Robotic sleeve gastrectomy

Indications

In the last decade, sleeve gastrectomy has been accepted as a surgical treatment option for morbid obesity and currently accounts for almost 60% of bariatric procedures. It is considered safe and technically less demanding in comparison to the Roux-en-Y gastric bypass. Weight loss surgery is recommended for those with a body mass index (BMI) ≥35 kg/m and at least one related comorbidity (i.e., hypertension, hypercholesterolemia, obstructive sleep apnea, or diabetes mellitus), or a BMI ≥40 kg/m . Laparoscopy has been the primary approach, but robot-assisted surgery in the morbidly obese population has gained popularity. With better visualization and ergonomics, the use of the da Vinci Xi surgical system (Intuitive Surgical, Inc., Sunnyvale, CA, USA) provides a safe alternative to this operation. Herein we describe our surgical technique for a robotic sleeve gastrectomy.

Patient preparation

We routinely prescreen all of our patients undergoing bariatric surgery with an upper endoscopy. Evidence of moderate-to-severe esophagitis and/or moderate-to-large (≥5 cm) hiatal hernias precludes patients from undergoing a sleeve gastrectomy, given the concern for postoperative gastroesophageal reflux disease. ^,

Patients are initiated on a clear liquid diet for two days prior to surgery. They are instructed to consume one 16-ounce carbohydrate drink 2 hours prior to surgery. The morning of surgery, patients receive medications to aid in postoperative pain control and decrease postoperative nausea ( Table 18.1 ). All patients are routinely administered a dose of subcutaneous heparin to prevent deep vein thrombosis.

Operating room setup and patient positioning

Room setup

We recommend positioning the robot on the patient’s right side for docking. Scrub nurses and assistants should have room at the foot of the patient’s bed to allow for a table of instruments and to exchange the robot arms. Fig. 18.1 is an overhead view of the recommended operating room configuration.