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B. Safadi and K. Karam222
Fig. 3 Sealing and dividing the gastro-epiploic vessels starts at the mid greater curvature and
continues toward the short gastric vessels at the upper pole of the spleen
Fig. 4 After reaching the superior pole of the spleen (S), it is easier to lift the fundus anteriorly,
develop the avascular plane along the oro-gastric tube (OGT) and then divide the posterior short
gastric vessels (SG) from medial to lateral
sealing and division of the gastro-epiploic vessels starts at the mid greater cur-
vature of the stomach since that part has little to no posterior attachment to
the pancreas and provides easy and efficient access to the lesser sac. Once the
lesser sac is opened and the posterior aspect of the stomach is visualized seal-
ing and dividing branches of the gastro-epiploic vessels along the greater cur-
vature of the stomach and the posterior short gastric ensues all the way to the
Angle of His (Fig. 3). It is easier and safer to expose the short gastric vessels by
lifting the fundus upward and sealing/dividing them posteriorly starting medi-
ally and then heading laterally toward the spleen. This is particularly helpful
when the fundus is stuck close to the spleen. The dissection stops when the left
crus of the diaphragm is reached (Fig. 4).
How the LSG is Performed: A Step-By-Step Procedure
223
Sealing and division of the vessels continues distally separating the greater
omentum from the stomach reaching 2 to 4 cms proximal to the pylorus. All
posterior attachments between the stomach and the pancreas are released by
cautery or sharp dissection until the greater curvature of the stomach is com-
pletely free and mobile.
C. Delineating the presence of a hiatal hernia
We perform routine gastroscopy on all patients pre-operatively so we know
ahead of time who has a hiatus hernia or a wide hiatus by the Hill classification
and those patients deserve a thorough intra-operative examination to determine
if there is a hiatal hernia. Hiatal hernias are sometimes easily seen on initial
exploration when there is a frank dimple sign or when the esophageal fat pad
is seen herniating into the mediastinum. More often, small hiatal hernias are
not easily seen upon initial exploration. When we get to the left crus of the
diaphragm, we incise the peritoneal layer overlying the inferior border of the
left crus and at that stage we should see clearly the longitudinal fibers of the
esophagus. If not, then we continue dissection of the phreno-esophageal mem-
brane anteriorly until we are sure the esophagus is seen. We routinely dissect
the esophageal fat pad and divide it at the level of the Angle of His. Sometimes
we see a large posterior fat pad herniating into the mediastinum and in that
case would reduce it and excise it and that will expose the defect in the hiatus.
Once we identify or highly suspect a hiatal hernia, we divide the gastro-hepatic
ligament. Any dominant left accessory or replaced hepatic artery is preserved.
The peritoneum at the inferior border of the right crus is incised to expose the
esophagus. The rest of the dissection is done bluntly. A plane is developed
behind the esophagus and posterior vagus nerve and the distal esophagus is
encircled with a Penrose drain and retracted. The rest of the peritoneal attach-
ments between the esophagus-crura and mediastinal attachments including dis-
tal perforators are sealed and divided to mobilize the esophagus and ensure at
least 2–4 cm of esophagus in the abdomen without tension. Approximation of
the crura is accomplished with non-absorbable sutures posteriorly and some-
times anteriorly taking care not to kink the esophagus anteriorly with excessive
posterior approximation. The closure of the hiatus is calibrated using the 40-Fr.
Oro-gastric tube. I usually perform the cruroplasty after stapling.
D. Stapling step by step
The stapling of the stomach should mirror the lesser curvature of the stomach
to get a symmetrical gastric tube at the end. I now use a 40-Fr. Oro-gastric
tube as a guide and no longer use the 32-Fr and 36-Fr tubes because of few
cases of gastric tube stenosis that developed while using these tubes. The
association between narrower oro-gastric tubes and higher complication rates
has been reported in numerous studies [11]. Stomachs come in different sizes
and shapes and some situations can create a challenge when it comes to sta-
pling. A J-shaped stomach with an acute angle at the Incisura is such an exam-
ple. I always start stapling from the right lateral port at 4-cm proximal to the
Pylorus and reticulate the stapler so that it is aligned parallel to the lesser cur-
vature (Fig. 5). The gastric wall here is thick and abundant with muscle and
B. Safadi and K. Karam224
Fig. 5 The first stapler is introduced via the right sided lateral port (Port 1, Fig. 1) and is placed
parallel to the lesser curvature at a point around 4 cm proximal to the pylorus. The distance
between the lesser curvature and the stapler is no less than 4 cm
Fig. 6 The second stapler is probably the most critical one during the LSG. It is introduced via
the umbilical port in most patients and is reticulated to an angle with the first staple to mimic the
lesser curvature bend at the Angularis Incisura. The 40-Fr. Orogastric tube is advanced into the
antrum after the stapler has been placed and before it is “fired” to ensure that the newly formed
gastric tube is not tight or twisted
therefore the stapler should be 60 mm long and at least 3.0 mm in height.
The gastric mucosa and submucosa gets displaced inward several millimeters
so it is important not to tighten the tube here and I try to keep it around 4 cm
wide. At this stage, I keep the 40-Fr. oro-gastric tube in the proximal aspect
of the stomach and do not advance it. The second 60-mm stapler is introduced
from the umbilical port with slight reticulation to the right (Fig. 6). This is
probably the most important staple application and it is crucial to avoid nar-
rowing the Angularis Incisura or torqueing/twisting the stomach here. Again,
How the LSG is Performed: A Step-By-Step Procedure
225
the orogastric tube is advanced only after the stapler is positioned to guaran-
tee that the tube can be advanced without difficulty. The stapler is applied and
the stomach is stapled and divided. There is a potential risk when the orogas-
tric tube is advanced early to the antrum and stapling is done with the tube in
place distally because the tube can distort the shape of the stomach and deceiv-
ingly “straighten” the stomach. This can result in narrowing and kinking at the
Angularis Incisura especially in J-shaped stomachs and that can only become
apparent once the tube in withdrawn.
The remaining staple applications past the Angularis Incisura are placed snug
alongside the tube with 3 applications of the 60-mm staplers on average (total
4–7 staplers with a median of 5) (Fig. 7). It is important to check the crotch
of the staple line and remove any loose staples as these might lead to subse-
quent staple malfunction. I toss the stomach back and forth anterior to posterior
to make sure I am not leaving any redundant stomach posteriorly, especially
the fundus that has to be completely excised. The last stapler is placed around
5 mm on the gastric side of the Angle of His. I try my best to avoid leaving
any significant fundic “dog ear” and in case that is present in excess I advocate
resection with another stapler [6] (Fig. 8).
E. Extraction of the resected stomach
Once stapling is completed, I remove the resected stomach from the umbilical
incision. I do it at this stage since the patient would still be paralyzed and it is
easier to remove it with adequate muscle relaxation. I do not place the stom-
ach in a bag but do make sure that the abdominal wall opening is lax enough
to allow easy retrieval and avoid excessive traction. Gastric dehiscence while
retrieving the stomach could result in significant intra-abdominal and wound
complications and should be avoided at all cost. If there is any concern, I would
re-introduce the stomach back in, placed it in a bag and repeat the process of
extraction.
F. Staple line re-enforcement/gastropexy
Several studies have shown that staple line re-enforcement reduces the risk of
bleeding and may reduce the risk of leak and I am a big proponent of staple
Fig. 7 Stapling is completed
with sequential 60-mm
staplers introduced via the
umbilical port alongside a
40-Fr. Orogastric tube. A
small (5-mm) rim of fundus
is left just below the EG
junction
B. Safadi and K. Karam226
Fig. 8 Residual fundic tissue can enlarge and develop a “neo-fundus. It is better to excise
such “dog ears” by re-stapling parallel to the oro-gastric tube to prevent the formation of a
“neo-fundus”
Fig. 9 The newly formed gastric tube is fixed with sutures to the transverse mesocolon at the
inferior border of the pancreas. This may help reduce the risk of axial twist and possibly mediastinal migration
line re-enforcement with serosa-to-serosa plication over the staple line [4, 9–
11]. I use an absorbable suture such as 3-O or 2-O polydioxanone PDS suture
(Johnson & Johnson Medical N.V.). Once we get proximal to the Angularis
Incisura, we use the same suture to attach the gastric tube to the transverse mes-
ocolon at the inferior edge of the pancreas to provide a form of gastropexy that
might help reduce axial rotation of the gastric tube and perhaps fix the stomach
intra-abdominally to reduce the risk of intra-thoracic migration [10] (Fig. 9).
G. Closing
I do not routinely test the staple line with provocative tests such as Methylene
blue or air insufflation. The risk of leak or staple line bleeding using this tech-
nique is under 1%, and reserve testing for difficult cases or when there is any
doubt of a technical mishap. Endoscopy is probably the best method in testing
the safety of the LSG and that has shown in some studies [12]. I use 12-mm
dilating trocars on the sides so I don’t close these. The fascia in the umbilicus
is closed with interrupted absorbable sutures and the skin with skin staples or
absorbable sutures.
How the LSG is Performed: A Step-By-Step Procedure
227
References
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working group: standardization of bariatric metabolic procedures: world consensus meeting
statement. Obes Surg. 2019;29(Suppl 4):309–45.
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comes of laparoscopic sleeve gastrectomy: a Lebanese center experience. Surg Obes Relat
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ranked by safety and efficacy: a video-based study. Surg Endosc. 2019;33(3):895–903.
4. Taha O, Abdelaal M, Talaat M, Abozeid M. A randomized comparison between staple-line
oversewing versus no reinforcement during laparoscopic vertical sleeve gastrectomy. Obes
Surg. 2018;28(1):218–25.
5. Goitein D, Lederfein D, Tzioni R, Berkenstadt H, Venturero M, Rubin M. Mapping of ghre-
lin gene expression and cell distribution in the stomach of morbidly obese patients—a possible guide for efficient sleeve gastrectomy construction. Obes Surg. 2012;22(4):617–22.
6. Silecchia G, De Angelis F, Rizzello M, Albanese A, Longo F, Foletto M. Residual fundus or
neofundus after laparoscopic sleeve gastrectomy: is fundectomy safe and effective as revision surgery? Surg Endosc. 2015;29(10):2899–903.
7. Dakour Aridi H, Asali M, Fouani T, Alami RS, Safadi BY. Gastroesophageal reflux disease
after laparoscopic sleeve gastrectomy with concomitant hiatal hernia repair: an unresolved
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Robotic Sleeve Gastrectomy
Maher El Chaar
1 Introduction
Innovation and technology have become an integral part of the rapid evolution of
bariatric surgery. Since the first laparoscopic Roux-en-Y gastric bypass was performed by Wittgrove et al. in 1993, laparoscopy has become the standard approach
to bariatric surgery and the advantages of the minimally invasive approach have
been well validated [1, 2]. Despite its widespread use and acceptance, there
remains limitations to the laparoscopic approach to bariatric surgery which include
limitations of movement due to thick abdominal walls and hepatomegaly, limited
workspace secondary to increased intra-abdominal fat, limited surgical dexterity,
and poor ergonomics. Because of these limitations and in light of recent evidence
from the gynecologic literature indicating certain advantages when operating on
morbidly obese patients [3, 4], we witnessed an increased interest in the use of
robotic platforms in bariatric surgery. However, the use of robotics in bariatric surgery remains controversial because of concerns related to the increased health care
costs associated with this new technology and the lack of level I evidence to support its widespread use [5, 6].
In addition to the widely popular Intuitive da Vinci platform, new platforms
are increasingly being implemented to improve on the capabilities of previously
established systems. A number of new FDA approved robotic surgical platforms
with the potential to be used in bariatric surgery have entered the market. These
M. El Chaar (*)
St Luke’s University Hospital and Health Network, Fountain Hill, USA
e-mail: maher.elchaar@gmail.com
M. El Chaar
Lewis Katz School of Medicine, Temple University, Philadelphia, USA
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_25
229
M. El Chaar230
include Senhance™ Surgical System (TransEnterix), Versius (CMR Surgical), Verb
Surgical (Google, Johnson & Johnson), and Medrobotics Flex® Robotic System.
Future studies are needed to further evaluate the advantages and disadvantages of
each robotic surgical device and platform as well as their role in bariatric surgery.
Currently, the sleeve gastrectomy (SG) is the most commonly performed
procedure in the United States according to the most recent estimates by the
American Society for Metabolic and Bariatric Surgery (ASMBS) and its worldwide prevalence has significantly increased in the last years as well [7]. Multiple
reports have been published to evaluate the safety and feasibility of roboticassisted sleeve gastrectomy (RSG) in addition to the cost associated with this new
innovative approach. This chapter will evaluate the available literature on robotic
assisted sleeve gastrectomy and explore the steps necessary for the establishment
of a robotic bariatric program.
2 Robotic-Assisted Sleeve Gastrectomy
According to the most recent estimates by the ASMBS, the SG is now the
most commonly performed bariatric surgery in the United States [7]. Its popularity is a reflection of its relative ease, low complication rate, and excellent
short- and intermediate-term outcomes. Most SG procedures are performed
using conventional laparoscopy in a largely standardized fashion, though some
variation exists, such as in the management of the staple line after transection of the greater curvature. However, the growing popularity of the da Vinci
robotic platform (Intuitive Surgical, Atlanta, GA, USA) in other surgical specialties has prompted its limited but growing use in bariatric surgery, presently
accounting for 7% of all SG performed in the Metabolic and Bariatric Surgery
Accreditation and Quality Improvement Program (MBSAQIP) database [8].
There are a number of potential advantages of robotic technology in bariatric
procedures. These advantages are accentuated in the super morbid obese population (BMI>50). Sleeve gastrectomy performed in this population can be technically challenging due to the increased liver size, excess omental fat, and difficulty
obtaining adequate pneumoperitoneum, all of which decrease the working space
in the upper abdomen [9]. Additionally, the increased abdominal wall thickness of
these patients requires additional torque, making fine movements more technically
challenging with laparoscopic instruments. Robotic bariatric surgery overcomes
some of the limitations of laparoscopic techniques by allowing for 3-dimensional
visualization, improved surgeon dexterity, and increased degrees of motion [10–
13]. Another proposed benefit of robotic surgery in the super morbid obese popu-
lation is decreased port site trauma due to a decrease in abdominal wall torque
with the remote-center technology [14]. The robotic arms provide the mechanical power to overcome the increased torque required to manipulate instruments
in patients with thick abdominal walls thus allowing for finer movements and
decreasing surgeon fatigue.
Robotic Sleeve Gastrectomy
The primary arguments against RSG are the higher costs and longer operating
times and the lack of outcome data to support its superiority [5, 6]. These obstacles have resulted in the lack of widespread acceptance and adoption of this technology in bariatric surgery.
231
3 Cost of Robotic-Assisted Sleeve Gastrectomy
Although use of the da Vinci robotic platform in bariatric surgery is gaining
momentum, there are many financial concerns. The issue of cost is a critically
important issue for hospital administrators and third-party payers. Increased health
care cost associated with this technology is one of the main obstacles preventing
its widespread adoption in bariatric surgery.
In a recent meta-analysis, Li et al. was able to show that robotic surgery results
in increased health care costs [6]. However, other single institution studies have
shown that robotic surgery can be cost effective. In a retrospective study evaluating the cost of robotically assisted sleeve gastrectomy (R-SG) versus conventional
laparoscopic sleeve gastrectomy (L-SG), El Chaar et al. reported that the overall
cost for RSG and LSG was not statistically different (mean total cost for RSG and
LSG was $5308.99 and $4918.88, respectively) with a trend toward shorter length
of stay for R-SG over time (1.4 versus 1.5 d, respectively) [15] (see Table 3).
These findings, however, cannot be generalized given that cost data is institution
specific. More cost data should be collected in light of the new cheaper robotic
platforms and extended uses of robotic equipment in order to make meaningful
conclusions on whether robotic surgery is cost effective or not.
4 Adoption and Evolution of a Bariatric Robotic
Program
Clinical outcomes, training, cost, efficiency, and available local resources and
expertise are all critical components to consider when creating a robotic bariatric program. Having a validated training curriculum is very important for
patient safety and to avoid issues with credentialing and associated liability.
Proficiency-based training curricula that comprehensively address the skills necessary to perform robotic operations have shown construct and content validity as
well as feasibility [16–19].
In the development of our robotic surgery program at St Luke’s University
Hospital and Health Network, we have observed the importance of a systematic
approach through the establishment of training programs for both surgeons and
the operating room nursing staff, as well as creation of a dedicated robotic OR
team. Every new robotic surgeon is required to go through a strict and regimented
robotic training pathway involving many hours of on-robot training in a dry lab
setting, simulation, live case observations at robotic epicenters around the country,
and then a 1 to 2-day intensive training at the da Vinci accredited lab in Atlanta,
M. El Chaar232
GA, USA. The staff also goes through a similar process where they receive hours
of online and hands on training prior to being allowed in the robot room with a
patient. A specialized OR efficiency team called Genesis was used to help assemble robotic trays, organize equipment, and decrease turnover times. At the initiation of our robotic program, we started with a core robotic team of 5–6 surgical
technologists and nurses. Since that time, we have evolved into a much larger
robotic team and trained additional staff members due to the increased volume of
robotic cases. It is also very important for robotic programs to collect its data and
analyze it on a regular basis to improve efficiency, patient outcomes, and safety.
5 Operative Technique
For a RSG, the robotic team generally consists of a console surgeon and a bedside
surgeon or assistant. It is best performed in a dedicated robotic operating room with
dedicated robotically trained staff. Depending on what robotic platform is available, the room layout and docking techniques may vary. Additionally, depending
on the type and availability of robotic stapling devices, a fully robotic or hybrid
laparoscopic and robotic approach may be employed. In this chapter, the authors
describe a robotic sleeve gastrectomy technique using the Da Vinci Xi platform. For
Fig. 1 Trocar placement for
robotic sleeve gastrectomy
using the da Vinci Si
platform. Using the Si system
requires stapling through the
12 mm assistant port using
a laparoscopic stapler in
hybrid-type technique