Sleeve gastrectomy (SG) constituted the first stage of the duodenal switch and consisted in excising the fundus and greater curvature portion of the stomach, creating a narrow gastric tube. In the last years, SG has gained popularity. Because of it apparent simplicity and was considered as the first stage of the management of obese patients.
The da Vinci Surgical System® (Intuitive Surgical, Sunnyvale, CA) was introduced in the surgical practice and has gained popularity in different specialties, including obesity surgery. Its technology, including 3D vision, Endowrist movement, enables complex surgical movements and also procedures. Roux-en-Y gastric bypass (GBP) remains the most popular procedure for the treatment of obesity; however, it is still a challenging procedure performed by bariatric and general surgeons although laparoscopic duodenal switch is much more complex. SG is a less technically demanding procedure. We considered that SG gives you the possibility to dissect and suture the stapling line, and thus, robotic technology was applied in this type of procedure. In robotic surgical procedures, the surgical tools are connected to a mechanical system and the doctor manipulates them via a control suite. The robotic system is calibrated to move more precisely, steadily, and flexibly than a person’s hand can, and this allows for more accurate surgery, down to a microscopic scale. The likely result: less surgical wounds, less scarring, and less recovery time.
Between September 2006 and November 2012, 200 patients have undergone bariatric sleeve gastrectomy surgery. In an initial period, sleeve gastrectomy was performed laparoscopically (laparoscopic sleeve gastrectomy procedure, LS), and since May 2010, the procedure was also performed robotically (robotic sleeve gastrectomy procedure, RS). All patients included in this study have undergone a standard sleeve gastrectomy. All the patients were included in the obesity surgery program according to their medical criteria, and the study adhered to all ethical guidelines considered in our institution. A team of trained surgeons in advanced laparoscopic surgery performed all surgeries. In the robotic sleeve gastrectomy group, the surgical team consisted of two attending physicians who shared the console and the scrubbed table activities. Patients were included in both groups in a nonrandomized way.
Robot-assisted SG was performed in 100 patients and laparoscopic SG in another 100 patients. There were 47 male and 143 female patients. Their mean age was 44.1 years in the RS and 43.1 in the LS. Mean BMI were 48.8 kg/m2 in the RS group and 47.6 kg/m2 in the LS group. Fifty-two patients had type 2 diabetes mellitus (T2DM), 94 suffered from high blood pressure, 59 patients had dyslipidemia, and 157 were using a continuous positive airway pressure device (CPAP) device at home at the time of operation. There were no differences between the two groups. There were no perioperative complications, mortality, or conversions to a laparoscopic approach or open approach in any patient. In the robotic group, 89 patients received a manual robotic reinforcement, and 11 patients had a buttress material reinforcement. Similarly, in the LS group, 87 patients had their stapling line reinforced with a continuous suture. There were three leaks in the RG that were managed conservatively with CT drain and antibiotics. The overall leak rate in the RS and LS groups were 3 and 4 %, respectively. Both patients had Seamguard® reinforcement. One patient belonging to the RG had extraluminal bleeding that required a reoperation. All the other bleedings (belonging to the RS and LS group) were intraluminal and were managed conservatively. The overall bleeding rate in the RS and LS groups (including extraluminal and intraluminal) were 2 and 4 %, respectively. Hospital stay was similar in both groups ranging from 3 to 4 days (NS). All patients in both groups experienced a decrease of their weight and BMI. All patients from both groups recovered in high percentages their comorbidities after 1-year follow-up. T2DM resolved in 86 % of the cases from the RS group and 84 % of the patients from the LS group.
To our knowledge, we present the longest robotic SG series compared to the standard laparoscopic SG approach. SG is a purely restrictive operation where the size of the gastric reservoir is reduced to 60–100 mL, permitting the intake of only small amounts of food. Also, the stomach resection gives a feeling of satiety earlier during a meal. This procedure has been performed laparoscopically with good results. In 2000, the use of the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) was approved by the Food and Drug Administration for its use in general laparoscopic surgery. The system has been used in general surgery in order to improve their surgical outcomes. Robotic technology has also been used in bariatric surgery to complete different procedures such as GBP, which requires high levels of expertise even in trained surgeons. On the other hand, laparoscopic SG has gained standardization and consensus. Bariatric operations are challenging, and performing gastrointestinal anastomosis or long stapled lines can lead to life-threatening complications such as leakage, peritonitis, and bleeding. Also, the severe obesity of these patients gives a substantial difficulty in the procedure because of the thickness of the abdominal fat. A bad placement of a trocar can lead to a painful and tired hand and arm during the procedure. For this reason, robotic surgery can be useful according to previous experiences. It has shown to be effective in performing precise anastomosis and difficult access step. The use of the robotic da Vinci Surgical System® for morbidly obese patients has probably been more studied for the GBP. In this procedure, gastrojejunal and jejunojejunal anastomoses are performed, and the use of the robot can facilitate its fashion, avoiding in some cases even stapler use. In our institution, the implementation of the da Vinci Surgical System® leads us to understand its functioning and to try to apply it in our morbidly obese patients. For this reason, we thought that beginning with SG according to our technique (with a complete stapling line hand-sewn reinforcement) could be interesting. We found it easier to perform the procedure with this technology, with the surgeon being more comfortable upon using the robotic trocars and the 3D vision. The da Vinci system does not give tactile feedback to the surgeon. As we mentioned in our previous article, robotic surgery carries a longer setup time, including a longer learning curve and higher costs. However, we believe that the da Vinci system could be used in more challenging procedures, including revisional bariatric surgery. Our previous published results showed that the learning curve for robotic SG could be obtained after completing 20 procedures. This learning curve has allowed us to increase our experience and to switch to the robotic GBP. Perioperative morbidity and mortality have been acceptable according to our standards of quality during the learning curve. Although SG seems to be an easier procedure, it has to deal with very important and severe complications such as bleeding and leakage. Sleeve gastrectomy has the longest stapled line we can perform in a surgical procedure. Hemorrhage and leak are reported to be 0.4 and 0.8–1.45 %, respectively. Compared to laparoscopic surgery, robotic surgery offers the possibility for Endowrist, and this action facilitates the over sewing of the stapled line. The upper part of the sleeve, close to the esophageal gastric junction, is a crucial zone where more than 95 % of the leaks occur. For this reason, we consider that the robotic approach facilitates the maneuvers, where sometimes the liver can make reinforcement of this line difficult. In terms of training, we have seen that SG could be a preliminary step before undergoing more complex bariatric procedures such as GBP by using the robotic technology. When we do compare gastric closure during SG, many studies have tried to show between no stapled line reinforcement, buttressing of the stapled line with Gore-Seamguard®, or the stapled line suture alone. According to our experience, we do perform stapled line suturing, and only in extraordinary difficult cases do we reinforce with buttress material. In our series, the three leaks that occurred in the robotic group were in patients with a buttress material reinforcement, which may suggest that suturing could be more effective in terms of decreasing the risk of hemorrhage and leak. Also, some other authors consider that the reinforcement of the stapled line after SG is questionable. In this same idea, a short series of SG perform on the Da Vinci describes the technique without any type of reinforcement. However, we consider that an advanced technology such as a robotic system has to be used in order to perform more complex procedures by using all its technological features (3D vision, ergonomic, end wrist, movement precision). This is the main reason why, and according to our protocol, we consider that SG has to be reinforced but also could be an initial procedure in bariatric to get trained on the da Vinci Surgical System® robot. This study pretends to be a preliminary series that tries to show the safety and feasibility of the robotic SG considering the major outcomes. Also, this study tries to compare two different procedures, and many authors would agree that SG could easily be performed by laparoscopy. However, we achieve to have the same results in our series. The real benefit of reinforcing the stapled line remains unclear, and further studies, with major number of cases, would be needed. We have not performed a cost assessment in this study. Although the robotic approach is more expensive compared to the laparoscopic approach, the use of the robot should be based on several factors: institution financial support, availability, and a major concern about the technical aspects (stapled line integrity, bleeding). Some authors have already shown that robotic surgery could or could not be cost effective for GBP although this issue is still controversial.
Robotic SG is feasible, safe, and reproducible and may be a good alternative to treat morbidly obese patients. It can be a preliminary step before undergoing more challenging procedures such as GBP. Standard laparoscopic SG is the most frequent approach to perform SG; however, robotic technology could be applied according to its safety and feasibility. Accepting its disadvantages such as costs and operative time increase must be done by all the members of a robotic program. Probably, challenging cases should be performed by using the robotic system. The robot is the future of surgery as it provides a safer surgical treatment option for patients. Patients will benefit from:
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2. Theodoros Diamantis, Andreas Alexandrou, Nikolaos Nikiteas, Athanasios Giannopoulos, Eustathios Papalambros. Initial Experience with Robotic Sleeve Gastrectomy for Morbid Obesity. OBES SURG (2011), 21:1172–1179.
3. Rey Jesús Romero, Radomir Kosanovic, Jorge Rafael Rabaza, Rupa Seetharamaiah, Charan Donkor, Michelle Gallas, Anthony Michael Gonzalez. Robotic Sleeve Gastrectomy: Experience of 134 Cases and Comparison with a Systematic Review of the Laparoscopic Approach. OBES SURG (2013), 23:1743–1752.