The Use of Surgical Robots in Bariatric Surgery

by Charmaine V. Gentles, ANP, RNFA; Emmanuel Atta Agaba, MD; Larry Gellman, MD; and Dominick Gadaleta, MD

Charmaine V. Gentles, Larry Gellman, and Dominick Gadaleta ,is from the Department of Surgery, North Shore University Hospital, Manhasset, New York. Emmanuel Atta Agaba is from Medical Center at Albert Einstein College of Medicine, Bronx, New York.

Abstract
Computer-assisted surgery is an emerging technology that holds great promise in various surgical fields. While its role in urological surgery, such as radical prostatectomy, is well established, its role in other surgical fields is yet to be defined.
In bariatric surgery, because computer-assisted technology is well equipped with multiarticulated instruments that allow for delicate intra-abdominal movements, it is well suited for revisional procedures as well as those that requires extensive intracorporeal suturing and knot tying. Despite these advantages, its role in bariatric surgery is yet to be determined. In this article, we discuss the advantages, disadvantages and future of robot-assisted technology in bariatric surgery.

Introduction
Since robotic surgical systems gained Food and Drug Administration (FDA) approval in 2000, many centers across the United States have performed robotic surgeries for diverse procedures ranging from cholecystectomy to hysterectomy to distal pancreatectomy to prostatectomy. The robotic surgical system offers three-dimensional visualization with an improved camera image and has a precise range of motion, features that help to significantly reduce the risk of gastric or bowel perforation during robotic procedures.[1] Equipped with multiarticulated instruments that allow for precise intrabdominal movements, robot-assisted surgery is suited for procedures that require extensive intracorporeal suturing and knot tying, tasks that can cause the surgeon to get fatigued. Like conventional laparoscopy, robotic surgical systems are at a disadvantage due to lost tactile sensibility. On the other hand, the visual estimate of the amount of pressure applied to the tissue and adjustment of the grip strength of the instrument can be made accordingly.

Robotic Laparoscopic Roux-en-Y Gastric Bypass
The introduction of robotic technology in laparoscopic Roux-Y-gastric bypass (RYGB) heralds a major turning point in bariatric surgery. Laparoscopic RYGB is arguably one of the most challenging minimally invasive procedures in general surgery with a steep learning curve of 75 to 100 cases to achieve the highest level of proficiency.[2–4]

Robotic technology allows advanced laparoscopic procedures to be performed with results that parallel conventional laparoscopic approaches, thus reducing the learning curve as measured by operating time and morbidity.[5]

In a pooled study that compared outcome between conventional laparoscopic RYGB and robotic RYGB, Markar et al[6] observed a significant reduction in the incidence of anastomotic stricture among the robotic group. Other studies have shown a reduction in anastomotic leak rate among patients who underwent robotic RYGB. Snyder et al[7] conducted a large single institution experience in robotic gastric bypass. The study compared 320 robot-assisted surgeries with 356 laparoscopic RYGB procedures. They found a significant reduction in leak rate among the robot-assisted procedures (0% vs. 1.7% in laparoscopic approach; p= 0.05).[7] Similarly, it appears that the incidence of stomal ulceration and gastrojejunal stenosis occurs less frequently after robotic RYGB. In a comparative study recently published by Ayloo et al,[8] researchers compared the incidence of stomal ulceration and gastrojejunal stenosis among 90 robot-assisted RYGBs with 45 laparoscopic RYGBs. Although not statistically significant, the researchers observed a reduction in the incidence of these complications following robotic approach.

Also, unlike conventional laparoscopy where movements of the trocars in patients with super obesity may cause local tissue trauma, the robotic trocar rotates at a fulcrum on the abdominal wall resulting in less trauma and less postoperative pain.1
Several factors, including small gastric pouch and longer bypassed segment of small bowel, have shown to result in better weight loss after RYGB.[9] The robotic approach achieves these advantages by creating a smaller pouch, allowing better control of stoma size, and facilitating anastomosis in patients with morbid obesity.[4]

Revision and Conversion Procedures
Robotic technology is also a useful adjunct for patients requiring conversion from laparoscopic adjustable gastric banding (AGB) to others bariatric procedures as it allows for advanced and precise dissection. Sudan et al10 reported on their experience with conversion of laparoscopic AGB to robot-assisted laparoscopic biliopancreatic diversion with duodenal switch (BPD-DS) and concluded that the difficult phase of dissection is best achieved with robotic assistance. Sudan et al[10] have completed 17 robot-assisted BPD procedures, including performing anastomosis between the duodenum and the small bowel.

Laparoscopic Adjustable Gastric Banding
In the United States, the laparoscopic approach for placement of an AGB is the most common approach.[11] Experience with robotic gastric band placement is limited to specialized centers; it appears that the robot-assisted approach offers certain advantages over conventional laparoscopic approach. In a randomized study conducted by Moser et al,[11] 50 AGB procedures were performed with and without robotic assistance. They found in the robot-assisted groups that the complication rate and length of stay were comparable to conventional laparoscopy, although operative time was longer in the robot-assisted group. In addition, they observed that the greatest benefit of robotic assisted surgery is its ability to manipulate the articulating instruments in a small working area.

Robotic instruments are able to provide more force while operating in patients with thick abdominal walls because they are thicker than conventional laparoscopic instruments. Also, since the instruments are fixed fulcrum, the surgeon does not have to struggle to counter the torque from rotating instrument around a fixed pivot point. Due to these advantages, others11 have reserved robotic AGB for patients with body mass indices (BMIs) more than 65kg/mg.

In one study, Edelson et al[12] compared 287 robot-assisted procedures with 120 laparoscopic AGB procedures. While the outcomes between the two groups were similar in terms of operating time, length of postoperative hospital stay, and complications, Edelson et al12 found a significant reduction in operative time with the robot-assisted group.

Other studies have failed to show similar results in robot-assisted procedures performed on children and adolescents. In a retrospective review, Algahtani[13] compared the outcomes of 75 AGB procedures (25 robot-assisted and 50 laparoscopic) in children and adolescents. They concluded that although robotic AGB is feasible and safe in children and adolescents, the procedure requires significantly more operative time with no improved outcome.[13]

Advantages of Robot-assisted Surgery in Bariatric Surgery
Using robot-assisted surgical systems offers a better visualization through high definition 3D imagery that allows for an increased level of precision, dexterity, versatility and control than conventional laparoscopy leading to less complications, less trauma to the body, lower wound infection rate, shorter hospital stay and minimally invasive technique for patients with higher BMI who may not be suitable candidates for a single stage bariatric surgery.[4,7,8,18]

Single-Incision Robotic Assisted Bariatric Surgery
The new generation robot-assisted system (da Vinci Siä Surgical System®, Intuitive Surgical, Inc., Sunnyvale, California) allows bariatric procedures to be performed through a 2.5cm transumbilical incision. At the present time, only sleeve gastrectomy and AGB have been performed using this approach. It is likely that other procedures may be amendable to this approach in the future.

Cost
The routine use of robotic surgical technology has been hampered by the high operational cost associated with this technology. This high cost is related to the set-up time and the cost of acquiring this technology. As shown by Mohr et al,[4] the setup time can be significantly reduced by having two scrub nurses doing the preparation simultaneously (one nurse for the standard preparation and draping of the patient and the other to prepare and drape the robot). Also, the cost of acquiring robotic surgical systems may be amortized over other surgical procedures performed. Other studies have shown in robotic cardiac surgery that the differences in cost between standard laparoscopic and robotic procedures are largely driven by operating room time rather than the cost of surgical consumables.[14] Mohr et al[15] have shown that lower operating room times during robotic procedures can be achieved as experience is gained. Others studies[8,13] have reported similar experience. Scozzani et al,[18] on the other hand, in their report have found that robotic approach is associated with longer operative times and a higher cost with no proven advantage over standard laparoscopic approach in terms of hospital stay and complication rate.
Although it is unclear at this time whether computer-assisted laparoscopic surgery is more effective than conventional laparoscopic surgery in treating patients with morbid obesity, it appears to be less invasive and may have fewer side effects and faster recovery.[4,8,16]

Future Prospective
Despite the enhanced 3D imagery provided by the present generation of robotic surgical technology, the major technical criticism of the system is its lack of tactile feedback. Although setup time may be improved as experience is gained with this technology, overall, it has significant impact on the operative time. Because of the equipment’s bulky nature, it may compete with other equipment for the limited operating room space. As further advances are made with robotic technologies, it is likely that these pitfalls may be eliminated in newer technologies.

Finally, experience with computer-assisted surgery is limited to date. Several studies have shown that it is feasible and safe.4,17 Although, robotic surgery may take slightly longer and be more costly than conventional laparoscopy, we believe that the improved outcome and the reduced leak rate may help to offset the cost to an extent.

REFERENCES
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FUNDING: No funding was provided.

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

Category: Past Articles, Review