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Robotic Sleeve Gastrectomy
233
information on docking and approach to robotic sleeve gastrectomy using the Da
Vinci Si system, please refer to Fig. 1.
After induction of general anesthesia, the patient is placed in the supine position with both arms extended and secured to arm boards. A foot board is used to
allow for steep reverse Trendelenburg position during the surgery. The patient’s
abdominal wall is prepped and draped, and the robotic arms are draped in a sterile
fashion. The anesthesia drape barrier should be positioned low enough to allow for
sufficient working space for the robotic arms.
The procedure is then begun by obtaining access to the abdominal cavity using
a Veress needle technique. Once adequate insufflation is obtained, a 0 degree
5-mm laparoscope inside a robotic 8-mm Optiview trocar is used for optical entry
at the same site of Veress needle insertion. After inspection of the abdominal cavity, we routinely perform a transverse abdominis plane (TAP) block using a mixture of Exparel, Marcaine, and saline. Additional trocars are then placed under
direct visualization with an 8-mm trocar and a 12-mm trocar on the right side of
the abdominal wall, and an additional 8-mm trocar and 12-mm assistant port on
the left side of the abdominal wall (Fig. 2). It is critical to place all robotic trocar
sites at least 8 cm apart (10 cm with Si platform) to avoid collisions of the arms.
Fig. 2 Trocar placement for
robotic sleeve gastrectomy
using the da Vinci Xi platform
M. El Chaar234
The patient is then placed in steep reverse Trendelenburg position at a minimum of 20°. A Nathanson liver retractor is placed through a small stab incision
below the xiphoid process and is used to retract the left lobe of the liver in a
medial fashion. When securing the Nathanson liver retractor to the bed rail, it is
important to place the post low enough to allow for sufficient clearance for the
robotic arms.
Once the trocars and liver retractor have been placed and the patient is appropriately positioned, the robot is docked. We routinely position the robotic cart at
the patient’s right side. The camera port is docked first using robotic arm three
(R3). A 30° robotic scope is inserted into the abdomen in the 30° down position.
The target anatomy, in this case the stomach, is selected and the robotic targeting process is completed to align the camera port with the robotic column. The
remaining robotic arms (R1, R2, R4) are then docked. A 12–8 mm reducer is
placed in the 12-mm trocar initially. A robotic vessel sealer (R4) and two Cadiere
graspers (R1, R2) are then introduced into the abdomen under direct visualization.
The assistant port can be used for retraction, suction, and insertion of sponges or
needles as necessary.
The surgery begins with identifying a point 4 cm proximal to the pylorus along
the greater curvature of the stomach. A Cadiere grasper (R2) is then used to elevate the greater curvature of the stomach at this point and provide medial retraction. An atraumatic grasper may be used to provide lateral counter traction of the
gastrocolic ligament. The vessel sealer is then used to divide the gastrocolic ligament until the lesser sac is entered. Division of the gastrocolic ligament is then
carried superiorly to the angle of His using the vessel sealer (see Fig. 3). As dis-
section is carried out superiorly, the gastrosplenic ligament is divided to mobilize
the gastric fundus from the spleen and off the left crus of the diaphragm. To aid in
mobilization of the fundus, the second Cadiere grasper (R1) can be used to grasp
the greater curvature and roll the stomach by providing inferior and medial retraction. Full mobilization of the fundus is critical to avoid a large retained fundus as
well as to correctly identify the gastroesophageal junction and identify any potential hiatal hernia. If a hiatal hernia is identified, it should be repaired at that time.
Fig. 3 Division of the
gastrocolic ligament with the
robotic vessel sealing device
Robotic Sleeve Gastrectomy
235
Once mobilization is complete, the anesthesiologist advances a 36-French
ViSiGi™ bougie under direct visualization towards the pylorus. The bougie is
positioned along the lesser curvature of the stomach and then placed to suction
and secured. Stapling of the stomach is then begun using the robotic 60 mm
SureForm™ stapler through the second robotic arm (R2). Although the stapler
height varies depending on factors such as BMI, gender, and stomach thickness,
typically, we start with a black load followed by two green loads and then blue
loads for the remainder.
The first staple load with the robotic SureForm™ stapler is deployed across the
gastric antrum approximately 5 cm proximal to the pylorus at a slight horizontal
angle. During the second firing, care should be taken not to narrow the sleeve too
much at the level of the incisura to prevent distal obstruction (see Fig. 4). During
transection of the greater curvature of the stomach, particular attention is given
to retracting the stomach laterally at the site of the transected vessels to prevent
corkscrewing of the gastric sleeve. After the greater curvature is fully divided, the
staple line is imbricated using a 2-0 barbed absorbable suture while the bougie
remains in place.
After inspecting for hemostasis, the robot is undocked and moved away from
the operative field. The Nathanson liver retractor is removed under direct visualization. The 12-mm robotic trocar site is then extended and dilated to allow for
removal of the gastric specimen. The specimen is then sent for routine pathological evaluation. Although a specimen bag or wound protection device may be used,
we do not routinely use such devices. The site of specimen removal is then closed
using a #1 Vicryl suture with a laparoscopic trocar closure device before closing
the skin at all trocar sites with 4-0 monocryl suture.
6 Clinical Outcomes
Complications following RSG are similar to those seen following LSG and are
widely reported in the literature [20–22]. The overall 30-day mortality and morbidity following SG is reported to be 0% to 1.2% and 0% to 17.5%, respectively
Fig. 4 Stapling of stomach
using robotic 60 mm
SureForm™ stapling device
M. El Chaar236
[23]. Complications specific to SG include bleeding, stenosis, portal thrombosis
and leak. The most feared of these complications is the staple line leak because
of its associated high morbidity and mortality and significantly increased healthcare costs. The leak rate after sleeve gastrectomy has been reported between 0–6%
[24–29].
Although there is a paucity of long-term data following RSG, there are a number of studies looking at 30-day outcomes. Many of these studies have demonstrated that robotic bariatric surgery has a similar safety profile when compared
to laparoscopic bariatric surgery [21, 30, 31]. In a meta-analysis which included
sixteen studies and 29,787 patients, Magouliotis et al. found that the RSG technique showed significantly higher mean operative time and increased length of
hospital stay. Post-operative incidence of leakage, wound infection, and bleeding
were comparable to LSG [20]. Some have suggested that RSG may have improved
outcomes when compared with LSG [32]. In a propensity score-matched comparative analysis of the 2015–2016 MBSAQIP database, Sebastian et al. reported that
postoperative bleeding and blood transfusion are significantly reduced in bariatric
surgery when using a robotic platform [32].
However, other studies have suggested that RSG may be associated with
increased complications when compared with LSG. In a review of the MBSAQIP
database, Fazl-Alizadeh et al.’s report found no significant difference in 30-day
mortality between RSG and LSG (0.02% vs. 0.01%, P = 0.88). However, RSG
was associated with higher serious morbidity (1.1% vs. 0.8%, P < 0.01), higher
leak rate (1.5% vs. 0.5%, P < 0.01), and higher surgical site infection rate (0.7% vs.
0.4%, P = 0.01) [33] (see Table 1).
In a more recent review of the 2016 MBSAQIP database, Lundberg et al. report
no difference in serious adverse events or mortality when comparing laparoscopic
and robotic sleeve gastrectomy. However, RSG was found to have a higher rate of
organ space infection when compared to LSG (odds ratio 2.07). Otherwise, RSG
did not significantly differ from LSG save for a longer median operative time (89
vs. 63 min, respectively, P < 0.0001) [34] (see Table 2).
Although RSG is still an overall safe and effective procedure, consideration
should be given to these findings of increased complications when selecting the
approach to SG. The increased complications may be explained by the use of
older technology in previously reported outcomes as well as an undefined learning
curve. There has been some suggestion that robotic bariatric surgery outcomes are
improving over time making it reasonable to expect that we may continue to see
an improvement in the safety profile and benefits of the robotic platform in bariatric surgery [8]. Additional research with prospective randomized trials is needed to
confirm these findings (Table 3).
Robotic Sleeve Gastrectomy
P value
AOR 95% CI
237
LSG (N =70,293) RSG (N = 4781)
Complications
Table 1 Risk-adjusted analysis of postoperative outcomes after robotic sleeve gastrectomy versus laparoscopic sleeve gastrectomy [12]
30-day mortality 17 (0.02%) 1 (0.01%) 0.85 0.11–6.46 0.88
Serious morbidity 550 (0.8%) 52 (1.1%) 1.40 1.05–1.86 <0.01
Postoperative leak 318 (0.5%) 74 (1.5%) 3.42 2.65–4.42 <0.01
Acute renal failure 40 (0.1%) 0 (0%) – – –*
Renal insufficiency 54(0.1%) 4(0.1%) 1.12 0.40–3.11 0.82
Urinary tract infection 222 (0.3%) 10 (0.2%) 0.66 0.35–1.25 0.20
Unplanned intubation 70 (0.1%) 6 (0.1%) 1.26 0.54–2.90 0.58
Ventilator dependency 25 (0.0%) 5 (0.1%) 2.87 0.92–6.21 0.07
Pneumonia 90 (0.1%) 3 (0.1%) 0.48 0.15–1.54 0.22
Any respiratory complications 158 (0.2%) 13 (0.3%) 1.21 0.68–2.13 0.51
Pulmonary embolism 64 (0.1%) 8 (0.2%) 1.84 0.88–3.85 0.10
Deep vein thrombosis 118 (0.2%) 12 (0.3%) 1.50 0.82–2.72 0.18
Venous thromboembolism 172 (0.2%) 19 (0.4%) 1.63 1.01–2.62 0.04
Superficial SSI 172 (0.2%) 13 (0.3%) 1.09 0.62–1.92 0.75
Deep SSI 15 (0.02%) 0 (0%) – – –*
Organ space SSI 111 (0.2%) 19 (0.4%) 2.51 1.54–4 10 <0.01
Dehiscence 14 (0 .01%) 1 (0.02%) 1.03 0.13–7.89 0.97
Any SSI 310 (0.4%) 33 (0.7%) 1.55 1.08–2.23 0.01
Sepsis 60 (0.1%) 5 (0 .1%) 1.23 0.49–3.08 0.64
Bleeding disorders requiring transfusion 376 (0.5%) 22 (0.5%) 0.86 0.56–1.32 0.50
Reoperation 582 (0.8%) 53 (1.1%) 1.34 1.01–1.78 0.04
Rcadmission 2,302 (3.3%) 198 (4.1%) 1.27 109–1.47 <0.01
M. El Chaar238
Mortality at 30 dn (%)
(0.005)
Table 2 Outcomes of robotic versus laparoscopic sleeve gastrectomy based on MBSAQIP [E]. SLR = staple-line reinforcement; RSG = robot-assisted
sleeve gastrectomy; LSG = laparoscopic sleeve gastrectomy; SAE = significant adverse event; OR = odds ratio; CI = confidence interval; OSI = organ space
the multiple comparisons
infection. ⁎ Based on separate Mann Whitney rank sums tests, Χ2, or Fisher's exact tests, with P < 0.05 denoting statistical significance and no adjustment for
SAEn(%) OSln (%) Bleedingn (%)
Primary outcomes
SLR only: 729 (1.3) SLR only: 74 (0.1) SLR only: 224 (0.4) SLR only: 37 (0.07)
Conventiona laparoscopic (n = 100,341) None: 281 (1.2) None: 34 (0.2) None: 140 (0.6) None: 18 (0.08)
Oversew only: 107 (1.2) Oversew only: 10 (0.1) Oversew only: 50 (0.6) Oversew only: 5 (0.06)
Both: 136 (1.0%) Both: 14 (0.1) Both: 47 (0.4) Both: 6 (0.05)
Total: 1253 (1.3) Total: 132 (0.1) Total: 461 (0.5) Total: 66 (0.07)
Robotic-assisted (n = 7385) None: 21 (1.1) None: 6 (0.3) None: 6 (0.3) None: 2 (0.1)
SLR only: 35 (1.0) SLR only: 7 (0.2) SLR only: 15 (0.4) SLR only: 3 (0.08)
Oversew only: 7 (1.2) Oversew only: 3 (0.5) Oversew only: 3 (0.5) Oversew only: 0
Both: 17 (1.3) Both: 4 (0.3) Both: 2 (0.2) Both: 0
Total: 80 (1.1%) Total: 20 (0.3%) Total: 26 (0.4%) Total: 5 (0.07%)
0.14 0.79 0.003 0.49
P value*
None: 302 (0.3) None: 40 (0.04) None: 146 (0.2) None: 20 (0.02)
SLR only: 764 (0.7) SLR only: 81 (0.08) SLR only: 239 (0.2) SLR only: 40 (0.04)
Oversew only: 114 (0.1) Oversew only: 13 (0.01) Oversew only: 53 (0.05) Oversew only: 5
Total (N = 107,726)
Both: 183 (0.2%) Both: 18 (0.02%) Both: 49 (0.05%) Both: 6 (0.006%)
Robotic Sleeve Gastrectomy
239
Total (n = 98)
P
Robotic SG (n = 39) Laparoscopic SG (n = 59)
Total costs $3263.75 $4918.88 NS $5074.13
Supplies direct cost $3263.75 $3119.57 NS $3176.95
OR time direct cost $1340.65 $1111.83 <0.0001 $1202.89
Table 3 Cost analysis of robotic sleeve gastrectomy (R-SG) compared with laparoscopic sleeve gastrectomy (L-SG). SG = sleeve gastrectomy;
LOS = length of stay; NS = nonsignificant; OR = operating room. Based on separate Mann–Whitney rank sum tests due to the skewed distributions, with
P < 0.05 denoting statistical significance, and no adjustment for multiple testing
LOS Direct cost $704.60 $687.48 NS $694.29
M. El Chaar240
7 Future Directions
Although robotic surgery offers superior technology and many potential advantages, there is no level 1 evidence to suggest that it is superior to laparoscopy
for bariatric procedures. Additionally, concerns over cost and increase operative
times remain [5, 6]. However, with development of new robotic platforms and
technology and the introduction of competition into the robotic surgery market,
it is reasonable to expect an improvement in both cost and efficiency, as well as
a potential improvement in outcomes. To assess the outcomes and further determine the effectiveness of robotic bariatric surgery, it is essential to continually
track outcomes. Most robotic outcome studies in bariatric surgery are based on
the MBSAQIP database. Unfortunately, the MBSAQIP database does not collect
robotic specific data. Creation of multi-institutional robotic specific databases or
adding robotic specific data to national databases such as MBSAQIP will help further define the safety profile and advantages of robotic bariatric surgery.
8 Conclusion
Robotic sleeve gastrectomy is a safe and effective treatment for patients with morbid obesity. The operative steps are similar to that of a laparoscopic sleeve gastrectomy. The robotic approach to sleeve gastrectomy offers potential advantages such
as 3-dimensional visualization, improved surgeon dexterity, and increased degrees
of motion which may be particularly beneficial in super morbid obese patients.
Outcomes are comparable to laparoscopic sleeve gastrectomy. Further studies are
needed before meaningful conclusions can be made on whether robotic sleeve gastrectomy is advantageous or not.
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