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208
Fig. 17.35 The common
enterotomy is positioned
for closure
Fig. 17.36 The
enterotomy is closed using
a running 3/0 absorbable
suture
H. Takla
Fig. 17.37 Closure of
mesenteric defect behind
the jejunojejunostomy
using 2/0 permanent suture
Fig. 17.38 Completed
closure of mesenteric
defect
17 Robotic Roux-en-Y Gastric Bypass
Fig. 17.39 Exposure of
pseudo-Peterson space
Fig. 17.40 Closure of
pseudo-Peterson space
using a nonabsorbable
suture
209
Fig. 17.41 Endoscopy to
inspect the anastomosis
Postoperative Management andInstructions
• In our practice, all of our patients are admitted to the oor for observation for
24h and most are discharged the next morning when they meet the criteria for
discharge.
• We usually obtain a Hematocrit level 4h postoperatively and a complete blood
count (CBC) and basic metabolic panel (BMP) the next morning. This gives a
baseline in case any postoperative bleeding issues are encountered.
• The main monitoring parameters we follow are signs of bleeding, early leaks that
are very uncommon as well as venous thromboembolism (VTE) events. Some of
210
H. Takla
the signs are common between different parameters that include tachycardia,
fever, increasing abdominal pain, peritoneal signs, and metabolic derangements.
One should be diligent in investigating these signs as it may signify an underly-
ing early complication. Failure of normal progression should keep the surgeon
on alert to investigate the underlying etiology.
• We use prophylactic heparin routinely postoperatively unless the patient has a
contraindication or a coagulopathy that would require a different type of deep
venous thrombosis (DVT) prophylaxis.
• We usually start with a water trial in the recovery room once the patient is fully
conscious, and then advance to a noncarbonated, nonconcentrated sweet low-
calorie clear liquid diet in 3–4oz increments.
• The next morning the patient’s diet is advanced further to include protein shakes
in 3–4oz increments, and, if well tolerated, the patient is usually discharged
home within 24h of their procedure.
• We use scheduled Tylenol and IV NSAID for pain control while the patient is
admitted with small narcotic doses as needed for breakthrough pain, which is
infrequently needed.
• The patient is also placed on an oral proton pump inhibitor for 1month postop-
eratively to theoretically reduce hyperacidity and risk marginal ulcers as well as
allowing mucosal healing in the early postoperative period.
• The rst postoperative visit is usually scheduled within 1–2 weeks
postoperatively.
Complications
Early Complications
An anastomotic leak from the gastrojejunal anastomosis is a potentially fatal
complication. It typically manifests within 24h in a gastric bypass; however, it
could manifest later. We quote our patients 0.5–1% risk in our practice, especially with the different intraoperative checks, including leak test using ICG,
upper endoscopy, and checking blood supply at the anastomosis using ICG
as well.
Hemorrhage from anastomoses and staple lines has a high chance of resolving
spontaneously, but may require transfusion while awaiting resolution.
Bowel obstruction can occur early or late, the former due to Roux-en-O error,
where the closed-loop obstruction is created by misidentication of Roux and BP
limbs. Early bowel obstruction can also be due to iatrogenic stricture at the jejunojejunal anastomosis either due to a kink as the Roux limb enters the anastomosis or
due to intraluminal bleeding, port site hernia, and small bowel volvulus. Early internal hernias are very uncommon. If any of these issues are identied, prompt surgical
intervention is necessary to avoid further complications and avoid precipitation of a
Gastrojejunal anastomotic leak.
17 Robotic Roux-en-Y Gastric Bypass
211
Deep vein thrombosis or pulmonary embolism can be fatal after bariatric surgery, and so prevention is critical, with intermittent calf pumps intraoperatively,
compression stockings, and postoperatively chemical prophylaxis.
Late Complications
Internal herniation can occur in gastric bypass in one of three ways. Peterson’s hernia can occur following herniation of bowel through the defect created between the
jejunal mesentery of the alimentary limb and the transverse mesocolon. The other
two hernias can occur at the mesenteric defect created by the jejunojejunostomy (JJ)
anastomosis and through the mesocolic defect if the Roux limb passes retrocolic. As
weight is lost, the bowel anatomy changes and mesenteric defects can become
accentuated or created. The presentation is often subacute, with postprandial pain or
bloating; however, acute presentations with strangulation can also occur. Diagnostic
laparoscopy is the investigation of choice, with a reduction of the hernia and closure
of the mesenteric defect [13, 14].
Stricture at the gastrojejunal anastomosis can occur in up to 5% of patients.
Contributing factors include excess tension, ischemia and technical aspects of methods used to create the anastomosis [15, 16].
Micronutrient deciency can occur, and lifelong vitamin/mineral supplementation is essential for preventing these decits caused by the loss of absorption at the
duodenojejunal region of the bowel. Common deciencies include thiamine, vitamin B12, folate, iron, zinc, and vitamin D.
Dumping syndrome can present as postprandial malaise precipitated by the rapid
passage of food into the anastomosed jejunum at the GJ anastomosis. Management
is typically conservative with advice on altering diet and decreasing the size
of meals.
Outcomes andConclusion
• Roux-en-Y gastric bypass has been standard in metabolic and bariatric surgery
for several decades, and the outcomes and safety prole are well known and
beyond the context of this chapter.
• Patients who undergo RGYB are typically reported to experience approximately
60–70% excess body weight loss, with over 75% control of comorbidities. In a
study published in NEJM looking at 12-year weight and metabolic outcomes
after gastric bypass, the adjusted mean change from baseline body weight in the
surgical group was −45.0kg, −36.3kg, and−35.0kg at 2, 6, and 12years, while
that in the two nonsurgical groups (1: no surgery due to insurance reasons; 2: did
not seek surgery) at 12years was −2.9kg and 0.0 kg, respectively. Similarly,
higher rates of remission in the surgical group when evaluating preoperative
comorbidities such as type 2 diabetes (51% at 12 years), hypertension, and
hyperlipidemia [17].
212
H. Takla
• Roux-en-Y gastric bypass (RYGB) demonstrates high rates of type 2 diabetes
mellitus (T2DM) remission, a phenomenon hypothesized to be mediated mainly
by weight loss. Compared to procedures that do not bypass the proximal small
intestines, such as sleeve gastrectomy (SG), RYGB exhibits weight-loss-
independent intestinal mechanisms conducive to T2DM remission. In a retro-
spective review, Ghanem etal. showed that T2DM remission rates after RYGB
are maintained despite weight recurrence, arguing for a concurrent weight-loss-
independent metabolic benet likely facilitated by bypassing the proximal small
intestine [18].
• Furthermore, it was shown in a retrospective cohort review that patients with a
recent history of T2DM who undergo early RYGB experience signicantly
higher and earlier T2DM remission compared to patients with a prolonged his-
tory of preoperative T2DM, suggesting potential benet of early surgical inter-
vention to manage patients with obesity and T2DM [19].
• It is, however, important to mention and explore if the shift in paradigm toward
robotic bariatric surgery has contributed to improved surgical outcomes for these
procedures.
• There are several studies as mentioned in the introduction that looked at this, and
so far it has been demonstrated that the outcomes are comparable to the laparo-
scopic approach, especially after the surgeon moves past their learning curve.
• It is arguable that with the advanced ergonomics, superior visual tools, and
wristed instruments, the robotic platform is superior in its offerings to the sur-
geon and enables a wider variety of surgeons with variable skill set to adopt MIS
surgery, especially in the eld of bariatric surgery.
• The gastric bypass is a technically demanding operation with a variety of steps
that require superior technical skills and can be challenging for trainees and
young surgeons. In our experience, the robotic platform allows easier adoption
and teaching of these technically challenging steps.
• In addition, the marked increase in market share for robotic bariatric surgery is a
sign that the technology is here to stay and is well sought by surgeons as well as
patients.
References
1. Wittgrove AC, Clark GW, Tremblay LJ.Laparoscopic gastric bypass, Roux-en-Y: preliminary
report of ve cases. Obes Surg Incl Laparosc Allied Care. 1994;4(4):353–7.
2. Beckmann JH, Bernsmeier A, Kersebaum J-N, etal. The impact of robotics in learning Rouxen- Y gastric bypass: a retrospective analysis of 214 laparoscopic and robotic procedures. Obes
Surg. 2020;30:2403.
3. Bindal V, Bhatia P, Dudeja U, Kalhan S, Khetan M, John S, Wadhera S.Review of contemporary role of robotics in bariatric surgery. J Minim Access Surg. 2015;11(1):16–21. https://doi.
org/10.4103/0972- 9941.147673. PMID: 25598594; PMCID: PMC4290112.
4. Park CW, Torquati A. Physiology of weight loss surgery. Surg Clin North Am.
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5. Peterli R, Wölnerhanssen B, Peters T, Devaux N, Kern B, Christoffel-Courtin C, Drewe J, von
Flüe M, Beglinger C.Improvement in glucose metabolism after bariatric surgery: comparison
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of laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy: a prospective
randomized trial. Ann Surg. 2009;250(2):234–41.
6. Aminian A.Bariatric procedure selection in patients with type 2 diabetes: choice between
Roux-en-Y gastric bypass or sleeve gastrectomy. Surg Obes Relat Dis. 2020;16(2):332–9.
https://doi.org/10.1016/j.soard.2019.11.013. Epub 2019 Dec 2
7. Wallenius V, Alaraj A, Björnfot N, Orrenius B, Kylebäck A, Björklund P, Werling M, Thorell
A, Fändriks L, Maleckas A.Sleeve gastrectomy and Roux-en-Y gastric bypass in the treatment
of type 2 diabetes. Two-year results from a Swedish multicenter randomized controlled trial.
Surg Obes Relat Dis. 2020;16(8):1035–44. https://doi.org/10.1016/j.soard.2020.04.033. Epub
2020 May 5
8. Salminen P, Helmiö M, Ovaska J, Juuti A, Leivonen M, Peromaa-Haavisto P, Hurme S,
Soinio M, Nuutila P, Victorzon M.Effect of laparoscopic sleeve gastrectomy vs laparoscopic
Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity:
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J.The inuence of bariatric surgery on oral drug bioavailability in patients with obesity: a systematic review. Obes Rev. 2019;20(9):1299–311.
10. O’Brien PE. Bariatric surgery: mechanisms, indications and outcomes. J Gastroenterol
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11. Jamal MK, DeMaria EJ, Johnson JM, Carmody BJ, Wolfe LG, Kellum JM, Meador
JG. Insurance-mandated preoperative dietary counseling does not improve outcome and
increases dropout rates in patients considering gastric bypass surgery for morbid obesity. Surg
Obes Relat Dis. 2006;2(2):122–7. https://doi.org/10.1016/j.soard.2006.01.009.
12. Orandi BJ, Purvis JW, Cannon RM, Smith AB, Lewis CE, Terrault NA, Locke JE.Bariatric surgery to achieve transplant in end-stage organ disease patients: A systematic review and metaanalysis. Am J Surg. 2020;220(3):566–79. https://doi.org/10.1016/j.amjsurg.2020.04.041.
Epub 2020 Jun 13. PMID: 32600846; PMCID: PMC7484004
13. Altieri MS, Carter J, Aminian A, Docimo S Jr, Hinojosa MW, Cheguevara A, Campos GM,
Eisenberg D.Clinical Issues Committee of the American Society for Metabolic and Bariatric
Surgery. American Society for Metabolic and Bariatric Surgery literature review on prevention, diagnosis, and management of internal hernias after Roux-en-Y gastric bypass. Surg Obes
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14. Stenberg E, Ottosson J, Magnuson A, etal. Long-term safety and efcacy of closure of mesenteric defects in laparoscopic gastric bypass surgery: a randomized clinical trial. JAMA Surg.
2023;158(7):709–17. https://doi.org/10.1001/jamasurg.2023.1042.
15. Carrodeguas L, Szomstein S, Zundel N, Lo Menzo E, Rosenthal R.Gastrojejunal anastomotic
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16. Gonzalez R, Lin E, Venkatesh KR, Bowers SP, Smith CD.Gastrojejunostomy during laparoscopic gastric bypass: analysis of 3 techniques. Arch Surg. 2003;138:181–4.
17. Sarabu N. Weight and metabolic outcomes 12 years after gastric bypass. N Engl J Med.
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18. Ghanem OM, Abi Mosleh K, Kerbage A, Lu L, Hage K, Abu Dayyeh BK.Continued diabetes
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DS/SADI
18
PaulAnthonyKaram, SarahSamreen, AndrewLin,
andMaherEl Chaar
Introduction
Robotic-assisted (RA) surgery offers a unique set of advantages over traditional laparoscopic techniques, including enhanced precision, improved dexterity, and threedimensional visualization [1]. Those advantages have resulted in an increased
adoption rate in metabolic and bariatric surgery (MBS). In a recent manuscript by
Bauerle etal., there was a nationwide increase in the utilization rate of RA approach
in MBS between 2015 and 2020 according to the Metabolic and Bariatric Surgery
Accreditation and Quality Improvement Project (MBSAQIP) data [2]. However, the
use of the RA approach in MBS remains controversial for various reasons. To start,
studies comparing the outcomes of RA-MBS to standard laparoscopic techniques
based on MBSAQIP have shown conicting results [3–6]. The conicting results
may be due to selection and exclusion criteria, matching processes, and differences
in the denition of the outcome measures utilized in the studies [7]. In a recent study,
we suggested the use of a standardized denition of outcome measures in comparing
the RA approach to the standard laparoscopic approach using MBSAQIP data [8].
In addition, most studies have shown increased operation length and increased
healthcare costs [3, 9].
In our center, however, we have shown that the application of the RA approach for
the performance of MBS is not associated with increased healthcare costs compared
to the standard laparoscopic approach [10, 11]. We have also shown that the standardization of the surgical approach can result in improved operating room efciency
as measured by operating room length, wheels in wheels out, and turnover time [12].
P. A. Karam · A. Lin · M. El Chaar (*)
Bariatric Surgery Department, St Luke’s University Health Network, Bethlehem, PA, USA
S. Samreen
Surgery, The University of Texas Medical Branch, Galveston, TX, 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_18
215
216
P. A. Karam et al.
Therefore, standardization and experience can potentially improve operating room
efciency and lower healthcare costs irrespective of which surgical approach is utilized.
In terms of patient selection, currently, most health insurance payers follow the 1991
National Institutes of Health (NIH) guidelines for approval [13]. In 2022, the ASMBS/
IFSO guidelines recommended MBS for individuals with a BMI>35, regardless of
comorbidities, and patients with a BMI>30 with associated metabolic disease [14]. The
choice of the appropriate MBS procedure depends on patient obesity- related health conditions, patient expectations, and preferences and surgeon expertise. The role of the surgeon is to provide all the information to help the patient make an informed decision [15].
Currently, the sleeve gastrectomy is the most performed MBS procedure followed by the Roux-en-Y gastric bypass (RYGB) [16]. Biliopancreatic diversion
with duodenal switch (BPD-DS) and the single-anastomosis duodenoileal bypass
with sleeve gastrectomy (SADI-S) are less commonly performed but are gaining
popularity thanks to the RA approach. According to a recent study, up to 28% of
BPD-DS are performed using an RA approach [2].
The rst biliopancreatic diversion with duodenal switch (BPD-DS) that we know
today was rst performed in 1988 [17]. The advantage of BPD-DS over RYGB
includes higher weight loss in patients with a BMI>50 and better diabetes remission
rates [18]. However, given the complexity of this procedure and the increased
adverse events compared to RYGB [19–21], BPD-DS is not commonly performed
and constitutes less than 2% of the overall number of MBS cases performed in 2020
[16]. Variations in the lengths of the alimentary limb and common channel have
been described, with observed increased vitamin absorption and decreased number
of daily bowel movements in patients with a longer common channel [22, 23]. At
our institution, we prefer a longer common channel (200cm) over the standard
100cm to avoid long-term nutritional deciencies.
In 2007, a variant of the BPD-DS was introduced that involved creating a single
anastomosis: the single-anastomosis duodenoileal bypass with sleeve gastrectomy
(SADI-S) [24, 25]; by 2018, this procedure was established as a primary bariatric
procedure.
SADI-S was shown to be associated with higher diabetes remission rates and
similar weight loss results compared to RYGB [26]. Compared to BPD-DS, however, the results of SADI-S are suboptimal [27, 28]. Although SADI-S is technically
less challenging than BPD-DS, it is associated with higher early postoperative complication rates compared to RYGB when performed as a primary procedure [29–31].
Interestingly, it has been shown to be as safe as RYGB when performed as a revisional procedure following sleeve gastrectomy [32].
At our institution, SADI-S is primarily offered as a revisional procedure to patients
who have undergone previous sleeve gastrectomy and are suffering from weight
recurrence, provided they do not have concomitant gastroesophageal reux disease.
Patient Preparation
Patient preoperative workup includes nutritional and psychological assessment,
complete history with physical examination, upper endoscopy with biopsies to evaluate for H. pylori, evaluation for obstructive sleep apnea, as well as cardiac
18 DS/SADI
217
evaluation. Revision patients may undergo upper gastrointestinal series, 24h pH
studies or wireless pH studies, and high-resolution manometry as indicated. Patients
are also screened for any increased risk for VTE and/or PE.
We employ an enhanced recovery pathway for our MBS patients. Enhanced
recovery pathways differ among institutions and involve preoperative, intraoperative, and postoperative protocols [33]:
Prior to surgery, patients are placed on a liquid high-protein diet for 2weeks.
Although the benets of preoperative carbohydrate loading remain unknown, we
have our patients consume a carbohydrate drink the night before and the morning of
surgery as part of our pathway.
On the day of surgery, patients are given a preoperative dose of intravenous fosaprepitant [34], intravenous acetaminophen, and oral celecoxib [35] with the aim of decreasing postoperative nausea and postoperative opiate use. Patients are also given DVT
chemoprophylaxis and a single dose of intravenous antibiotics within 1h of incision.
Surgical Technique
The initial setup applies to all our bariatric procedures. We place the patient in the
supine position with the arms out and secured to arm boards with web rolls. This allows
us to keep the arms from falling off when positioning the OR bed without risking too
much constriction on the limbs. A footboard is also placed to avoid patient slippage.
Fig. 18.1 Layout of
robotic port placement
218
Fig. 18.2 Overhead view
of operating room
organization
P. A. Karam et al.
Our usual port layout includes four robotic ports and one assistant port, as shown
in Fig.18.1. We start off by measuring approximately 15–20cm caudally from the
xiphoid and slightly to the left of midline for our rst port, which will be our camera
port. We then introduce a Veress needle through the incision to establish pneumoperitoneum. For the patients who have undergone prior abdominal surgeries, we
introduce the Veress needle at Palmer’s point.
Once a bilateral TAP block has been performed, we place our ports in a line perpendicular to the midline at the same level as our initial camera port, ensuring that
the distance from each port is at least 8cm. The second port from the patient’s right
(robotic arm 2) will need to be a 12mm port to accommodate a robotic stapler. A
12mm assistant port is placed in the left lower quadrant, lateral to robotic arm 4.
The assistant port is helpful for introducing sutures and gauze into the abdominal
cavity without the need to remove any robotic arms and can also assist with retraction. Once all the ports have been placed, a liver retractor is placed in the epigastric
region for exposure.
The DaVinci robot will be positioned on the patient’s right, and the assistant will
be on the patient’s left, as shown in Fig.18.2. Automatic targeting is completed
using a robotic 30-degree endoscope, and the robotic arms are docked.
Single Anastomosis DuodenoIleal Bypass
Sleeve Gastrectomy
We start by placing the patient in the reverse Trendelenburg position at approximately 15–20° to perform our sleeve gastrectomy. A Cadiere forceps is placed in
arms 1 and 2 (arm 2 will be used most frequently while arm 1 is used to assist with
retraction) and a vessel sealer in arm 4. Using the vessel sealer, we start by taking
down the omental attachments along the greater curve staying close to the stomach.
We carry this dissection all the way past the short gastrics and to the left crus. In