Robotic-Assisted Roux-en-Y Gastric Bypass: Learning Curve Assessment Using Cumulative Sum and Literature Review

American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass

BACKGROUND

Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB).

OBJECTIVE

This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU).

METHODS

PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee.

RESULTS

Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures.

CONCLUSIONS

This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.

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.

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.

A cognitive task analysis of expert surgeons performing the robotic roux-en-y gastric bypass

BACKGROUND

The safe and effective performance of a robotic roux-en-y gastric bypass (RRNY) requires the application of a complex body of knowledge and skills. This qualitative study aims to: (1) define the tasks, subtasks, decision points, and pitfalls in a RRNY; (2) create a framework upon which training and objective evaluation of a RRNY can be based.

METHODS

Hierarchical and cognitive task analyses for a RRNY were performed using semi-structured interviews of expert bariatric surgeons to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed verbatim, supplemented with literary and video resources, coded, and thematically analyzed.

RESULTS

A conceptual framework was synthesized based on three book chapters, three articles, eight online videos, nine field observations, and interviews of four subject matter experts (SME). At the time of the interview, SME had practiced a median of 12.5 years and had completed a median of 424 RRNY cases. They estimated the number of RRNY to achieve competence and expertise were 25 cases and 237.5 cases, respectively. After four rounds of inductive analysis, 83 subtasks, 75 potential errors, 60 technical tips, and 15 decision points were identified and categorized into eight major procedural steps (pre-procedure preparation, abdominal entry & port placement, gastric pouch creation, omega loop creation, gastrojejunal anastomosis, jejunojejunal anastomosis, closure of mesenteric defects, leak test & port closure). Nine cognitive behaviors were elucidated (respect for patient-specific factors, tactical modification, adherence to core surgical principles, task completion, judicious technique & instrument selection, visuospatial awareness, team-based communication, anticipation & forward planning, finessed tissue handling).

CONCLUSION

This study defines the key elements that formed the basis of a conceptual framework used by expert bariatric surgeons to perform the RRNY safely and effectively. This framework has the potential to serve as foundational tool for training novices.

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.

Laparoscopic Versus Robot-Assisted Roux-en-Y Gastric Bypass: A Center of Excellence for the EAC-BC Experience

Background: After the first laparoscopic Roux-en-Y gastric bypass (RYGB) in 1994 by Wittgrove, the introduction of robot-assisted procedures was the next step in the surgical race to reduce invasiveness. This breakthrough allowed us to perform bariatric surgery with less surgical trauma in obese patients with metabolic disorders, producing an exponential increase in procedures performed. Methods: This is a retrospective cohort study of a prospective database for patients who underwent RYGB during a 7-year period through two different approaches, laparoscopic and robotic. The robotic cases were performed by two generations of the da Vinci platform (S and Xi), and three groups were identified and compared (L-RYGB, RYGB-S, and RYGB-Xi). Results: A total of 495 patients underwent RYGB, of which 224 by laparoscopy (45.2%) and 271 by robotic approach (54.7%): 134 RYGB-S and 137 RYGB-Xi. The majority of the patients (71.1%) were females, with a mean age of 46.2 years and a mean body mass index of 44 kg/m2. The mean intraoperative time and intraoperative complication rate were higher in the robotic groups, especially in the RYGB-S group. Postoperative complications were higher in the same group, with a rate of 11.9%, where the main leakage occurred on the upper part of the gastric pouch and not in the hand-sewed robotic anastomosis (7.5%). General mortality was 0.6%. We found no significant differences at 1-year percentage of total weight loss (%TWL); at 2 years, the RYGB-Xi group had the lowest %TWL (25.24 ± 14.54, P ≤ .001). Conclusions: The present study reflects our experience during the robotic bariatric introduction and performance since 2011. Features of the da Vinci S platform along our learning curve may explain a higher complication rate. The patients who have been operated by the RYGB-Xi system had lower complications than the laparoscopic group. The robotic approach did not differ with laparoscopy in terms of weight loss and chronic complications after 24 months of follow-up.

Long-term Comparison of Robotic and Laparoscopic Gastrectomy for Gastric Cancer: A Propensity Score-weighted Analysis of 2084 Consecutive Patients

OBJECTIVE

To compare long-term outcomes between robotic and LG approaches using propensity score weighting based on a generalized boosted method to control for selection bias.

SUMMARY OF BACKGROUND DATA

Minimally invasive surgical approaches for GC are increasing, yet limited evidence exists for long-term outcomes of robotic gastrectomy (RG).

METHODS

Patients (n = 2084) with GC stages I-III who underwent LG or RG between 2009 and 2017 were analyzed. Generalized boosted method was used to estimate a propensity score derived from all available preoperative characteristics. Long-term outcomes were compared using the adjusted Kaplan-Meier method and the weighted Cox proportional hazards regression model.

RESULTS

After propensity score weighting, the population was balanced. Patients who underwent RG showed reduced blood loss (16 mL less, P = 0.025), sufficient lymph node harvest from the initial period, and no changes in surgical outcomes over time. With 52-month median follow-up, no difference was noted in 5-year overall survival in unweighted [91.5% in LG vs 94% in RG; hazard ratio (HR), 0.71; 95% confidence interval (CI), 0.46-1.1; P = 0.126] and weighted populations (94.2% in LG vs 93.2% in RG; HR, 0.88; 95% CI, 0.52-1.48; P = 0.636). There were no differences in 5-year recurrence-free survival (RFS), with unweighted 5-year RFS of 95.4% for LG and 95.2% for RG (HR, 0.95; 95% CI, 0.55-1.64; P = 0.845) and weighted 5-year RFS of 96.3% for LG and 95.3% for RG (HR, 1.24; 95% CI, 0.66-2.33; P = 0.498).

CONCLUSIONS

After balancing covariates, RG demonstrated reliable surgical outcomes from the beginning. Long-term survival after RG and LG for GC was similar.

The Longitudinal Efficiency of Robotic Surgery: an MBSAQIP Propensity Matched 4-Year Comparison of Robotic and Laparoscopic Bariatric Surgery

BACKGROUND

The objective of this study was to examine the MBSAQIP database to assess efficiency trends and perioperative outcomes in robotic bariatric surgery.

METHODS

Robotic (RA) and laparoscopic (L) sleeve gastrectomy (SG) and gastric bypass (RYGB) were compared using the 2015-2018 MBSAQIP Participant Use Data Files. Patients were propensity matched 1:1 based on sex, body mass index, assistant, and previous obesity or foregut surgery. A total of 93,802 patients were included.

RESULTS

Median operative times were significantly longer for both RA-SG (89 vs. 62 min; p < 0.0001) and RA-RYGB (141 vs. 105 min; p < 0.0001) compared with laparoscopic. Over the 4-year period, the difference in operative times (OR delta) between RA-SG and L-SG was unchanged while the difference in operative times between RA-RYGB and L-RYGB increased. Both robotic groups were significantly more likely to be readmitted (RA-SG p = 0.001, RA-RYGB p = 0.006). Robotic SG was more likely to have a reintervention (p = 0.018) and extended length of stay (LOS) (> 4 days) compared with laparoscopic (p = < 0.0002). No significant differences were noted in morbidity and mortality by approach.

CONCLUSIONS

Operative times were 30% longer for RA-SG and 25% longer for RA-RYGB when compared with laparoscopic. There was no significant improvement in OR delta for either RA-SG or RA-RYGB over the four years. Readmission rates were higher for both RA-SG and RA-RYGB. Robotic SG had a greater percentage of patients with extended LOS compared with laparoscopic. No evidence of improved efficiency for robotic bariatric surgery as defined by operative time or clinical outcomes was identified.

Motion analysis of the JHU-ISI Gesture and Skill Assessment Working Set II: learning curve analysis

PURPOSE

The Johns Hopkins-Intuitive Gesture and Skill Assessment Working Set (JIGSAWS) dataset is used to develop robotic surgery skill assessment tools, but there has been no detailed analysis of this dataset. The aim of this study is to perform a learning curve analysis of the existing JIGSAWS dataset.

METHODS

Five trials were performed in JIGSAWS by eight participants (four novices, two intermediates and two experts) for three exercises (suturing, knot-tying and needle passing). Global Rating Scores and time, path length and movements were analyzed quantitatively and qualitatively by graphical analysis.

RESULTS

There are no significant differences in Global Rating Scale scores over time. Time in the suturing exercise and path length in needle passing had significant differences. Other kinematic parameters were not significantly different. Qualitative analysis shows a learning curve only for suturing. Cumulative sum analysis suggests completion of the learning curve for suturing by trial 4.

CONCLUSIONS

The existing JIGSAWS dataset does not show a quantitative learning curve for Global Rating Scale scores, or most kinematic parameters which may be due in part to the limited size of the dataset. Qualitative analysis shows a learning curve for suturing. Cumulative sum analysis suggests completion of the suturing learning curve by trial 4. An expanded dataset is needed to facilitate subset analyses.

Robotic-assisted surgery enhances the learning curve while maintaining quality outcomes in sleeve gastrectomy: a preliminary, multicenter study

BACKGROUND

The frequency of robotic-assisted bariatric surgery has been on the rise. An increasing number of fellowship programs have adopted robotic surgery as part of the curriculum. Our aim was to compare technical efficiency of a surgeon during the first year of practice after completing an advanced minimally invasive fellowship with a mentor surgeon.

METHODS

A systematic review of a prospectively maintained database was performed of consecutive patients undergoing robotic-assisted sleeve gastrectomy between 2015 and 2019 at a tertiary-care bariatric center (mentor group) and between 2018 and 2019 at a semi-academic community-based bariatric program (mentee 1 group) and 2019-2020 at a tertiary-care academic center (mentee 2 group).

RESULTS

257 patients in the mentor group, 45 patients in the mentee 1 group, and 11 patients in the mentee 2 group were included. The mentee operative times during the first year in practice were significantly faster than the mentor's times in the first three (mentee 1 group) and two (mentee 2 group) years (P < 0.05) but remained significantly longer than the mentor's times in the last two (mentee 1 group) and one (mentee 2 group) years (P < 0.05). There was no significant difference in venothromboembolic events (P = 0.89) or readmission rates (P = 0.93). The mean length of stay was 1.8 ± 0.5 days, 1.3 ± 0.5 days, and 1.5 ± 0.5 days in the mentor, mentee 1, and mentee 2 groups, respectively (P < 0.0001). There were no reoperations, conversion to laparoscopy or open, no staple line leaks, strictures, or deaths in any group.

CONCLUSIONS

This is one of the first series to show that the robotic platform can safely be taught and may translate into outcomes consistent with surgeons with more experience while mitigating the learning curve as early as the first year in practice. Long-term follow-up of mentees will be necessary to assess the evolution of fellowship training and outcomes.

Analysis of the learning process for laparoscopic sleeve gastrectomy: CUSUM-curve of 110 consecutive patients with 1-year follow-up

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric procedure worldwide. A tremendous recent increase in the number of LSGs has not been driven by an accurate learning process, especially in low volume bariatric centers. The cumulative-sum (CUSUM) method is an effective analysis of the learning process, taking intraoperative and postoperative variables into account. This study was aimed at establishing a CUSUM learning curve for LSG in order to define the number of procedures needed to achieve sufficient surgical skill.

METHODS

All LSGs performed by a single general surgeon between September 2014 and November 2017 were considered. We hypothesized that the key t variables related to the LSG learning process (LP) are: operative time (OT), intraoperative complications or difficulties, need for expert assistance, length of hospital stay (LOS), and 3-month postoperative morbidity. All of these parameters are binary variables analyzed with the risk-adjusted CUSUM method. Two groups, learning group (LG) and experienced group (EG), were identified and compared by univariate analysis. Multivariate analysis was performed to identify the variables most closely associated with operative time and surgical success. One-year weight loss outcomes were likewise analyzed.

RESULTS

One hundred and ten (110) consecutive LSGs were considered. CUSUM-LSG showed that the mean number of consecutive interventions necessary to reach proficiency in LSG was 58. In multivariate analysis, surgical success was negatively correlated with longer operative time and need for expert assistance. Body mass index was not correlated with surgical success.

CONCLUSION

Fifty-eight LSG procedures were required to achieve surgical skill. Operative time and the need for expert assistance were variables most closely associated with surgical success.

ACGME COMPETENCY

Practice-based learning and improvement.