Clinical Challenges in Robotic Bariatric Surgery: The Robot is Here to Stay!

Join us as we dissect the use of robotics in bariatric surgery – where precision meets programming, and the scalpel gets a software upgrade.

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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