Robotic gastric bypass

Indications

Bariatric surgery continues to be the most effective treatment available for the treatment of obesity and its associated medical problems. In the USA, it is indicated for patients with body mass index (BMI) 40 and above or those with BMI 35–40 with medical comorbid conditions such as diabetes, hypertension, and sleep apnea. Multiple studies have demonstrated improved survival in morbidly obese patients who undergo bariatric surgery compared to those who do not. ^, Numerous randomized controlled trials have shown the benefits of gastric bypass over those of nonsurgical measures against diabetes.

Gastric bypass was introduced by Dr. Mason in the 1960s. Since then, while other bariatric operations have come and gone, the gastric bypass has stood the test of time. In 1994, Wittgrove presented the first laparoscopic approach to the operation. With the benefits of minimally invasive surgery and improvements in technology, laparoscopic surgery grew to become the primary modality for performing the gastric bypass. In 1999, Himpens and Cadier performed the first robotic bariatric surgery—gastric banding. Since then, with improvements in robotic technology, more surgeons have applied robotics to bariatric surgery, and specifically to gastric bypass. Some of the benefits driving this adoption include the high quality and steadiness of the visualization, better ergonomics, less physical strain on the surgeon, control of more aspects of the operation, ability to work in tighter spaces, wristed instrumentation, and ease of suturing. These benefits are particularly evident in severely morbidly obese patients with thick abdominal walls, small working spaces covered by large livers, and extensive visceral fat.

In this chapter, I will describe how I perform gastric bypass using the da Vinci Xi robot (Intuitive Surgical, Sunnyvale, CA, USA).

Patient selection

When a surgeon is starting out, it is important to focus on cases that are relatively more straightforward. The robotic approach can be applied to most cases. When extensive midabdominal adhesions are encountered, they could be lysed laparoscopically or alternatively the surgeon can dock the robot laterally for the lysis of adhesions and then re-dock the robot once the midabdomen is adequately freed of adhesions, and additional trocars could be placed. The approach can be challenging in short patients or those with a super high BMI. Short patients often present small working spaces with short distances between the trocars and the target anatomy. A thick abdominal wall and large liver with a small working space can create additional challenges. The robotic approach can take the strain off the surgeon and may make it easier to achieve precision in the smaller working space.

Operating room setup and patient positioning

The patient is positioned on the operating table supine with the arms out. Footboards are used to support the patient when in the reverse Trendelenburg position. Foley catheters are not routinely placed. However, for cases expected to take several hours (i.e., when expecting a challenging case or early in the learning curve), catheters should be considered.

The da Vinci Xi robot could be brought in from any angle in relation to the bed. This platform does not have to be docked over the head of the patient, enabling easier access to the airway for the anesthesiologist and easier passage of bougies, orogastric tubes, temperature probes, and endoscopy. In our operating room the robot is brought in from the patient’s right side. The scrub technician is set up on the patient’s left side. All patients receive preoperative thromboprophylaxis and antibiotics as per protocol, and compression devices are placed.

Key operative steps

Entry, port placement, and nathanson retractor

A Veress needle is used to insufflate the abdomen to a pressure of 15 mm Hg. Access to the peritoneal cavity is then achieved using an optical trocar.

The optical trocar is placed approximately 18–20 cm from the xiphoid, just to the left of the patient’s midline to try to avoid the linea alba. Prior to the placement of the other trocars, the peritoneal cavity is examined and the position of this initial trocar relative to the target anatomy is assessed. If the trocar position is not optimal, the camera trocar could be placed higher or lower. The rest of the trocars are placed in a straight line relative to the optical trocar. Two 8-mm robotic trocars are then placed to the patient’s left. A 12-mm robotic trocar is placed 8–10 cm to the right. Another 8-mm robotic trocar is used to replace the initial optical trocar ( Fig. 19.1 ). An assistant trocar is not routinely used, but one can be placed to facilitate suture insertion, retraction, and suctioning.

Ideally, the camera and instrumentation should be positioned such that one could comfortably work both in the midabdomen on the small bowel and be able to reach into the upper abdomen to work on the pouch and diaphragm. If the trocars are positioned too high, it becomes very challenging to work on the small bowel because it will be too close to the instrumentation. This is particularly challenging for the stapler, which has a longer intra-abdominal length and requires a longer distance for the wrist to clear the trocar. The reach has rarely been a problem in my experience—in the occasional case in which the stapler cannot reach the upper abdomen, one might consider temporarily advancing the trocar further into the abdomen to allow greater reach. Generally, I find that 18–20 cm from the xiphoid works for most patients. The rule of thumb is that “it is better to be a bit too far than a bit too close.”

Operating on shorter patients who have shorter distances to the target anatomy and less working space on the abdominal wall can be relatively more challenging; at times, I have had to place the trocars at or below the level of the umbilicus to achieve the necessary spacing.

The angulation of the bed can be used to help in further optimally positioning the anatomy for the case. I use a reverse Trendelenburg position of approximately 30–45 degrees. The angulation allows gravity to help lower the stomach and fatty gastrosplenic ligament to better expose the hiatus.

A Nathanson liver retractor is placed through a subxiphoid incision to retract the left lobe of the liver. To minimize collisions between the retractor and robot Arm #2, care is taken to make sure that the elbow and screws of the Nathanson are down and out of the way. Also, it helps to rotate the elbows of Arm #2 more to the patient’s right side to be better spaced away from the retractor.

Generally, the process of incision, port placement, and docking (the cut to console time) takes us approximately 6–10 minutes.