay ≥ 3 days) were identified using univariable and multivariable analyses.

RESULTS

Major complications in patients undergoing robotic bariatric surgery were associated with both pre-operative and intraoperative factors including pre-existing cardiac morbidity (OR = 1.41, CI = [1.09-1.82]), gastroesophageal reflux disease [GERD] (OR = 1.23, CI = [1.11-1.38]), pulmonary embolism (OR = 1.51, CI = [1.02-2.22]), prior bariatric surgery (OR = 1.66, CI = [1.43-1.94]), increased operating time (OR = 1.003, CI = [1.002-1.004]), gastric bypass or duodenal switch (OR = 1.58, CI = [1.40-1.79]), and intraoperative drain placement (OR = 1.28, CI = [1.11-1.47]). With regard to 30-day readmission, non-white race (OR = 1.25, CI = [1.14-1.39]), preoperative hyperlipidemia (OR = 1.16, CI = [1.14-1.38]), DVT (OR = 1.48, CI = [1.10-1.99]), therapeutic anticoagulation (OR = 1.48, CI = [1.16-1.89]), limited ambulation (OR = 1.33, CI = [1.01-1.74]), and dialysis (OR = 2.14, CI = [1.13-4.09]) were significantly associated factors. Age ≥ 65 (OR = 1.18, CI = [1.04-1.34]), female gender (OR = 1.21, CI = [1.10-1.32]), hypertension (OR = 1.08, CI = [1.01-1.15]), renal insufficiency (OR = 2.32, CI = [1.69-3.17]), COPD (OR = 1.49, CI = [1.23-1.82]), sleep apnea (OR = 1.10, CI = [1.03-1.18]), oxygen dependence (OR = 1.47, CI = [1.10-2.0]), steroid use (OR = 1.26, CI = [1.02-1.55]), IVC filter (OR = 1.52, CI = [1.15-2.0]), and BMI ≥ 40 (OR = 1.12, CI = [1.04-1.21]) were risk factors associated with delayed discharge.

CONCLUSION

When selecting patients for bariatric surgery, surgeons early in their learning curve for utilizing robotics should avoid individuals with pre-existing cardiac or renal morbidities, venous thromboembolism, and limited functional status. Patients who have had previous bariatric surgery or require technically demanding operations are at higher risk for complications. An evidence-based approach in selecting bariatric candidates may potentially minimize the overall costs associated with adopting the technology.

Robot-assisted pericystectomy using Da Vinci Xi surgical system with indocyanine green fluorescence imaging for hepatic cystic echinococcosis

OBJECT

The clinical efficacy of robot-assisted laparoscopic pericystectomy using the Da Vinci Xi surgical system plus indocyanine green（ICG） fluorescence imaging and the conventional laparotomy for en bloc pericystectomy was compared.

METHODS

The clinical data of 7 patients treated by robot-assisted laparoscopic pericystectomy using the Da Vinci Xi surgical system plus ICG fluorescence imaging at our hospital between October 2019 and July 2021 and 15 patients treated by conventional laparotomy for en bloc pericystectomy were retrospectively analyzed.

RESULT

Compared with the conventional laparotomy group, the intraoperative blood loss was reduced using the Da Vinci surgical system [(225.43 ± 44.75)ml: (521.33 ± 246.34) ml, P = 0.015]. The indwelling time of the urinary catheter was also shorter [2.86 ± 0.75)d: (3.87 ± 0.81)d, P = 0.012]. However, the total expense was increased significantly [(49.9 ± 3.7) thousand RMB: (28.7 ± 5.0) thousand RMB, P < 0.001]. The two groups of patients were not significantly different in operation time, time to flatulence after surgery, time to eat a liquid diet after surgery, length of hospital stay after surgery, time to drainage tube removal, and the incidence of postoperative complications (P = 0.899). Both two groups were followed up for 3-12 months after surgery. The patients were generally good without recurrence or intra-abdominal implantation.

CONCLUSION

The Da Vinci Xi surgical system could be feasibly and safely applied to the robot-assisted laparoscopic pericystectomy plus ICG fluorescence imaging for Hepatic cystic echinococcosis(HCE). This procedure could effectively remove the hepatic hydatid cysts under the ICG fluorescence imaging with a higher resection rate, causing less trauma and fewer complications.

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.

Australian experience with robot-assisted Roux-en-Y gastric bypass with comparison to a conventional laparoscopic series

BACKGROUND

Robotic surgery is a novel approach to abdominal surgery. In Australia, the uptake of robotic assistance for bariatric surgery has been relatively slow compared to many other countries. The aim of this study is to report the first high volume experience of robotic-assisted Roux-en-Y gastric bypass surgery in Australia (RRYGB) and compare outcomes with a similar laparoscopic group (LRYGB).

METHODS

Retrospective analysis of 100 RRYGB versus 100 LRYGB was carried out over a period of seven years performed by two surgeons. These groups were matched by revisional status. Outcomes recorded included operative times, conversion rate, hospital stay, short-term (30 days) complication rates, and long-term complication rates. Baseline comorbidities of patients were also recorded.

RESULTS

Baseline characteristics of the two groups were similar except for comorbidity rates (higher in LRYGB group). The mean age was 43 (RRYGB) and 44(LRYGB) years, respectively. The mean pre-op BMI was 44.3 in the RRYGB group and 44.7 in the LRYGB group. Mean operating time in the RRYGB group was 208 min compared to 175 min in the LRYGB group. The number of patients with major complications was 1 in the robotic group versus 5 in the laparoscopic group (P: 0.2166). Minor complications were higher in the robotic group (17 vs. 5, P: 0.0054). Median length of stay of patients with RRYGB was 4 days compared to 5 days for the LRYGB group.

CONCLUSION

RRYGB has been successfully implemented in Australia with low complication rates compared to conventional laparoscopic RYGB. Operating times are longer compared to LRYGB which is consistent with most published literature. To justify increased costs generally associated with robotic surgery, better quality studies are needed to accurately assess potential cost savings with length of stay and safety benefits to patients and institutions.

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.

Understanding the Current Role of Robotic-Assisted Bariatric Surgery

BACKGROUND

The role of robotic surgery in bariatrics remains controversial. Patient selection for robotic surgery is not well-studied. The objective of this study was to identify factors associated with robotic surgery and its temporal trends.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database from 2015 to 2018 was used. Adult patients undergoing primary sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) using the laparoscopic or robotic approach were identified. Revisional, hybrid, or those with concomitant procedures were excluded. Logistic regression was conducted to identify factors associated with undergoing robotic-assisted surgery.

RESULTS

Among 211,568 patients who underwent SG, 9.1% underwent a robotic SG; among 76,805 patients who underwent RYGB, 7.9% of patients underwent a robotic RYGB. During 2015-2018, robotics increased from 7.1 to 11.3% for SG and 7.4 to 8.6% for RYGB. After controlling for patient characteristics, there was still an increasing trend in the use of robotic surgery: SG (multivariable-adjusted odds ratio, aOR, 1.18; 95% confidence interval, CI, 1.17-1.20) and RYGB (aOR, 1.05; 95% CI, 1.03-1.08). For both robotic SG and RYGB, functional status and African American race were associated with undergoing robotic surgery, while races other than White or African American and Hispanic ethnicity were not. Pre-operative IVC filter was associated with robotic SG, while the presence of GERD, diabetes, and COPD were associated with robotic RYGB.

CONCLUSIONS

Robotic bariatric surgery has increased over time. Our findings identified factors associated with the receipt of robotic surgery. Reasons for these factors require further investigation to better delineate indications for this technology.

Robotic stapler use: Is it safe?-FDA database analysis across multiple surgical specialties

Introduction

Robotic-assisted techniques are common across many surgical subspecialties. While robotic stapling offers increased surgeon control, there is limited information on surgical complications related to robotic stapler use.

Methods

We reviewed the FDA’s MAUDE database for adverse events related to robotic stapler use.

Results

Upon review of the FDA database, the most frequently reported robotic stapler complications were malfunction, failure to form staple line, device fragmentation, and misfire. 31 Clavien-Dindo grade II or higher complications were attributed to stapler use since 2014.

Conclusions

Further research on prevalence of robotic stapler use is needed to quantity the associated complication rate.

Robotic bariatric surgery for the obesity: a systematic review and meta-analysis

OBJECTIVE

The aim of this meta-analysis is to evaluate the safety and efficacy of bariatric surgery (BS) in patients with obesity by robotic bariatric surgery (RBS) compared with laparoscopic bariatric surgery (LBS).

METHODS

The study was performed through searching in Pubmed, Web of Science, Embase database and Cochrane Library until March 31, 2020 comparing RBS with LBS. Data were calculated on the following endpoints: operative time, length of hospital stay, reoperation within 30 days, overall complications, leak, stricture, pulmonary embolisms, estimated blood loss and mortality. Data as relative risks (OR), or weighted mean difference (WMD) were summarized with 95% confidence interval (CI). Risk of publication bias was assessed through standard methods.

RESULTS

Thirty eligible trials including 7,239 robotic and 203,181 laparoscopic surgery cases showed that RBS was referred to attain longer operative time [WMD = 27.61 min; 95%CI (16.27-38.96); P < 0.01] and lower mortality [OR 2.40; 95% CI (1.24-4.64); P = 0.009] than LBS. Length of hospital stay [WMD = - 0.02; 95% CI (- 0.19-0.15); P = 0.819], reoperation within 30 days [OR 1.36; 95% CI (0.65-2.82); P = 0.411], overall complications [OR 0.88; 95% CI (0.68-1.15); P = 0.362], leak [OR 1.04; 95% CI (0.43-2.51); P = 0.933], stricture [OR 1.05; 95% CI (0.52-2.12); P = 0.895], pulmonary embolisms [OR 1.97; 95% CI (0.93-4.17); P = 0.075], estimated blood loss[WMD = - 1.93; 95% CI (- 4.61-0.75); P = 0.158] were almost similar in both RBS group and LBS group. Three was no statistically significant difference between RRYGB and LRYGB in EWL%, no statistical significance between RSG and LSG after 1 year, 2 years and 3 years.

CONCLUSION

RBS presented lower mortality within 90 days and longer operative time in this meta-analysis with similar safety and efficacy for the obesity compared with LBS in other outcomes. Additionally, RBS might be beneficial in the future if it would be evaluated in comprehensive and long-term endpoints.

The Impact of Robotics in Learning Roux-en-Y Gastric Bypass: a Retrospective Analysis of 214 Laparoscopic and Robotic Procedures : Robotic Vs. Laparoscopic RYGB

BACKGROUND

Proximal Roux-en-Y gastric bypass is commonly used to manage obesity, performed using laparoscopic or robot-assisted minimally invasive surgery. As the prevalence of robotic bariatric surgery increases, further data is required to justify its use.

METHODS

This was a large, retrospective analysis of prospectively recorded data for Roux-en-Y gastric bypass (RYGB) procedures performed using laparoscopic (LRYGB) or robotic (RRYGB; da Vinci Xi system, Intuitive Surgical Sàrl) surgery between January 2016 and March 2019. The surgical techniques did not differ apart from different trocar placements. Data collected included patient characteristics before and after RYGB, operative outcomes and complications.

RESULTS

In total, 114 RRYGB and 108 LRYGB primary surgeries were performed. There were no significant differences between the groups, apart from a significantly shorter duration of surgery (116.9 vs. 128.9 min, respectively), lower C-reactive protein values at days 1 (31.1 vs. 44.1 mg/l) and 2 (50.3 vs. 77.8 mg/l) after the intervention, and overall complication rate (4.4 vs. 12.0%, Clavien-Dindo classification II-V) with RRYGB compared with LRYGB. There was a lower hemoglobin value in the postoperative course after RRYGB (12.1 vs. 12.6 g/dl, day 2).

CONCLUSIONS

In our experience, robotic RYGB has proven to be safe and efficient, with a shorter duration of surgery and lower rate of complications than laparoscopic RYGB. RRYGB is easier to learn and seems safer in less experienced centers. Increasing experience with the robotic system can reduce the duration of surgery over time. Further studies with higher evidence level are necessary to confirm our results.

Robotic Roux en Y gastric bypass can be safe and cost-effective in a rural setting: clinical outcomes from a community hospital bariatric program

Robotic Roux en Y gastric bypass (R-RYGB) is becoming more common due to the shifting trend toward robotic gastrointestinal surgery. The goal of this study is to determine if R-RYGB can be safely implemented at a robotic bariatric surgery program in a community hospital with similar results to laparoscopic RYGB (L-RYGB) in a cost-effective manner. A total of 50 R-RYGB procedures were performed with the Xi and the X da Vinci systems and compared with 50 L-RYGB cases by a single surgeon from October 2018 to January 2020 at an acute-care community hospital in a rural setting with a high-volume MBSAQIP-accredited program. A retrospective chart review was conducted with IRB approval and statistical analysis of 30-day morbidity, mortality, re-interventions, and resolution of co-morbidities, with financial analysis of cost reduction. Both groups were similar in age, gender, ASA class, co-morbidities, and body mass index (BMI). There was no mortality or anastomotic leak. The 30-day morbidity for R-RYGB was 10.0% with a re-operation rate of 4.0%. There were no conversions to open, and the mean hospital length of stay was 2.22 ± 1.19 days. There were no statistically significant differences between R-RYGB and L-RYGB with respect to any measured outcome, including intraoperative time (121.94 vs. 113.52, respectively; p = 0.1495). However, when incidences and percentages were used, R-RYGB had improved performance for most of the outcomes measuring safety. There was an average cost reduction of $816.90 per case (total saving of $40,845.00 for 50 cases) in the R-RYGB by transitioning from a hybrid approach to a totally robotic approach. R-RYGB appears to be as safe as L-RYGB and can be performed in a rural community hospital while maintaining a low complication rate, achieving a high co-morbidity resolution rate, and saving costs with a totally robotic approach.

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

Benefits of robotic surgery for Roux-en-Y gastric bypass (RYGB) are still debated. We aimed to compare conventional laparoscopic (L-RYGB) to robotic RYGB (R-RYGB) and evaluate safety, efficacy, advantages and drawbacks of each procedure. A prospective cohort study with a retrospective review approach was conducted to analyze results of L-RYGB and R-RYGB performed at a bariatric center of excellence. Patient demographics, perioperative data, weight loss, comorbidities evolution and cost were assessed. One hundred and sixty-one severely obese patients underwent R-RYGB and L-RYGB, respectively. Patient's characteristics were similar between groups. Intraoperative blood loss was similar (p = 0.91), with no requirement for blood transfusion. Median operative time was significantly reduced for R-RYGB (127 vs 160 min; p < 0.001). Seven patients (11.4%) in the L-RYGB group and 15 patients (15%) in the R-RYGB group had early postoperative complications (p = 0.63), with more anastomotic leaks and stenosis for R-RYGB during initial learning curve (p = NS). Mortality was null. Median length of hospital stay was similar (6 days; p = 0.20). Mean hospital cost was non-significantly increased for R-RYGB ($5730 vs. $4879; p = 0.34). Two years after surgery, median BMI and mean EWL% were similar for both groups (26.1 vs 26.5 kg/m² and 89.9% vs 90.9% for L-RYGB and R-RYGB groups, respectively; p = 0.71 and 0.85, respectively), with no statistically significant difference in comorbidities between the two groups (p = 0.80). R-RYGB is feasible and safe within the reach of every laparoscopic surgeon. In our series, it was associated with shorter operative time and equivalent length of stay and weight loss outcomes compared to L-RYGB. Further well-designed randomized studies are necessary to draw safe conclusions.

Robotic surgery results in better outcomes following Roux-en-Y gastric bypass: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program analysis for the years 2015-2018

BACKGROUND

The use of robotic surgery in bariatric patients is controversial.

OBJECTIVES

To evaluate the outcome of robotic surgery in Roux-en-Y gastric bypass (RYGB) patients.

SETTING

Tertiary-care referral hospital.

METHODS

A total of 149,132 patients who underwent RYGB in the 2015 to 2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database were included in our initial analysis. The propensity-matched analysis that was performed resulted in 21,736 patients, whose data were utilized to compare outcomes of the robotic (R) and laparoscopic (L) groups. Patients were also compared after dividing them into obese (body mass index [BMI] < 50 kg/m²) and super-obese categories (BMI ≥ 50 kg/m²).

RESULTS

R-RYGB patients had a significantly lower 30-day incidence of serious adverse events (SAEs) and bleeding (2.0% and .7%, respectively, for R-RYGB versus 2.4% and 1.3%, respectively, for L-RYGB; P ≤ .05) but a higher incidence of 30-day reoperation compared to L-RYGB patients (2.7% versus 2.3%, respectively; P ≤ .05). The R-RYGB group also had a shorter length of hospital stay compared to the L-RYGB group (1.98 versus 2.02 days, respectively; P ≤ .05), but higher readmission rates (7.1% versus 5.8%, respectively; P ≤ .05). The robotic approach also resulted in lower mortality rates for those in the super-obese category. In that BMI category, 30-day mortality rates were .4% versus .2% for L-RYGB and R-RYGB patients, respectively (P ≤ .05).

CONCLUSION

The use of robotic surgery in bariatric patients is controversial. Our analysis, based on the MBSAQIP database for the years 2015 to 2018, demonstrated lower overall SAEs and bleeding rates, in addition to a shorter hospital stay, favoring robotic RYGB compared to laparoscopic RYGB. However, readmission and reoperation rates were higher in the robotic group. Randomized controlled trials are needed to further clarify the benefit of robotic surgery in bariatric patients.

Three-dimensional laparoscopic Roux-en-Y gastric bypass with totally hand-sewn anastomoses for morbid obesity. A single center experience

PURPOSE

To assess the impact of three-dimensional (3D) vision use on operative time (OT) in laparoscopic Roux-en-Y gastric bypass (LRYGB) with hand-sewn anastomoses.

METHODS

We analyzed a prospectively collected database of patients who underwent LRYGB. We included all patients operated on with either 2D or 3D vision. Demographics and clinical characteristics, operative time, hospital stay and 30-day postoperative complications were collected for all patients and analyzed.

RESULTS

During the study time, out of 143 patients who underwent LRYGB for morbid obesity, 111 were considered eligible. Seventy-eight patients were operated with 2D vision and 33 patients with 3D vision. Demographics and clinical characteristics were not different among groups. Mean OT was 203±51 and 167±32 minutes in the 2D and 3D groups respectively (p<0.001). Multivariate analyses showed that increasing age and BMI were independently related to prolonged OT, while 3D vision (OR 6.675, 95% CI 2.380-24.752, p<0.001) was strongly associated with shorter OT.

CONCLUSIONS

The use of 3D vision in LRYGB significantly reduced the OT, though intra- and postoperative complication rates and the length of hospital stay were not affected. Despite its limitations, our study supports the value of 3D vision laparoscopy in bariatric surgery.

Evolving Trends in North American Gastric Bypass Delivery: a Retrospective MBSAQIP Analysis of Technical Factors and Outcomes from 2015 to 2018

PURPOSE

A number of procedural and technical factors have been adopted over time to overcome the steep learning curve and adverse safety profile of Roux-en-Y gastric bypass (RYGB). However, the evolution and impact of these factors are not currently known which limits our ability to optimize RYGB delivery.

MATERIALS AND METHODS

Data was extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to 2018. All primary RYGB procedures were included while prior revisional surgeries and emergency surgeries were excluded. Primary outcomes included characterizing the trends in procedural and technical factors associated with RYGB.

RESULTS

A total of 156,941 patients underwent primary RYGB from 2015 to 2018 with a mean age of 45.2 ± 11.9 years and a mean body mass index of 46.4 ± 8.4 kg/m [1]. The majority of patients were female (80.3%), of white racial status (73.5%), and of non-smoking status (92.1%). The most commonly performed approach was laparoscopic RYGB although an increase in robotic cases was observed over time. Rates of drain placement and postoperative swallow studies decreased by 10% from 2015 to 2018. Together, these trends were associated with reductions in serious complications, readmission, and re-intervention rates over time.

CONCLUSION

The proportion of RYGB cases performed in MBSAQIP accredited centers has decreased from 2015 to 2018 associated with an increased adoption of sleeve gastrectomy Leaks, serious complications, readmission, and reintervention rates improved with each operative year suggesting that the technical proficiency and safety of RYGB continue to evolve with time.

Cost Analysis of Robotic Roux-en-Y Gastric Bypass in a Single Academic Center: How Expensive Is Expensive?

BACKGROUND

Although the use of da Vinci robotic platforms in bariatric surgery is gaining momentum, it is still controversial because of financial concerns.

OBJECTIVES

The objective of our study is to evaluate the cost of robotically assisted Roux-en-Y gastric bypass (R-RYGB) versus conventional laparoscopic Roux-en-Y gastric bypass (L-RYGB).

METHODS

We analyzed consecutive primary bariatric patients who underwent R-RYGB and compared them with patients who underwent L-RYGB during the same time period. Primary outcomes were overall cost for length of stay, operating time, and supplies. Direct cost data was generated using the StrataJazz reporting module, which is fed daily from EPIC, our electronic health record system, and contains hospital-based data only. Secondary outcomes were 30-day rates of complications, reoperations, and readmissions.

RESULTS

We found no difference in primary or secondary outcomes following R-RYGB and L-RYGB. The overall cost for R-RYGB and L-RYGB was not statistically different (median total cost for R-RYGB and L-RYBG was $6431.34 and $6349.09, P > 0.05, respectively). Operating time cost was significantly higher for R-RYGB compared with L-RYGB ($2248.51 versus $19,836.29, respectively, P < 0.0001, respectively). R-RYGB had lower cost of supplies as well as a shorter length of stay compared with L-RYGB (mean 1.5 versus 1.7 days, respectively).

CONCLUSIONS

Our study revealed no cost difference between R-RYGB and L-RYGB, with a decreased cost of supplies and trend toward lower hospital stay favoring R-RYGB. Further studies are needed to evaluate the outcomes of R-RYGB compared with L-RYGB; however, the cost of robotic surgery may not be a prohibitive factor.

Outcomes of robotic surgery in revisional bariatric cases: a propensity score-matched analysis of the MBSAQIP registry

In recent years, there has been a significant increase in the number of Revisional Bariatric Surgery (RBS) cases performed to address complications and weight recidivism. The use of the da Vinci robotic platform, considered controversial by many, may offer advantages in RBS. The objective of our study is to compare the outcomes of Robotic RBS (R-RBS) to Laparoscopic RBS (L-RBS). Using the 2015-2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we selected all RBS and we matched R-RBS to L-RBS using a propensity score matching system to create balanced groups. Our primary outcomes were 30-day Serious Adverse Events (SAE), 30-day Organ Specific Infection (OSI), 30-day reoperation and 30-day interventions. Our secondary outcomes included length of operation and 30-day readmission. We conducted separate Mann-Whitney rank sums tests or chi-square tests and Fisher exact test. R-RBS and L-RBS included 220 patients each. The overall incidence of 30-day SAEs, 30-day OSIs, 30-day reoperations, 30-day interventions were lower for R-RBS (6.4%, 0.9%, 2.7% and 2.3%, respectively) compared L-RBS (7.7%, 1.4%, 3.6% and 3.6%, respectively). Subgroup analysis showed that R-RBS had a lower rate of complications for the Gastric Bypass procedure but not for Sleeve gastrectomy cases. However, 30-day readmission was higher for R-RBS compared to L-RBS (9.1% vs 6.4% respectively). None of the analyses reached statistical significance. R-RBS took significantly longer compared to L-RBS (169 min vs 138 min, p < 0.05). Our study shows that R-RBS has lower complication rate albeit non-significant as compared to L-RBS.

Pros and Cons of Robotic Revisional Bariatric Surgery

Introduction

Revisional procedures in bariatric surgery are regarded as technically more demanding and riskier than primary interventions. While the use of the surgical robot has not yet proven to be advantageous in primary bariatric interventions, the question remains whether its use is justified for more complex revisional procedures.

Objective

To show that revisional bariatric surgery can be performed safely using the da Vinci® Xi surgical system.

Methods

We performed a retrospective analysis of prospectively recorded data for revisional bariatric procedures between January 2016 and November 2019.

Results

Of 78 revision operations, four (5.1%) were performed by open surgery, 30 (38.5%) by laparoscopic surgery, and 44 (56.4%) by robotic surgery. A comparative analysis of robotic (n = 41) versus laparoscopic (n = 18) revisional Roux-en-Y gastric bypasses (rRYGB) revealed significant differences favoring the robotic approach for operative time (130.7 vs. 167.6 min), C-reactive protein values at days 1 (27.9 vs. 49.1 mg/L) and 2 (48.2 vs. 83.6 mg/L) after surgery, and length of stay (4.9 vs. 6.2 days). Lower complication rates (Clavien-Dindo II-V) were found after rRRYGB (7.3 vs. 22.2%, not significant).

Conclusions

Revisional bariatric surgery using a robotic system is safe. The operative time performing rRRYGB is significantly shorter than rLRYGB in our experience. Otherwise, results were largely comparable. Due to different indications, different index operations and a wide range of revisional procedures, further studies are necessary to confirm these results.

Evolution of outcomes of robotic bariatric surgery: first report based on MBSAQIP database

BACKGROUND

Robotic surgery is increasingly being used in bariatric surgery; however, the benefits of robotic surgery in bariatrics remain controversial.

OBJECTIVES

The objective of this study was to compare the outcomes of robotic bariatric surgery with laparoscopic surgery over a 3-year period between 2015 and 2017 using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

SETTING

University Hospital, United States.

METHODS

Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for the years 2015 to 2017, we included patients who underwent primary robotic or laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass procedures. Patients were divided into either robotic or laparoscopic groups. Primary outcomes included serious adverse events, organ space infection (OSI), readmissions, reoperations, and interventions at 30 days. Secondary outcomes included operation length and hospital stay. We performed propensity score matching based on clinically relevant preoperative variables to create balanced groups before analysis. We analyzed our data using separate Cochran-Mantel-Haenszel tests with year as the stratification variable and conducted subgroup analyses for robotic patients only using separate t tests for proportions, with P < .05 denoting statistical significance.

RESULTS

Of the 315,647 patients available for comparison in the 2015 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant User Files, there were 41,364 matched in the final data set. Using the Cochran-Mantel-Haenszel test, we found a significant association between year of performance and outcomes for OSI, 30 day-readmission, and intervention. The incidence of OSI after laparoscopic and robotic cases was .3% and .4%, respectively, in 2015 versus .2% and .3%, respectively, in 2017 (P = .04, odds ratio = 1.49). Thirty-day readmission for robotic cases was 5.2% in 2015 and 4.0% in 2017 (P < .05, odds ratio = 1.16). The incidence of 30-day intervention for robotic cases also dropped from 2.2% in 2015 to 1.3% in 2017 (P < .05, odds ratio = 1.37). Using a Student's t test, there was also a statistically significant decrease in serious adverse events in the robotic group between 2015 and 2017 (incidence of serious adverse events in 2015 was 5.2% versus 3.7% in 2017, P < .05). Rate of 30-day reoperation for the robotic group did change over time but was comparable to the laparoscopic group (1.4% versus 1.3%).

CONCLUSIONS

Our study showed between 2015 and 2017 the outcomes of robotic bariatric surgery have improved as evidenced by the significant decrease in the rate of OSI, readmissions, and interventions at 30 days.

Systematic assessment of complications after robotic-assisted total versus distal gastrectomy for advanced gastric cancer: A retrospective propensity score-matched study using Clavien-Dindo classification

BACKGROUND

Despite increasing evidence demonstrated robot-assisted distal gastrectomy (RADG) is safe and feasible for the treatment of advanced gastric cancer (AGC), robot-assisted total gastrectomy (RATG) remains a challenging procedure due to its technical difficulties and possible postoperative complications (POCs). This study aimed to systematically evaluate POCs following RATG.

METHODS

Between January 2017 and January 2019, 319 AGC patients with pathological stage T2-4aN0-3M0 who underwent RADG or RATG were enrolled. POCs were stratified using the Clavien-Dindo classification. One-to-one propensity score matching was performed to reduce confounding differences.

RESULTS

After matching, 266 patients met the criteria for further analysis. Ultimately, 64 patients (24.1%) who developed POCs had 126 clinical manifestation events. Overall the POCs rate was significantly greater after RATG in comparison with RADG (29.3% vs. 18.8%; P = 0.045), and more major POCs (Clavien-Dindo grade ≥ IIIa) were observed in the RATG group (14.3% vs. 5.3%; P = 0.013). The POCs were then classified into local and systemic POCs. The rates of local POCs (35.3% vs. 19.5%; P = 0.004) and systemic POCs (24.8% vs. 15.0%; P = 0.046) were significantly higher in the RATG group than the RADG group. Subgroup analysis showed that the anastomotic leakage rate was higher after RATG (5.3% vs. 0.8%; P = 0.031), whereas the remaining POCs were similar between the two groups. Patients with higher POCs significantly had longer postoperative length of stay (R = 0.895, P = 0.003). Multivariate analysis confirmed age, extent of resection, and TNM stage were risk factors for all POCs.

CONCLUSIONS

These findings demonstrated that RATG is technically feasible and safe for treatment of AGC with acceptable morbidity and mortality rates. The POCs rate of RATG was higher than RADG, especially for anastomotic leakage. More effective anastomotic techniques are needed in RATG to prevent leakage.

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.

Cost analysis of robotic sleeve gastrectomy (R-SG) compared with laparoscopic sleeve gastrectomy (L-SG) in a single academic center: debunking a myth!

BACKGROUND

Although use of the da Vinci robotic platform in bariatric surgery is gaining momentum, there are financial concerns.

OBJECTIVES

Our retrospective study evaluated the cost of robotically assisted sleeve gastrectomy (R-SG) versus conventional laparoscopic sleeve gastrectomy (L-SG).

SETTING

Center of Excellence bariatric surgery center in Allentown, Pennsylvania.

METHODS

We analyzed consecutive patients who underwent primary R-SG and compared them with L-SG patients. Primary outcomes were overall cost for length of stay, operating time, and supplies. Secondary outcomes were 30-day complications, reoperations, and readmissions.

RESULTS

We had no adverse events in either group. The overall cost for R-SG and L-SG was not statistically different (mean total cost for R-SG and L-SG was $5308.99 and $4918.88, respectively). Operating time cost was significantly higher for R-SG compared with L-SG ($1340 versus $112 for R-SG and L-SG, respectively). R-SG had a shorter length of stay compared with L-SG (1.4 versus 1.5 d, respectively).

CONCLUSIONS

Our study revealed no difference in cost R-SG and L-SG, with a trend toward shorter length of stay for R-SG over time.

Surgical management of obesity

Weight loss surgery is the most effective intervention for addressing obesity and related metabolic disorders such as diabetes. We describe common surgical procedures as well as emerging and investigational procedures in terms of their capacity to induce weight reduction and their risk profiles. We then discuss the impact of weight loss surgery on important obesity related disorders including diabetes, cardiovascular disease, and non-alcoholic fatty liver disease. The question of operative choice is discussed with respect to benefits and risks of common procedures. Reoperative weight loss surgery, an increasingly common element of weight loss surgical practice, is reviewed. We briefly discuss the metabolic mechanism of action of weight loss surgery. Lack of access to and under-utilization of weight loss surgery represent important challenges to adequate obesity treatment, and we review these topics as well.

Robotic-assisted bariatric surgery: case series analysis and comparison with the laparoscopic approach

OBJECTIVE

to report a series of cases of robotic bariatric surgery in the treatment of obesity in Brazil.

METHODS

we evaluated patients undergoing robotic bariatric surgery at the Garrido Institute and compared them with a group submitted to conventional laparoscopic surgery.

RESULTS

we analyzed 45 patients, with a mean age of 39.44 years, of which 34 were female, with an initial mean BMI of 41.26kg/m2. Among the procedures performed, 91.11% were Roux-en-Y gastric bypass, while 8.89% were sleeve gastrectomy. The mean total surgery time was 158 (±56.54) minutes, with mean docking time of 7.93 (±3.9) minutes, and console time 113.0 (±41.4) minutes. The average pain presented in the post anesthetic recovery was 2.61 (±3.30) points on a scale of 0 to 10; four patients presented with mild signs of nausea, responding well to drug treatment. Only one patient needed ICU admission for a period of two days after surgery due to previous cardiopathy. In two cases, there was an incisional hernia at the trocar site, which were surgically treated without further complications. In the comparison between robotic versus laparoscopic surgery groups, 45 patients were selected for each group. Operative time was significantly longer in the robotic surgery group, with most other variables being equivalent, including postoperative control of comorbidities.

CONCLUSION

robotic bariatric surgery is a safe procedure, with results comparable to laparoscopic surgery.

Robotic gastric bypass is getting better: first results from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program

BACKGROUND

The use of robotic platforms in performing laparoscopic Roux-en-Y gastric bypass (LRYGB) is increasing, though their safety compared with the conventional laparoscopic approach remains unclear.

OBJECTIVE

The objective of this study was to evaluate perioperative data and 30-day outcomes of conventional and robot-assisted LRYGB using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry.

SETTING

University health network, United States.

METHODS

We reviewed all conventional and robot-assisted LRYGB cases entered between January 1 and December 31, 2016 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. Demographic characteristics and 30-day outcomes were analyzed based on separate Mann-Whitney rank sums tests, χ², or Fisher's exact tests as appropriate, with P ≤ .05 denoting statistical significance with no adjustment for multiple testing.

RESULTS

Of the 39,425 patients who underwent LRYGB, 2822 were robot-assisted. The robot-assisted approach required significantly more time (138 versus 108 min, P < .0001). Rates of organ space infection, bleeding, and other significant adverse events after the conventional and robot-assisted approaches were .3% versus .5% (P = .13), 1.1% versus .8% (P = .11), and 2.3% versus 2.3% (P = .96), respectively. There were also no significant differences in the rates of mortality, length of stay, reoperation, or readmission between the 2 groups.

CONCLUSIONS

Robot-assisted LRYGB is an increasingly popular alternative to the conventional laparoscopic approach. According to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, the early safety of these 2 techniques is equal, although the robotic approach requires more operative time.