Bariatric Robotic Surgery: A Comprehensive Guide

The present book intends to provide a comprehensive guide to the field of robotic bariatric surgery. It covers all the stages and procedures needed to fulfill credentialing for performing robotic surgery. Also, robotic surgery is presented as an institutional program, and we describe how to establish a robotic program in a hospital environment. The currently accepted and most common procedures – sleeve gastrectomy, gastric bypass and duodenal switch – are described in detail, with a step-by-step description of the techniques, followed by a wealth of photos and videos for each case.
Special attention is given to the employment of robotic bariatric surgery in exceptional conditions, such as in super-obese patients, reoperations and revisional procedures. Critical issues, for the success of the robotic surgical interventions, such as anesthesia, are also addressed. Finally, the outcomes of robotic bariatric surgery are described, including long-term weight loss, improvement and resolution of comorbidities and improvement in quality of life. Bariatric Robotic Surgery is the first book specially devoted to this modality of surgical intervention. It is a fundamental tool for surgeons, residents and fellows who want to start a robotic bariatric surgery program. The book also helps experienced robotic surgeons to keep up to date with the various available robotic surgical techniques.

• Language: English
• Publisher: Springer
• Release date: Jul 5, 2019
• ISBN: 9783030172237

Book preview

© Springer Nature Switzerland AG 2019

Carlos Eduardo Domene, Keith C. Kim, Ramon Vilallonga Puy and Paula Volpe (eds.)Bariatric Robotic Surgeryhttps://doi.org/10.1007/978-3-030-17223-7_1

1. Bariatric Surgery: An Overview

Carlos Eduardo Domene¹  , Paula Volpe¹  , Frederico A. Heitor¹   and André Valente Santana¹  

(1)

Hospital São Luiz Itaim, São Paulo, Brazil

Carlos Eduardo Domene (Corresponding author)

Paula Volpe

Frederico A. Heitor

André Valente Santana

Keywords

Bariatric surgeryRobotic surgery

Bariatric surgery has evolved significantly over the past 20 years. Complications have decreased and the leaks and fistulae occur in less than 0.5% of cases [1]. Bleeding, anastomosis leaks and fistula, conversions, and immediate reoperation rates are currently very low [2]. Bariatric surgery has achieved levels of excellence, thanks to the incremental advances and the standardization and systematization of the surgical procedure. The best outcomes are obtained by the services with high case volumes [3].

Robotic surgery – the performance of a laparoscopic procedure with the aid of mechanical arms under remote control – offers new opportunities for improving this surgery [4]. The three-dimensional view of robotic surgery, combined with the precision of the movements, as well as the degree of freedom of the robotic forceps, offers new perspectives to the most complex laparoscopic surgeries [5].

Patients who are candidates for bariatric surgery tend to have one or more of the following: very thick abdominal walls, large quantities of visceral fat, and very large livers. These patient attributes limit the space for the pneumoperitoneum and result in a confined operative field that is difficult to access. Conventional laparoscopic bypass surgery requires considerable physical strength by the surgical team, which inevitably compromises the precision of movements and prolongs the procedure. The robotic platform has inherent advantages that resolve some of these challenges [6].

The robotic arms are fixed and in constant traction, obviating the need for force on the part of the surgeon. The puncture point of the abdominal wall is stable, and the arm rotates around that point, not exerting any force on the wall. Indeed, once the arm is docked, the traction of the trocar allows the abdominal wall to be lifted a few centimeters higher increasing the abdominal cavity.

This creates a larger and more stable working space than that of conventional laparoscopy, without the need to exert force during the manipulation of the instruments. These features help the surgeon to perform the procedure safely and with precision. The three-dimensional view and the high magnification of the image enable the surgeon to operate in a small operative field. The fixed camera and the stable auxiliary arm also promote precision and safety. This feature of the positioning and fixation of the robot may, however, be responsible for an increased number of postoperative trocar hernias [7].

These advantages of the robot may contribute to better outcomes than those obtained with conventional laparoscopic bariatric surgery. However, analyses of case series, comparative studies, and systematic reviews conducted to date have yet to prove a significant advantage of the robot over conventional laparoscopy. One reason is that current laparoscopic treatment has such a low rate of morbidity and mortality that a study with a very large number of patients is likely to be necessary in order for findings to attain statistical significance [8].

Prospective studies comparing laparoscopic and robotic gastric bypass demonstrate comparable outcomes [1, 9, 10] or better results with the robot [11, 12]. In one study which compared an initial robotic series with a prior laparoscopic series, there were more immediate complications and longer hospitalizations in the robotic series [13].

The analysis of these studies requires assessment of the so-called learning curve, which may influence outcomes and thus hinder a fair comparison. All the groups who began series of robotic surgeries had extensive prior experience with conventional laparoscopy and with the surgical procedure, i.e., they had great proficiency in laparoscopy and then started using the robot. There is a clear tendency that studies with this design, even prospective studies, favor the procedure for which the surgeon has more experience, which in this case is the conventional laparoscopic procedure.

Moreover, the learning curve for robotic surgery has many variables. Given that the surgeon may have had a long and intensive training prior to performing his first robotic procedure on patients, it is difficult to make comparison between different learning curves. Some studies show a considerably shorter learning curve with robotic surgery than with laparoscopic surgery. Of course in all these studies the surgeons were already proficient in laparoscopy, which greatly helps the learning of the robotic technique [14–18].

The number of proctored procedures that different authors say a surgeon should perform to climb the learning curve – generally reflected in a shorter operative time and fewer complications – varies widely: as few as eight and as many as 84 surgeries. In one study, after eight surgeries [14], the mean docking time was 8.5 minutes and mean console time was 187 minutes; in our series, the corresponding mean times were 4 and 105 minutes.

The type, duration, and intensity of previous training decisively influence the pace of one’s progression on the learning curve. Even for surgeons who are proficient in laparoscopy, the current requirements – theory, dry, and animal laboratories in 2 days, observing cases and proctoring during the first five surgeries – seem insufficient to enable the surgeon to starting performing unproctored robotic surgeries with short operative times and low complication rates.

Prolonged proctoring ensures exposure to ingenious solutions and creative suggestions for the unusual situations that are only encountered over the course of a large number of surgeries. In addition to facilitating the surgical anastomoses [3], the robotic platform can also be advantageous in special situations such as surgeries on super-obese [6] and revisional surgeries [19, 20].

The ability to operate in an extremely small visual field, the privileged and stable view of surgical field, and the smoothness of movements due to the stability of the fixed robotic arms that do not require any physical effort on the part of the surgical team make it possible to operate on the super-obese as one does with patient with lower BMIs [6].

The privileged view, in three dimensions, stable and very close to the surgical field, combined with the precision of the forceps and of the movements of the robotic arms (arm movements are scaled in relation to the amplitude of the outward movement, in accordance with the requirements of each procedure), allows the surgeon to perform very precise dissection of the anatomic structures, facilitating the identification of the surgical planes during reoperations. The revisional cases become safer when performed using the robotic platform [21]. The operating times of the four revisions in this series were almost equal to the primary surgeries, with a comparable postoperative course.

Robotic surgery’s stable operating field, optimal visualization, and better ergonomics facilitate the performance of all types of gastric bypass procedures whether they are primary surgeries, revisions, or performed on super-obese patients. The anastomoses, especially the gastrojejunal anastomoses, are better visualized and executed with greater stability and safety. These attributes may contribute to a difference in outcomes relative to conventional laparoscopic gastric bypass. The future use of digital resources, only possible in robotic surgery, to identify ischemic areas in the gastric stump and intestinal loop, theoretically could contribute to the reduction of leaks.

Proper training reduces or abolishes the learning curve of the robotic gastric bypass for surgeons with experience in laparoscopy. The robot’s stability and its privileged view and precise movements favor good outcomes in super-obese patients and revisional surgeries.

Implementation of a Robotic-Assisted Surgery Program in the Hospital Environment

The hospital board is required to prepare a structured business plan, appropriate to the local needs in order to financially enable the program. The high cost of implementation, maintenance, and resources demands adequate planning to diminish these costs, thereby enabling the accomplishment of a large number of robotic procedures. The marketing department of the hospital is required to perform an individualized project to create visibility for the robotic program, highlighting its characteristics and benefits.

The hospital’s engineering department requires specific training and should provide skilled technicians to solve technical problems during emergency situations under time constraints owing to the hospital having only one robot available, without hindering its replacement and greatly changing the agenda of surgeries if the robot stays in maintenance for several days. For example, the use of paired surgical rooms, where the console is common to two rooms that communicate, would allow the rapid mobilization of the computer and visualization tower streamlining the exchange of rooms and increasing productivity.

The training of the nursing team is specialized, and nurses who have completely mastered robotic functions will be required on all shifts. The nursing staff need to understand the diverse commands and connections, which vary among different procedures, and deal with emergency situations or recoverable failures. The preparation of the robot, which requires covering the robotic arms with sterile plastic as well as preparing the camera for some robot versions, is the responsibility of the nursing staff. The positioning of the robot in relation to the patient may vary for each procedure, and prior knowledge by the nursing staff regarding these variations will streamline the beginning of the surgery. Robotic-assisted surgery often requires patients to adopt the lying position (pronounced decubitus); further, it is critical that the patient is adequately secured to the table. Once the robot has been positioned, the patient cannot slip from the table, thereby removing any risk of serious injury. Data collection according to various indicators allows the tabulation of the values recorded, leading to an improvement of processes when necessary.

Anesthesia in robotic surgery should aim for deep relaxation throughout the procedures, as the patient cannot move at any time; often the surgeon does not have access to the patient’s head and needs to be prepared for these situations. Adequate clamping and accurate placement of the monitoring equipment is also part of the anesthesiologist’s function. Steep Trendelenburg position also requires specific hydration care and monitoring.

The hospital’s board may select surgeons and specialties to be included in the robotic program, and should ensure the adequate training and certification of the team, establishing an individualized business plan to allow the continued use of the robot by surgeons.

The type of training required has no defined roadmap but includes deep knowledge by surgeons about the operation and commands of the robot, participating in numerous surgeries and training sessions, and sufficient virtual simulation, being monitored by supervisors at the beginning of the experience.

References

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Renaud M, Reibel N, Zarnegar R, Germain A, Quilliot D, Ayav A, Bresler L, Brunaud L. Multifatorial analysis of the learning curve for totally robotic Roux-en-Y gastric by-pass for morbid obesity. Obes Surg. 2013;23(11):1753–60.Crossref

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Wilson EB, Sudan R. The evolution of robotic bariatric surgery. World J Surg. 2013;37(12):2756–60.Crossref

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Markar SR, Karthikesalingam AP, Venkat-Ramen V, Kinross J, Ziprin P. Robotic vs laparoscopic Roux-en-Y gastric by-pass in morbidly obese patients: systematic review and pooled analysis. Int J Med Robot. 2011;7(4):393–400.Crossref

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Markar SR, Penna M, Hashemi M. Robotic bariatric surgery: by-pass, band or sleeve. Where are we now? And what is the future? Minerva Gastroenterol Dietol. 2012;58(3):181–90.PubMed

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Buchs NC, Pugin F, Azagury DE, Huber O, Chassot G, Morel P. Robotic revisional bariatric surgery: a comparative study with laparoscopic and open surgery. Int J Med Robot. 2014;10(2):213–7.Crossref

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Park CW, Lam EC, Walsh TM, Karimoto M, Ma AT, Koo M, Hammill C, Murayama K, Lorenzo CS, Bueno R. Robotic-assisted Roux-en-Y gastric by-pass performed in a community hospital setting: the future of bariatric surgery? Surg Endosc. 2011;25(10):3312–21.Crossref

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Benizri EI, Renaud M, Reibel N, Germain A, Ziegler O, Zarnegar R, Ayav A, Bresler L, Brunaud L. Perioperative outcomes after totally robotic gastric by-pass: a prospective nonrandomized controlled study. Am J Surg. 2013;206(2):145–51.Crossref

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Ayloo S, Fernandes E, Choudhury N. Learning curve and robot set-up/operative times in singly docked totally robotic Roux-en-Y gastric by-pass. Surg Endosc. 2014;28(5):1629–33.Crossref

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Scozzi G, Zanini M, Cravero F, Passera R, Rebecchi F, Morino M. High incidence of trocar site hernia after laparoscopic or robotic Roux-en-Y gastric by-pass. Surg Endosc. 2014;28(5):620–8.

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Tieu K, Allison N, Snyder B, Wilson T, Toder M, Wilson E. Robotic-assisted Roux-en-Y gastric by-pass: update from 2 high-volume centers. Surg Obes Relat Dis. 2013;9(2):284–8.Crossref

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© Springer Nature Switzerland AG 2019

Carlos Eduardo Domene, Keith C. Kim, Ramon Vilallonga Puy and Paula Volpe (eds.)Bariatric Robotic Surgeryhttps://doi.org/10.1007/978-3-030-17223-7_2

2. Obesity Surgery: Evolution from Laparoscopy to Robotics

Carlos Eduardo Domene¹   and Paula Volpe¹  

(1)

Hospital São Luiz Itaim, São Paulo, Brazil

Carlos Eduardo Domene (Corresponding author)

Paula Volpe

Keywords

Laparoscopic surgeryRobotic surgery

Although surgery-related problems have decreased markedly in excellent bariatric surgery centers over the past decade, the risk of serious surgical complications remains a concern for both surgeons and patients, especially those with morbid obesity at a very advanced stage (super obesity), which has led to an ongoing search for new methods, equipment, and techniques that provide a risk reduction benefit, improved results, and a quick recovery. Thus, a gradual and constant shift from the laparoscopic approach to video-assisted laparoscopy has occurred in recent years [1–4].

As bariatric procedures performed by video-assisted laparoscopy are minimally invasive, they provide the benefits of reduced surgical trauma, morbidity rates, and patient recovery time. Therefore, they are currently the preferred surgical technique [5–10]. However, video-assisted laparoscopy does not fully satisfy surgical teams because the two-dimensional (2D) view is limited; it is ergonomically difficult, especially in super obese patients; and the instruments require