Establishing robotic bariatric surgery at an academic tertiary hospital: a learning curve analysis for totally robotic Roux-en-Y gastric bypass

Robotic bariatric surgery: the Italian point of view to go beyond

Italian robotic community discussed critical issues about data of robotic bariatric surgery activity in Italy. A working group of Italian bariatric surgeon evaluated the current evidence on robotic use discussed its limits, advantages and future perspective in bariatric field. The chair of the working group (MR) and a group of participants (G.F., B.P., G.N.) reported results of Italian SICOB Registry data and discussed about future perspective on the behalf of the Italian Working Group on Robotic Bariatric Surgery (IGRoBS).

MATERIAL

Database of SICOB Italian Registry was analysed since 2014. All procedures were categorized by years from 2014 to October 2024 and evaluated compared than total bariatric procedures (robotic rate). Type of procedures was classified: Roux-en-Y gastric bypass (RYGB), One-anastomosis gastric bypass (OAGB), Sleeve Gastrectomy (SG), Single anastomosis duodenal-ileal bypass (SADIS), Gastric Plication (GP), Gastric Banding (GB) .

RESULTS

168.309 bariatric procedures from 2014 to October 2024 was recorded in SICOB Registry. 1086 procedures (0.64%) were recorded as robotic approach. Robotic bariatric procedures increased by years from 19 robotic procedures in 2014 to 344 procedures in the first 10 months in 2024. Robotic bariatric rate increased in the last years from 0,2% in 2014 to 3,7% in 2024. Robotic procedure types were RYGB 549, SG 433, OAGB 73, SADIS 21, GP 10, GB 5. In the last year, robotic SG was more widespread than other procedures (174 SG versus 147 RYGB).

CONCLUSION

Data showed an increased robotic activity in Italy. Literature reported that more complex procedures, such as revisional procedures, bariatric procedures combined with hiatal hernia repair, and complex cases, including superobese patients and procedures requiring manual anastomosis are promising areas for validating the use of robotic surgery. Future prospective could be resume in three answer: could robotic platforms be more useful than laparoscopy for achieving a safe and efficient learning curve? Could it offer a viable path toward solo-surgery? Could it value for AI applications, and for training and proctoring of new users?

Learning curves for adoption of robotic bariatric surgery: a systematic review of safety, efficiency and clinical outcomes

Robotic bariatric surgery may overcome challenges associated with laparoscopy, potentially achieving technically superior results. This review aims to summarise current literature reporting on learning curves for surgeons newly adopting robotic bariatrics and implications for safety, efficiency and outcomes. A systematic review was performed in line with the PRISMA guidelines. Electronic databases PubMed and MEDLINE were searched and articles reporting on learning curves in robotic bariatric surgery were identified. Studies that reported changes in outcome over time, or learning curves for surgeons newly adopting robotic bariatric surgery were included in this review. Eleven studies reporting on 1237 patients were included in this review. Most surgeons reported prior bariatric surgical experience. Differences were noted regarding the approach and adoption of robotics. Ten studies found significant reduction in operative time, with the shortest learning curve of 11 cases. Reporting of clinical outcomes was limited. Three studies reported statistically significant improvement in outcomes after the learning curve. Long-term outcomes were in line with current literature, though none assessed differences between learning curve groups. Reported learning curves in robotic bariatric surgery is variable, with limited reporting of clinical outcomes. With appropriate mentorship, surgeons can improve efficiency, safety and clinical outcomes, maximising the benefits of minimally invasive surgery.

Global benchmarks in primary robotic bariatric surgery redefine quality standards for Roux-en-Y gastric bypass and sleeve gastrectomy

BACKGROUND

Whether the benefits of the robotic platform in bariatric surgery translate into superior surgical outcomes remains unclear. The aim of this retrospective study was to establish the 'best possible' outcomes for robotic bariatric surgery and compare them with the established laparoscopic benchmarks.

METHODS

Benchmark cut-offs were established for consecutive primary robotic bariatric surgery patients of 17 centres across four continents (13 expert centres and 4 learning phase centres) using the 75th percentile of the median outcome values until 90 days after surgery. The benchmark patients had no previous laparotomy, diabetes, sleep apnoea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI greater than 50 kg/m2, or age greater than 65 years.

RESULTS

A total of 9097 patients were included, who were mainly female (75.5%) and who had a mean(s.d.) age of 44.7(11.5) years and a mean(s.d.) baseline BMI of 44.6(7.7) kg/m2. In expert centres, 13.74% of the 3020 patients who underwent primary robotic Roux-en-Y gastric bypass and 5.9% of the 4078 patients who underwent primary robotic sleeve gastrectomy presented with greater than or equal to one complication within 90 postoperative days. No patient died and 1.1% of patients had adverse events related to the robotic platform. When compared with laparoscopic benchmarks, robotic Roux-en-Y gastric bypass had lower benchmark cut-offs for hospital stay, postoperative bleeding, and marginal ulceration, but the duration of the operation was 42 min longer. For most surgical outcomes, robotic sleeve gastrectomy outperformed laparoscopic sleeve gastrectomy with a comparable duration of the operation. In robotic learning phase centres, outcomes were within the established benchmarks only for low-risk robotic Roux-en-Y gastric bypass.

CONCLUSION

The newly established benchmarks suggest that robotic bariatric surgery may enhance surgical safety compared with laparoscopic bariatric surgery; however, the duration of the operation for robotic Roux-en-Y gastric bypass is longer.

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.