Robot bariatric surgery

Introduction

Bariatric surgery represents a field in which one operation can “cure” a patient of numerous medical comorbidities and is the only proven method that results in long-term weight loss for patients. Since its inception, the field has undergone continuous improvements in operative technique, with the most recent advancement being the adaptation of the procedures to facilitate robotic-assisted surgeries. It is estimated that there were approximately 25,000 robotic bariatric surgeries performed in the United States in 2017.

The concept of surgical weight loss procedures came about in the 1950s at the University of Minnesota. Bariatric surgery has undergone multiple iterations, leading to improved patient outcomes. In 1954, the first jejunoileal bypass surgery was performed in which the proximal jejunum was anastomosed to the distal ileum. ^, Although this procedure was associated with weight loss and decreased lipid levels for patients, it was rife with complications, including diarrhea, dehydration, vitamin deficiencies leading to night blindness and osteoporosis, protein-calorie malnutrition, kidney stones, and toxic overgrowth of bacteria in the bypassed intestine. ^, Throughout the 1960s and 1970s, several modifications to the technique were attempted but ultimately were unsuccessful.

Many bariatric procedures, namely the mason bypass, vertical banded gastroplasty, Roux-en-Y gastric bypass, laparoscopic gastric band, sleeve gastrectomy, biliopancreatic diversion with and without duodenal switch, and single anastomosis duodenal switch were developed and implemented with success. Starting in the 1990s, these procedures were able to be accomplished laparoscopically. The world’s first robotic obesity surgery, a gastric band placement, was successfully performed in 1999. Once laparoscopic-assisted surgery was introduced, bariatric surgery procedures were quickly adapted and resulted in lower morbidity than open procedures. Some of the benefits of robotic-assisted bariatric surgery include articulating instruments with reduced torque on the operator’s wrists and fingers, improved visualization, and increased precision in suture placement. For the purpose of this chapter, we shall limit our discussion to the mainstream bariatric surgeries currently performed. This chapter discusses the basic principles and robotic operative techniques for sleeve gastrectomy, Roux-en-Y gastric bypass, and duodenal switch procedures using the Intuitive surgical Xi Platform. It covers all technical aspects in detail, including supplemental videos. Specialty equipment required for these procedures is listed in the box that follows.

Patient selection and preparation

The American Society for Metabolic and Bariatric Surgery (ASMBS) published guidelines detailing qualifications for patients desiring bariatric surgery. The qualifications include: BMI ≥ 40 and BMI ≥35 with at least two obesity related comorbidities, such as: type 2 diabetes, hypertension, sleep apnea and other respiratory disorders, nonalcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, heart disease, and an inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts. These guidelines are echoed by the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), with their guidelines adding in recommendations: age 18 to 65; no drug dependency; a capacity to understand the risks and commitment associated with the surgery; and pregnancy not anticipated within the first year following surgery. The National Institute of Health, American College of Surgeons, and ASMBS also recommend that patients desiring these types of surgery undergo their procedure with a board-certified surgeon specializing in bariatric and metabolic surgery at a center with a multidisciplinary team of experts for follow-up care.

Robot-assisted sleeve gastrectomy

The sleeve gastrectomy was first described in 1993 by Picard Marceau as part of the biliopancreatic diversion with duodenal switch operations. A sleeve gastrectomy is effective for two primary reasons. First, it is restrictive and removes the gastric fundus. In a sleeve gastrectomy, the pylorus is left intact, which creates a narrow lumen that causes early satiety while restricting the maximum quantity of gastric contents. Additionally, by removing the ghrelin producing portion of the stomach, there is a long-term reduction in the hunger feeling, further reducing patient food intake. Sleeve gastrectomy has been demonstrated to be an effective weight loss operation, leading to improvements in obesity-related comorbidities, such as noninsulin dependent diabetes, arterial hypertension, and dyslipidemia, and is capable of inducing desirable changes in inflammatory, kidney, and liver-related biomarkers such as creatinine, C-reactive protein, and uric acid levels. The sleeve gastrectomy procedure is considered by most bariatric surgeons as technically a relatively easier operation compared to other bariatric procedures; however, it is the authors’ opinion that this is an excellent index procedure for bariatric surgeons who wish to incorporate robotic surgery into their practice. In higher BMI patients, robotic assistance is invaluable in getting exposure to the short gastric vessels and accessing the relatively tight space for dissection near the angle of His.

Positioning, trocar placement, and operative steps

Patient should be positioned supine on the operating room (OR) table and prepped and draped in the normal sterile fashion. All pressure points should be padded with gel and foam pads. Patient arms should be extended out just shy of 90 degrees. Ensure that the patient is secured to the OR table with a belt and a footboard in place. The box that follows outlines the key steps of this operation.

KEY STEPS

• 1.

  Induce pneumoperitoneum and place trocars as indicated in Fig. 55.1 .

• 2.

  Dock the robot and complete targeting.

• 3.

  Visually inspect the hiatus.

• 4.

  Begin sealing and dividing the gastrocolic and gastrosplenic ligaments.

• 5.

  Anesthesia places 40 French bougie.

• 6.

  Begin stapling along the bougie, starting 6 cm proximal to the pylorus.

• 7.

  Remove remnant stomach.

Pneumoperitoneum can be established using the Veress needle technique. Trocars are then placed under direct visualization. Placement is as outlined in Fig. 55.1 . An 8.5 mm port should be placed 15 cm inferior to the xiphoid and 5 cm left of midline and will be used as the camera port. From there, two additional 8.5 mm ports are placed approximately a hands-width lateral from the camera port. A 12 mm port should then be placed hands width to the right of the camera port, this should be placed to facilitate sleeve creation using the robotic stapler. A 5 mm trocar is placed in the right side, which will be used for liver retraction, facilitating enhanced visualization of the stomach. Alternatively, a port can be placed in the subxiphoid region for liver retraction. The patient should then be placed in 30-degree reverse Trendelenburg position for the procedure.

At this point, docking of the robot can begin. The camera is advanced through the supraumbilical 8.5 mm port and used to finalize placement of the robot arms by completing targeting, using the mid stomach as the target point. The remaining arms are then docked to their respective ports. The liver is retracted to ensure adequate visualization of the stomach. Once this is complete, the console surgeon can step away from the patient and go to the console, leaving the assistant at the bedside.

The first step is a visual inspection of the hiatus to ensure that a hiatal hernia is not present; if one is, it should be dissected free, and a posterior hiatal hernia repair performed. Using two Cardiere graspers and the vessel sealer, the lesser sac is entered at the level of the mid-point of the greater curvature of the stomach. The gastrocolic and gastrosplenic ligaments are taken from approximately 6 cm proximal to the pylorus up to the level of the gastroesophageal junction (GEJ), being aware of the position of the spleen in relation to the dissection. One of the benefits of the robot in this area is the precision it affords the surgeon, helping to avoid injury to the spleen while allowing for adequate visualization and ligation of the short gastric arteries. Once the greater curvature has been appropriately mobilized, the anesthesiologist can advance a bougie to add in the calibration of the sleeve. We recommend use of a 40 French bougie. Using the robotic stapler and starting at the antrum approximately 6 cm proximal to the pylorus, the stapling of the stomach begins. The bougie remains in place and the stapler is fired lateral to the bougie. This is continued to the level of the GEJ, thus freeing the remnant stomach from the remaining gastric sleeve. Care must be taken not to narrow the incisura angularis, and dissection must be adequate to ensure removal of the entire fundus. The remnant stomach can be removed through the right sided 12 mm stapler port after enlarging the port. Hemostasis along the staple line is ensured. For most patients, a blue load stapler is adequate in performing the sleeve gastrectomy; however, occasionally in large male patients with a thick antrum, one may have to upsize to a green load for the stapler if the message that the tissue is too thick to staple is relayed by the robot and repositioning the stapler with the blue load does not work.

A leak test may be performed, as is the practice by individual surgeons, with methylene blue or ICG with Firefly mode on the robot. Our practice has been to perform an upper endoscopy to examine the sleeve creation; we do not perform a leak test. After hemostasis is obtained, the extraction site for the sleeve specimen is then closed with a port closure assist device using permanent sutures.

Roux-en-Y gastric bypass

The Roux-en-Y gastric bypass is a moderately complex, yet technically demanding, operation, making it an excellent procedure to be accomplished robotically. The efficacy of this procedure is due to two primary reasons: (1) the small gastric pouch created allows for increased satiety, thereby reducing the portion size, and (2) by bypassing of the first portion of the small bowel, it initiates a cascade of hormones which facilitate weight loss and improve insulin sensitivity. While there have been multiple adaptations to how the procedure is performed, the traditional and most well described technique involves the creation of a small gastric pouch, a biliary limb of approximately 50 cm and a Roux limb of approximately 75 cm. Multiple studies have demonstrated that performing a Roux-en-Y gastric bypass with robotic assistance has multiple advantages as compared to laparoscopically performing the procedure. The robotic approach is associated with decreased rates of hemorrhage, anastomotic fistulas, and gastrojejunal anastomotic strictures, as well as shorter duration of surgery, shorter hospital stays, and a lower readmission rate. After undergoing a Roux-en-Y gastric bypass, patients will typically lose between 60% and 75% of their excess body weight and are able to maintain greater than 50% excess body weight loss for greater than 15 years. ^,