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Fig. 16.2 Dissection of
the gastrocolic ligament
Fig. 16.3 Positioning of
the bougie or Visigi
M. S. Altieri
addition, dissection helps identify any hiatal hernia, which should be repaired at the
same time.
Mobilization of the stomach is complete once the lesser curvature vessels are
visible from the posterior view. We ensure that the gastrocolic ligament is dissected
at least about 5–6cm distance from the pylorus and all posterior attachments are
dissected.
When mobilization is complete, the anesthesiologist is asked to advance the bougie or Visigi into the stomach as the surgeon ensures that it lies along the lesser
curvature of the stomach (Fig.16.3). The stapler is introduced via R1 as the staple
height is determined based on the stomach thickness. We prefer to use green load as
the initial stapler load. As previously mentioned, the rst load is red about 5–6cm
16 Robotic Sleeve Gastrectomy
Fig. 16.4 Stapling the
stomach
189
distance from the pylorus. Prior to the ring of the stapler, it is important to ensure
that no other tubing is in the stomach in order not to incorporate it in the stapled
stomach. If during the ring of the rst load there is no resistance, we proceed with
blue loads. Each staple is lined next to the bougie or Visigi with care not to constrict
or leave too much stomach behind (Fig.16.4). Also, the lateral retraction is important in order to ensure to grasp tissue in such a way so it does not cause twisting of
the sleeved stomach. We are not using any buttressed reinforcements, but others can
use stapled reinforcements or oversaw the staple line.
When the sleeve is complete, a leak test can be performed. Some surgeons prefer
to do that with diluted methylene blue or indocyanine green (ICG) and/or air in
order to detect leakage. In addition, performing an endoscopy can be done to evaluate for twisting, intraluminal bleeding, while at the same time performing a leak
test. Then the robotic platform is undocked and the specimen removed. Tisseal can
be applied, especially if no staple line reinforcement or no oversawing of the staple
line is performed, although there is no literature if this helps lower leak or bleeding
rates [12]. The 12mm port is usually closed with a 0-Vicryl.
A great addition to the robotic platform is the ability to follow your trends on the
My Intuitive app. Through this app, the surgeon can compare their times to other
surgeons and see areas of improvement, such as instrument changes and time being
active on the console. In addition, especially at a teaching institution, the surgeon
can see how much is being done by the trainee, thus it can be used as a teaching tool.
Conclusion
The robotic platform appears benecial in patients with super-obesity, although longer operative times can be noted. However, robotic assistance may help overcome
the operative difculties encountered in the patients with super-obesity. In addition,
rapid reduction in operative times with growing experience can be achieved. While
190
M. S. Altieri
surgeon satisfaction and experience cannot be measured, the robotic platform can
provide a better ergonomics and experience for surgeons.
References
1. Alsuhibani A, Thompson JR, Wigle PR, Guo JJ, Lin AC, Rao MB, Hincapie AL.Metabolic and
bariatric surgery utilization trends in the United States: evidence from 2012 to 2021 National
Electronic Medical Records Network. Ann Surg Open. 2023;4(4):e317.
2. Cadiere GB, Himpens J, Vertruyen M, Favretti F.The world’s rst obesity surgery performed
by a surgeon at a distance. Obes Surg. 1999;9:206–9.
3. Cadière GB, Himpens J, Vertruyen M, Bruyns J, Germay O, Leman G, etal. Evaluation of
telesurgical (robotic) NISSEN fundoplication. Surg Endosc. 2001;15:918–23.
4. Elli E, Gonzalez-Heredia R, SarvepalliS MM.Laparoscopic and robotic sleeve gastrectomy:
short- and long-term results. Obes Surg. 2015;25:967–74.
5. Nasser H, Ivanics RRS, Leonard-Murali S, Genaw J.Perioperative outcomes of robotic versus
laparoscopic sleeve gastrectomy in the super-obese. J Surg Res. 2020;249:34041.
6. Magouliotis D, Tasiopoulou VS, Sioka E, Sacharouis D. Robotic versus laparoscopic
sleeve gastrectomy for morbid obesity: a systematic review and meta-analysis. Obes Surg.
2017;27(1):245–53.
7. Ho K, Hsu C, Maegawa F, etal. Operative time and 30-day outcome in bariatric surgery: comparison between robotic and laparoscopic approach: 4-year MBSAIP database analysis. J Am
Coll Surg. 2022;235:1138–44.
8. Benedix F, Bwnwsix DD, Knoll C, etal. Are there risk factors that increased the rate of staple
line leakage in patients undergoing primary sleeve gastrectomy for morbid obesity? Obes
Surg. 2014;24:1610–6.
9. Surgery., Clinical Issues Committee of American Society for Metabolic and Bariatric. Sleeve
gastrectomy as a bariatric procedure. Surg Obes Relat Dis. 2007;3:573–6.
10. Adair MJ, Alharthi S, Ortiz J, etal. Robotic surgery is more expensive with similar outcomes
in sleeve gastrectomy: analysis of the NIS database. Am Surg. 2019;85(1):39045.
11. El Chaar M, Gacke J, Ringold S, Stoltzfus J.Cost analysis of robotic sleeve gastrectomy
(R-SG) compared with laparoscopic sleeve gastrectomy (L-SG) in an single academic center:
debunking a myth! Surg Obes Relat Dis. 2019;15(5):P675–9.
12. Aggarwal S, etal. Outcome of laparoscopic sleeve gastrectomy with and without staple line
oversewing in morbidly obese patients: a randomized study. J Laparoendosc Adv Surg Tech
A. 2013;23(11):895–9.
Robotic Roux-en-Y Gastric Bypass
17
HanyTakla
Abbreviations
ASMBS American Society of Metabolic and Bariatric Surgery
BMI Body Mass Index
BMP Basic Metabolic Panel
CBC Complete Blood Count
CCK Cholecystokinin
DVT Deep Venous Thrombosis
EWL Excess Weight loss
FDA Food and drug administration
GLP1 Glucagon like peptide 1
ICG Indocyanine green
IFSO International federation for the Surgery of Obesity and Metabolic
Disorders
IV Intravenous
JJ Jejunojejunostomy
MBSAQIP Metabolic and Bariatric surgery Accreditation and Quality improve-
ment Program
MBS Metabolic and Bariatric surgery
MIS Minimally invasive surgery
NSAID Non-Steroidal anti-inammatory drugs
PYY Peptide tyrosine tyrosine
SG Sleeve gastrectomy
T2D Type 2 Diabetes Mellitus
VTE Venous Thromboembolism
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 86927- 3_17.
H. Takla (*)
Bariatric and abdominal wall Surgery, Orlando Health Weight loss and Bariatric Surgery
Institute, Orlando, Florida, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
S. Samreen et al. (eds.), The SAGES Manual of Robotic Surgery,
https://doi.org/10.1007/978-3-031-86927-3_17
191
192
H. Takla
Introduction
Minimally invasive bariatric surgical procedures have been the standard practice for
several decades. Laparoscopy is currently considered the standard of care as an
approach for different bariatric procedures [1].
Robotic surgery as an approach for bariatric surgery has been a subject of debate
for at least two decades since the platform passed FDA approval. One could argue
that the exponential growth of robotics in surgery could end such a debate. The
robotic platform offers several advantages that are always advertised, but in the
morbidly obese population it offers an added advantage. The weight of the abdominal wall translates into a torque or force to resist in order to be able to move the
instruments, which, in laparoscopy with a straight instrument, offers a challenge to
the operating surgeon and assistant, and the visceral fat retraction and exposure of
tight angles at the angle of His also adds to the challenge. All of these factors are
dealt with by the operating surgeon and assistant in addition to the technical challenges of a demanding operation such as the gastric bypass. The robotic platform
with all the technical and visual advantages takes these physical challenges out of
the equation. It offers the operating surgeon physical comfort, superior threedimensional vision, and seamless stable retraction to allow the focus to fall onto the
technical steps of the operation [2].
There are several studies in the literature looking into this, and most concluded
that robotic gastric bypass is certainly equivalent and, in some instances, superior to
laparoscopy despite the longer operative times for novel surgeons [3] (Table17.1).
Expert robotic surgeons will always argue that with experience comes shorter
operative times and better outcomes like with any novel instrument or approach.
The last argument is looking at the market share and growth of robotic gastric
Table 17.1 Review of contemporary role of robotics in bariatric surgery by Bindal etal. [3]
Operative
time
Study
Sanchez (5) 50 RCT 130.8 0 0 1 2.72
Ayloo (6) 90 CCT 207 2.2 1.1 0 2
Fourman (7) 1,750 Systematic
Hagen (8) 143 CCT NA 16.1 NA 1.4 7.4
Tieu (9) 1100 Case series 155 14 4.09 0 NA
Renaud (10) 154 Case series 141 33.1 11 2.6 NA
Ahmad (10) 172 CCT 155 NA 0 0 2.4
Smeenk (11) 100 CCT 117 5 3 0 2
Economopoulos
(12)
Myers (13) 100 CCT 144 NA 12 NA 2.1
Benizri (14) 100 CCT 130 24 13 0 9.3
Nasser (4)
(Revisional)
RCT randomized controlled trial, CCT clinical controlled trial, RS retrospective study, NA not
available
N Type
review
5155 Meta-
analysis
1230 RS 196.7 9.3% NA 0.7 2.4
(min)
192 7.9 NA NA 2.72–3
NA NA NA NA NA
Overall
morbidity
(%)
Major
morbidity
(%)
Conversion
(%)
Los
(day)
17 Robotic Roux-en-Y Gastric Bypass
193
bypass over the past 5–10years. In this chapter, we will try to highlight the indications, preoperative preparation, technical steps, and postoperative instructions and
outcomes for robotic traditional Roux-en-Y gastric bypass (RYGB).
RYGB was initially thought to result in weight loss both by a restrictive and
malabsorptive mechanism. However, the mechanism in which the operation works
is quite complex, including an increase in energy expenditure and alteration in the
hormonal network, gut microbiota, and metabolic efciency.
Ghrelin, also known as the hunger hormone, produces an orexigenic state and thus
has been of great interest in obesity and bariatric surgery research. The production of
this hormone is by cells located in the gastric fundus that is predominantly excluded in
RYGB, postulating a decreased postsurgical circulating level. However, there have
been inconsistencies in bariatric research, with some studies showing no change in
levels of ghrelin after bariatric surgery, while some were showing an increase. Studies,
including that by le Roux etal., report that concomitant vagotomy in RYGB patients
may inhibit the effect of ghrelin on appetite stimulation [4]. An increase in anorexigenic hormones such as CCK, GLP-1, PYY, and amylin may be attributed to the
decrease in meal sizes observed in these patients postoperatively. Furthermore, GLP-1,
released by L-cells in the terminal ileum and colon, has many physiologic functions
apart from increased satiety and decreased food intake—it not only stimulates insulin
secretion but also increases insulin sensitivity. Postprandial increase in GLP-1 is reportedly seen as early as 1week postoperative and is proposed to be essential in the resolution of diabetes mellitus after RYGB [5].
Indications
• Basic indications for bariatric surgery have evolved over the years. In this sec-
tion, we will try to highlight important points to be discussed with the patient
prior to choosing a gastric bypass. In October 2022, american society of meta-
bolic and bariatric surgery (ASMBS) and international federation for the surgery
of obesity and metabolic disorders (IFSO) published updated indications for
metabolic and bariatric surgery, which includes individuals with a body mass
index (BMI) ≥35 kg/m2, regardless of the presence, absence, or severity of
comorbidities. Metabolic and baritric surgery (MBS) should be considered for
individuals with metabolic disease and BMI of 30–34.9kg/m2. BMI thresholds
should be adjusted in the Asian population such that a BMI ≥25kg/m2 suggests
clinical obesity, and individuals with BMI ≥27.5kg/m2 should be offered MBS.
• In clinical practice, we usually discuss the benets and risks for each procedure
and give the patient the choice to pick which procedure ts their weight and
metabolic prole. Part of the informed decision about pursuing a gastric bypass
is to utilize the available online calculators such as the MBSAQIP Bariatric Risk/
Benet Calculator as well as literature review support.
• Typically, from the weight loss standpoint RYGB offers 60–70% Excess Weight
loss or equivalent to 30% of total body weight.Although gastric bypass com-
pared with sleeve gastrectomy was associated with greater percentage excess
weight loss at 5years, the difference was not statistically signicant [8].
194
• We advise all of our patients with regards to weight loss that the RYGB is able to
achieve 60–70% excess weight loss (EWL).Our experience in our center has
been more consistent toward the 70% range.
• From the metabolic standpoint, despite superior weight loss after RYGB, T2D
remission rates did not differ signicantly between RYGB and SG after 2years.
Long-term follow-up data are needed to dene the role of SG in the treatment of
patients with obesity and T2D [6, 7].
• Reux disease has been a matter of debate; however, it is now well established
that sleeve gastrectomy is a reuxogenic procedure and typically in practice we
prefer to offer RYGB for patients who have severe symptomatic reux despite
medical therapy, patients who suffer from Barrett’s esophagus, and patients with
grade C and D esophagitis on preoperative endoscopy. This could be regarded as
a more aggressive approach favoring RYGB in these patients. However, RYGB
procedure has had the most success over the years despite some of the rare long-
term potential complications such as marginal ulcers and internal hernias.
• We routinely use the MBSAQIP Bariatric Surgical Risk/Benet Calculator with our
patients to help them make an informed decision about the choice of their operation.
• It is also of additional benet to have the patient answer a brief questionnaire
about individual procedures to ensure they understand all aspects as well as long-
term risks and follow-up necessary to avoid complications.
H. Takla
Contraindications
• Relative contraindications can include Crohn’s disease and psychosocial disorders,
including drug or alcohol use disorders. A high degree of patient understanding of
risks and lifestyle implications of surgery needs to be proven, and hence patients
with severe intellectual disability are unlikely to be successful candidates. Patients
with epilepsy should have a review of their medications as the absorption is affected
by bypass surgery. Hence, careful decision-making with the involvement of phar-
macists and neurologists should be sought preoperatively [9].
• Absolute contraindications include pregnancy. Those with severe incapacitating
systemic diseases, including end-stage renal disease, unstable coronary artery
disease, severe heart failure, cirrhosis, portal hypertension, and/or active cancer,
are not offered surgery [10].
Patient Preparation
• Preoperative preparation involves having a formal evaluation for bariatric surgery,
which is not only an anatomical change but also a mindset change for the patient.
• Typically, our patients go through a behavioral modication class to assess and
improve their ability to cope with the dietary and lifestyle modications involved
after bariatric surgery. In addition, we require our patients to follow a medically
supervised diet guided by our dieticians for at least 3months prior to surgery.
17 Robotic Roux-en-Y Gastric Bypass
195
Obviously, insurance requirements vary, but as suggested by the ASMBS letter
to insurance companies regarding mandatory pre-bariatric surgery diet regimens
the longer patients wait before surgery the less successful and invested they
become in the preoperative preparation phase without any improvement in out-
comes or success rate [11].
• During the preparation phase, we also require all of our patients to have a formal
psychological evaluation to assess for major psychologic or eating disorders that
gives time for therapy if needed prior to surgery.
• Our patients are also assessed by our nurse practitioner to see if there is a specic
medical workup that is required to optimize their medical condition for the procedure.
• In recent years and with progress in minimally invasive techniques and improve-
ment of operative times with experience, the anesthetic risks for bariatric surgery
are very minimal even for elderly patients and patients pursuing bariatric surgery
as a bridge for organ transplant [12].
• After maximum medical optimization as well as patient readiness and full under-
standing of the procedure and lifestyle modication commitment, the patient is
considered ready for surgery.
Operating Room Setup andPatient Positioning
In this section, we will try to highlight the operating room setup as well as patient
positioning prior to starting the procedure and utilize visual illustrations more than
text to give a better picture and understanding of the setup. This also in our experience helps novice surgeons have a better understanding of the procedural steps
(Video 17.1).
• After anesthesia induction, the patient is positioned supine with both arms placed
out on arm boards. We use a foot board to secure the patient while in reverse
Trendelenburg position. Proper padding and positioning are conrmed (Fig.17.1).
Fig. 17.1 Patient
positioned supine with
both arms out
196
H. Takla
Technique (Key Operative Steps)
• We usually gain access to the peritoneal cavity using a Veress needle in the left
upper quadrant at Palmer’s point.
• There are a variety of techniques, and we would recommend continuing to use
the same method used in training or the method that the surgeon is most comfort-
able with.
• We then enter the abdominal cavity after insufation to 15mm Hg using an
8mm optiview technique. This provides a cushion during trocar entry to mini-
mize the risk of visceral injury.
• For Roux -en- Y Gastric bypass, our technique involves using four trocars, two
12mm robotic trocars, and two 8mm robotic trocars placed as shown in Fig.17.2.
• We prefer using two 12mm ports as it provides a more comfortable angle for the
vertical staple line while creating the gastric pouch.
• The patient is then placed in reverse Trendelenburg position, and the robotic
platform is docked (Figs.17.3, 17.4, 17.5 and 17.6).
• The rst step of the operation is to retract the left lobe of the liver. This is usually
done using a standard Nathanson retractor or a barbed suture to create a liver
Hammock. The following step is to dissect the phreno-esophageal ligament and
separate the GE junction from the left crus of the diaphragm. This also allows for
inspection for hiatal hernia (Figs.17.7 and 17.8).
Fig. 17.2 Port placement
17 Robotic Roux-en-Y Gastric Bypass
Fig. 17.3 Patient in
reverse Trendelenburg
position
Fig. 17.4 Robotic arms
docked
197