Fully ambulatory robotic single anastomosis duodeno-ileal bypass (SADI): 40 consecutive patients in a single tertiary bariatric center.

BACKGROUND: Single Anastomosis Duodeno-Ileal bypass (SADI) is becoming a key option as a revision procedure after laparoscopic sleeve gastrectomy (LSG). However, its safety as an ambulatory procedure (length of stay < 12 h) has not been widely described. METHODS: A prospective bariatric study of 40 patients undergoing SADI robotic surgery after LSG with same day discharge (SDD), was undertaken in April 2021. Strict inclusion and exclusion criteria were applied and the enhanced recovery after bariatric surgery protocol was followed. Anesthesia and robotic procedures were standardized. Early follow-up (30 days) analyzed postoperative (PO) outcomes. RESULTS: Forty patients (37 F/3 M, mean age: 40.3yo), with a mean pre-operative BMI = 40.5 kg/m2 were operated. Median time after LSG was 54 months (21-146). Preoperative comorbidities included: hypertension (n = 3), obstructive sleep apnea (n = 2) and type 2 diabetes (n = 1). Mean total operative time was 128 min (100-180) (mean robotic time: 66 min (42-85)), including patient setup. All patients were discharged home at least 6 h after surgery. There were four minor complications (10%) and two major complications (5%) in the first 30 days postoperative (one intrabdominal abscess PO day-20 (radiological drainage and antibiotic therapy) and one peritonitis due to duodenal leak PO day-1 (treated surgically)). There were six emergency department visits (15%), readmission rate was 5% (n = 2) and reintervention rate was 2.5% (n = 1) There was no mortality and no unplanned overnight hospitalization. CONCLUSIONS: Robotic SADI can be safe for SDD, with appropriate patient selection, in a high-volume center.

Outcomes of same-day discharge in bariatric surgery.

BACKGROUND: Restrictions during the COVID-19 pandemic influenced a shift to same-day discharge in bariatric surgery. Current studies show conflicting findings regarding morbidity and mortality. We aim to compare outcomes for same-day discharge versus admission after bariatric surgery. METHODS: Subjects included patients who underwent primary laparoscopic or robotic-assisted sleeve gastrectomy or Roux-En-Y gastric bypass at an academic center. The inpatient group included patients discharged postoperative day one, and the outpatient group included patients discharged on the day of surgery. Primary outcomes included the number of emergency room visits, reoperations, IV fluid treatments, readmissions, and mortality within 30 days. Secondary outcomes were morbidity, including skin and soft tissue infection, pulmonary embolism, and acute kidney injury. RESULTS: 1225 patients met the inclusion criteria. In the gastric sleeve group, 852 subjects were outpatients and 227 inpatients. In the gastric bypass group, 70 subjects were outpatients, and 40 were inpatients. The mean age was 44.63 (17.38-85.31) years, and the mean preoperative BMI was 46.07 ± 8.14 kg/m2. The subjects in the outpatient group had lower BMI with fewer comorbidities. The groups differed significantly in age, BMI, and presence of several chronic comorbidities. The inpatient and outpatient groups for each surgery type did not differ significantly regarding reoperations, IV fluid treatments, or 30-day mortality. The inpatient sleeve group demonstrated a significantly higher readmission percentage than the outpatient group (4.6% vs 2.1%; p = 0.02882). The inpatient bypass group showed significantly greater ER visits (21.7% vs 10%; p = 0.0108). The incidence of adverse events regarding the secondary outcomes was not statistically different. CONCLUSION: Same-day discharge after bariatric surgery is a safe and reasonable option for patients with few comorbidities.

Endoluminal Vacuum Therapy as a Salvage Procedure for Difficult Anastomotic Leak Post Roux-en-Y Gastric Bypass.

We present a case of a woman in her 60s, with a history of a gastric sleeve resection, over 50% excess body weight loss, and subsequent severe gastroesophageal reflux disease refractory to maximal medical therapy, who underwent a conversion of a sleeve gastrectomy to a Roux-en-Y gastric bypass with hiatal hernia repair. On postoperative day five, she was evaluated at our emergency department for vomiting and inability to tolerate oral intake. Imaging revealed a large retrocardiac hiatal hernia and extraluminal contrast extravasation. She was taken to the operating room after resuscitation, where the gastric pouch and roux limb were found to have significant edema with recurrence of the hernia. This was able to be reduced and a frank perforation was found at the posterior aspect of the anastomosis. A covered metal stent was placed by the gastroenterologist and drains were left in place.  In the ICU, nasojejunal feeds were stopped given suspicion of backflow with persistent leak. A decision was made to remove the stent and place an endoluminal vacuum (endoscopic vacuum-assisted wound closure [EVAC]). After three subsequent vacuum-sponge changes, the perforation was found to have healed. Patient was tolerating a diet on discharge. This case is an example of a complication where a multidisciplinary approach to a difficult leak resulted in recovery with the use of EVAC. We believe this is a valuable tool to have in our armamentarium for difficult-to-manage leaks.

The downtrending cost of robotic bariatric surgery: a cost analysis of 47,788 bariatric patients.

The surgical robot is assumed to be a fixed, indirect cost. We hypothesized rising volume of robotic bariatric procedures would decrease cost per patient over time. Patients who underwent elective, initial gastric bypass (GB) or sleeve gastrectomy (SG) for morbid obesity were selected from Florida Agency for Health Care Administration database from 2017 to 2021. Inflation-adjusted cost per patient was collected. Cost-over-time ($/patient year) and change in cost-over-time were calculated for open, laparoscopic, and robotic cases. Linear regression on cost generated predictive parameters. Density plots utilizing area under the curve demonstrated cost overlap. Among 76 hospitals, 11,472 bypasses (223 open, 6885 laparoscopic, 4364 robotic) and 36,316 sleeves (26,596 laparoscopic, 9724 robotic) were included. Total cost for robotic was approximately 1.5-fold higher (p < 0.001) than laparoscopic for both procedures. For GB, laparoscopic had lower total ($15,520) and operative ($6497) average cost compared to open (total $17,779; operative $9273) and robotic (total $21,756; operative $10,896). For SG, laparoscopic total cost was significantly less than robotic ($10,691 vs. $16,393). Robotic GB cost-over-time increased until 2021, when there was a large decrease in cost (-$944, compared with 2020). Robotic SG total cost-over time fluctuated, but decreased significantly in 2021 (-$490 compared with 2020). While surgical costs rose significantly in 2020 for bariatric procedures, our study suggests a possible downward trend in robotic bariatric surgery as total and operative costs are decreasing at a higher rate than laparoscopic costs.

Can robotic gastric bypass be considered a valid alternative to laparoscopy? Our early experience and literature review.

Background: Robotic bariatric surgery serves as an alternative to laparoscopy. The technology provides the surgeon with an accurate three-dimensional view, allowing complex maneuvers while maintaining full control of the operating room. Hypothesis: We report our experience with this innovative surgery compared with laparoscopy during Roux-en-Y gastric bypass to demonstrate its safety and feasibility. The aim of this study is to evaluate potential differences between the robotic and laparoscopic techniques. Materials and methods: Our study retrospectively identified 153 consecutive obese patients who underwent either laparoscopic or robotic gastric bypass (RGB) procedures over a 2-year period at the Department of Medical and Surgical Sciences, University of Foggia. Data on demographics, operative time, conversion rate, length of hospital stay, and mortality were collected and compared between two groups of patients: 82 patients who underwent laparoscopic procedures and 71 who underwent robotic procedures. Results: We analyzed 153 patients who underwent gastric bypass with a mean age of 42.58 years, of whom 74 were female; 71 were treated with a robotic approach and 82 with a laparoscopic approach. The mean operative time was 224.75 ± 10.4 min for RGB (including docking time) and 101.22 min for laparoscopic gastric bypass (LGB) (p < 0.05), which is statistically significant. The median length of stay was 4.1 days for the RGB group and 3.9 days for the LGB group (p = 0.89). There is only one conversion to laparoscopy in the RGB group. We observed only one case of postoperative complications, specifically one episode of endoluminal bleeding in the laparoscopic group, which was successfully managed with medical treatment. No mortality was observed in either group. Conclusion: The statistical analysis shows to support the robotic approach that had a lower incidence of complications but a longer operative duration. Based on our experience, the laparoscopic approach remains a technique with more haptic feedback than the robotic approach, making surgeons feel more confident.This study has been registered on ClinicalTrial.gov Protocol Registration and Results System with this ID: NCT05746936 for the Organization UFoggia (https://clinicaltrials.gov/ct2/show/NCT05746936).

[Robotic sleeve gastrectomy: single-center experience]. / Roboticheskaya «rukavnaya gastrektomiya¼: opyt kliniki.

OBJECTIVE: To demonstrate safe introduction of a new technology (Da Vinci robotic system) into laparoscopic bariatric practice. MATERIAL AND METHODS: We analyzed treatment outcomes in patients with morbid obesity who underwent robot-assisted sleeve gastrectomy between 2020 and 2023. The same team of surgeons performed all operations. Evolution of technique and preparation of the operating theatre were recorded. Demographic data of patients, surgery time (docking and total surgery time), simultaneity of intervention, intraoperative and postoperative complications, as well as weight loss after 6 months were retrospectively analyzed. RESULTS: There were 15 robot-assisted sleeve gastrectomies between 2020 and 2023. Of these, 14 patients underwent surgery without complications. One patient was diagnosed with portal vein thrombosis that required anticoagulation. Median surgery time 194 [173.5; 241] min, period between incision and docking - 35 [30; 36] min. The length of hospital-stay was 3 days. The median weight loss after 6 months was 37.5% [29.5; 51.2]. CONCLUSION: This study demonstrates safe introduction of a new technology to prepare the bariatric team for more complex surgical interventions in the future.

Do advances in technology translate to improved outcomes? Comparing robotic bariatric surgery outcomes over two-time intervals utilizing the MBSAQIP database.

BACKGROUND: This study aims to compare outcomes and utilization of robotics in bariatric procedures across two-time intervals, chosen because they correspond to drastic changes in technology utilization-namely, a new platform and a new stapling device. Outcomes of robotic Roux-en-Y gastric bypass (rRYGB) and robotic sleeve gastrectomy (rSG) across this changing landscape have not been well studied, despite increasing popularity. METHODS: The MBSAQIP database was analyzed over early (2015-2016) and late (2019-2020) time intervals. Patients who underwent rSG and rRYGB were identified, and the cohorts were matched for 26 preoperative characteristics using Propensity Score Matching Analysis. We then compared 30-day outcomes and bariatric-specific complications between the early and late time frames for rSG and rRYGB. RESULTS: 49,442 rSG were identified: 13,526 cases in the early time frame and 35,916 in the late time frame. The matched cohorts were 13,526 for the two groups. 30-day outcomes showed that in the late time frame, rSG was associated with lower rates of pulmonary complications (0.1% vs 0.3%, p < 0.001), readmissions (2.5% vs 3.6%, p < 0.001), interventions (0.6% vs 1.4%, p < 0.001), reoperations (0.7% vs 1.0%, p = 0.024), length of stay (1.36 ± 1.01 days vs 1.76 ± 1.79 days, p < 0.001), operative time (92.47 ± 41.70 min vs102.76 ± 45.67 min p < 0.001), staple line leaks (0.2% vs 0.4%, p = 0.001) and strictures (0.0% vs 0.2%, p < 0.001). Similarly, 21,933 rRYGB were found: 6,514 cases were identified in the early time frame and 15,419 in the late time frame. The matched cohorts were 6,513 for the two groups. 30-day outcomes revealed that the late time fame rRYGB was associated with lower rates of pulmonary complications (0.1% vs 0.3%, p = 0.012), readmissions (6.3% vs 7.2%, p = 0.050), interventions (2.0% vs 3.1%, p < 0.001), length of stay (1.69 ± 1.46 days vs 2.13 ± 2.12 days p < 0.001), postoperative bleeding (0.4% vs 0.7%, p = 0.001), stricture (0.4% vs 0.8%, p < 0.001) and anastomotic ulcer (0.2% vs 0.4%, p = 0.013). CONCLUSION: Compared to early robotic bariatric surgery outcomes, a significant reduction in pulmonary complications, readmissions, reoperations, interventions and length of stay were seen in 2019-20 after rSG and rRYGB. Potential contributing factors include increased surgical experience and advances in the robotic platform. A significant recent reduction in staple line leaks with faster operative times associated with rSG suggests that stapling technology has had a positive impact on patient outcomes.

Identifying Workflow Disruptions in Robotic-Assisted Bariatric Surgery: Elucidating Challenges Experienced by Surgical Teams.

PURPOSE: Bariatric surgery is an effective and durable treatment for weight loss for patients with extreme obesity. Although traditionally approached laparoscopically, robotic bariatric surgery (RBS) has unique benefits for both surgeons and patients. Nonetheless, the technological complexity of robotic surgery presents new challenges for OR teams and the wider clinical system. Further assessment of the role of RBS in delivering quality care for patients with obesity is necessary and can be done through a human factors approach. This observational study sought to investigate the impact of RBS on the surgical work system via the study of flow disruptions (FDs), or deviations from the natural workflow progression. MATERIALS AND METHODS: RBS procedures were observed between October 2019 and March 2022. FDs were recorded in real time and subsequently classified into one of nine work system categories. Coordination FDs were further classified into additional sub-categories. RESULTS: Twenty-nine RBS procedures were observed at three sites. An average FD rate of 25.05 (CI = ± 2.77) was observed overall. FDs were highest between insufflation and robot docking (M = 29.37, CI = ± 4.01) and between patient closing and wheels out (M = 30.00, CI = ± 6.03). FD rates due to coordination issues were highest overall, occurring once every 4 min during docking (M = 14.28, CI = ± 3.11). CONCLUSION: FDs occur roughly once every 2.4 min and happen most frequently during the final patient transfer and robot docking phases of RBS. Coordination challenges associated with waiting for staff/instruments not readily available and readjusting equipment contributed most to these disruptions.

Five Year Trends in the Utilization of Robotic Bariatric Surgery Procedures, United States 2015-2019.

PURPOSE: Robotic approaches have been steadily replacing laparoscopic approaches in metabolic and bariatric surgeries (MBS); however, their superiority has not been rigorously evaluated. The main goal of the study was to evaluate the 5-year utilization trends of robotic MBS and to compare to laparoscopic outcomes. METHODS: Retrospective analysis of 2015-2019 MBSAQIP data. Kruskal-Wallis test/Wilcoxon and Fisher's exact/chi-square were used to compare continuous and categorical variables, respectively. Generalized linear models were used to compare surgery outcomes. RESULTS: The use of robotic MBS increased from 6.2% in 2015 to 13.5% in 2019 (N= 775,258). Robotic MBS patients had significantly higher age, BMI, and likelihood of 12 diseases compared to laparoscopic patients. After adjustment, robotic MBS patients showed higher 30-day interventions and 30-day readmissions alongside longer surgery time (26-38 min). CONCLUSION: Robotic MBS shows higher intervention and readmission even after controlling for cofounding variables.

Robot-assisted versus laparoscopic approach to concurrent bariatric surgery and hiatal hernia repair: propensity score matching analysis using the 2015-2018 MBSAQIP.

BACKGROUND: Up to 37% of class three obesity patients have a Hiatal Hernia (HH). Most of the existent HHs get repaired at the time of bariatric surgery. Although the robotic platform might offer potential technical advantages over traditional laparoscopy, the clinical outcomes of the concurrent bariatric surgery and HH repair comparing robotic vs laparoscopic approaches have not been reported. METHODS: Using the 2015-2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, patients between 18 and 65 year old who underwent Sleeve gastrectomy (SG) or Roux en-Y Gastric Bypass (RYGB) with concurrent HH repair were identified. Demographic, operative, and 30-day postoperative outcomes data were compared between laparoscopic and robotic groups. To adjust for potential confounders, 1:1 propensity score matching was performed using 22 preoperative characteristics. RESULTS: 75,034 patients underwent SG (n = 61,458) or RYGB (n = 13,576) with concurrent HH repair. The operative time was significantly longer in the Robotic-assisted compared to the laparoscopic approach both for SG (102.31 ± 44 vs. 75.27 ± 37; P < 0.001) and for RYGB (163.48 ± 65 vs. 132.87 ± 57; P < 0.001). In the SG cohort (4639 matched cases), the robotic approach showed similar results in 30 day outcomes as in the laparoscopic approach, with no statistical difference. Conversely, for the RYGB cohort (1502 matched cases), the robotic approach showed significantly fewer requirements for blood transfusions (0.3% vs. 1.7%; P = 0.001), fewer anastomotic leaks (0.2% vs. 0.8%; P = 0.035), and less postoperative bleeding (0.4% vs. 1.1%; P = 0.049). CONCLUSION: Robotic concurrent bariatric surgery and HH repair leads to similar overall clinical outcomes as the laparoscopic approach despite longer operative times. Furthermore, the robotic approach is associated with reduced blood transfusion and anastomotic leak incidence in the RYGB group.

Robotic Revisional Bariatric Surgery: a High-Volume Center Experience.

PURPOSE: The number of bariatric revisional procedures is growing. Scarce evidence is available regarding the role and postoperative outcomes of robotic-assisted revisional bariatric surgery (RRBS). The aim of this study is to evaluate the safety and postoperative outcomes of RRBS. MATERIALS AND METHODS: A retrospective analysis of a prospectively collected database of patients who underwent RRBS between 2012 and 2019 was performed. Primary outcomes of interest were 30-day major morbidity, mortality, length of hospital stay (LOS), urgent reoperation rates, and percentage of total weight loss (%TWL). RESULTS: RRBS was performed in 76 patients; among these 60 (78.9%) underwent conversion to Roux-en-Y gastric bypass (C-RYGB). Failed weight loss (76%) and gastroesophageal reflux (9.2%) were the main indications for revision. Primary bariatric procedures included gastric band (LAGB) (50%), sleeve gastrectomy (SG) (40.8%), and RYGB (6.6%). Major morbidity and mortality rates were 3.9% and 1.3%, respectively. Mean LOS was 2.1 days, and 3 patients (3.9%) required urgent reoperation. The %TWL at 3, 6, 12, and 24 months was 10.2%, 16.6%, 18.3%, and 22.4% respectively. Comparative analysis of C-RYGB after failed LAGB and SG showed similar morbidity. Higher readmission rates (SG: 22.2% vs. LAGB: 0%, p = 0.007) and lower %EWL at 3, 6, 12, and 24 months were found in C-RYGB after SG. CONCLUSION: This is one of the largest single-center series of RRBS published in the literature; the data indicate that robotic approach for revisional bariatric surgery is safe and helps achieving further weight loss. RRBS outcomes might be influenced by the primary procedure.

Robotic-Assisted Surgery Results in a Shorter Hospital Stay Following Revisional Bariatric Surgery.

BACKGROUND: Revisional surgery is rapidly growing within the field of bariatric surgery. The use of robotic assisted surgery, considered controversial by many, may offer advantages in revisional bariatric surgery (RBS). There are few studies comparing laparoscopic and robotic-assisted RBS. The aim of this study is to compare the safety and outcome of laparoscopic and robotic RBS in a single accredited center. METHODS: A retrospective analysis of data collected prospectively on patients undergoing either laparoscopic (L-RBS) or robotic (R-RBS) RBS between January 1, 2017 and December 31, 2019 was performed. The primary outcomes included length of stay (LOS), 30-day major and minor complication rates, readmission rates, and mortality rates. RESULTS: A total of 167 patients were included in our analysis. Fifty-two patients underwent R-RBS (31%), and 115 underwent L-RBS (69%). Thirty-day major and minor complication rates for R-RBS and L-RBS were 1.9% and 5.8% vs 5.2% and 5.2%, respectively (p > .05). There was no difference in readmission rates (3.8% vs 8.7%, p > 0.05) or intraoperative blood loss (35.5 mL vs 37.4 mL, p > .05) between R-RBS and L-RBS. R-RBS resulted in a shorter length of stay when compared with L-RBS (40.2 h vs 62.6 h, p < .05). CONCLUSIONS: R-RBS has a decreased, albeit non-significant, rate of 30-day major complications with no difference in minor complications, readmission rates, or intraoperative blood loss when compared with L-RBS. R-RBS resulted in a decreased length of stay when compared with L-RBS. Randomized clinical trials are needed to better elucidate our findings.

Trends in the utilization and perioperative outcomes of primary robotic bariatric surgery from 2015 to 2018: a study of 46,764 patients from the MBSAQIP data registry.

BACKGROUND: Utilization of robotic surgery has increased over time. Outcomes in bariatric surgery have been variable. This study used the Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program (MBSAQIP) dataset to compare nationwide trends in utilization and outcomes improvement for robotic and laparoscopic bariatric surgery over a four-year period. METHODS: We identified all adult patients who underwent robotic or laparoscopic primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from 2015 to 2018. Those with previous bariatric/foregut surgery or open conversion were excluded. Trends in clinical outcomes of different surgery types over years were compared through multivariable regression models. Subgroup analysis was performed for patients in 2018, comparing outcomes among different surgery types. RESULTS: A total of 571,417 patients underwent bariatric surgery, of which 46,764 (8.2%) were performed robotically. Utilization of the robotic platform increased annually, from 6.7% in 2015 to 10.3% in 2018 (p < 0.0001). The majority of patients underwent SG (n = 33,891, 72.5%). Perioperative outcomes improved over time for both robotic and laparoscopic procedures. Improvement was more pronounced in the robotic cohort for extended length of stay (OR 0.76 vs 0.8, p < 0.0001) and operative time (OR 0.98 vs 0.99, p < 0.0001). In the 2018 subgroup, multivariable analysis found laparoscopic RYGB was associated with increased bleeding (OR 2.220, p = 0.0004), overall complications (OR 1.356, p = 0.0013), and extended LOS (OR 1.178, p < 0.0001) compared to robotic surgery. Laparoscopic SG was associated with decreased anastomotic/staple line leak (OR 0.718, p = 0.0321), 30-d readmission (OR 0.826, p = 0.0005), 30-d reintervention (OR 0.723, p = 0.0014), overall event (OR 0.862, p = 0.0009), and extended LOS (OR 0.950, p = 0.0113). Across the board, laparoscopic surgery was associated with decreased operative time (Adjusted Ratio = 0.704, p < 0.0001). CONCLUSION: Robotic utilization for bariatric surgery is increasing and outcomes continue to improve with time. There is a differential impact of the robotic approach on SG and RYGB, which requires further assessment.

Evolution of outcomes of robotic bariatric surgery: first report based on MBSAQIP database.

BACKGROUND: Robotic surgery is increasingly being used in bariatric surgery; however, the benefits of robotic surgery in bariatrics remain controversial. OBJECTIVES: The objective of this study was to compare the outcomes of robotic bariatric surgery with laparoscopic surgery over a 3-year period between 2015 and 2017 using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. SETTING: University Hospital, United States. METHODS: Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for the years 2015 to 2017, we included patients who underwent primary robotic or laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass procedures. Patients were divided into either robotic or laparoscopic groups. Primary outcomes included serious adverse events, organ space infection (OSI), readmissions, reoperations, and interventions at 30 days. Secondary outcomes included operation length and hospital stay. We performed propensity score matching based on clinically relevant preoperative variables to create balanced groups before analysis. We analyzed our data using separate Cochran-Mantel-Haenszel tests with year as the stratification variable and conducted subgroup analyses for robotic patients only using separate t tests for proportions, with P < .05 denoting statistical significance. RESULTS: Of the 315,647 patients available for comparison in the 2015 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant User Files, there were 41,364 matched in the final data set. Using the Cochran-Mantel-Haenszel test, we found a significant association between year of performance and outcomes for OSI, 30 day-readmission, and intervention. The incidence of OSI after laparoscopic and robotic cases was .3% and .4%, respectively, in 2015 versus .2% and .3%, respectively, in 2017 (P = .04, odds ratio = 1.49). Thirty-day readmission for robotic cases was 5.2% in 2015 and 4.0% in 2017 (P < .05, odds ratio = 1.16). The incidence of 30-day intervention for robotic cases also dropped from 2.2% in 2015 to 1.3% in 2017 (P < .05, odds ratio = 1.37). Using a Student's t test, there was also a statistically significant decrease in serious adverse events in the robotic group between 2015 and 2017 (incidence of serious adverse events in 2015 was 5.2% versus 3.7% in 2017, P < .05). Rate of 30-day reoperation for the robotic group did change over time but was comparable to the laparoscopic group (1.4% versus 1.3%). CONCLUSIONS: Our study showed between 2015 and 2017 the outcomes of robotic bariatric surgery have improved as evidenced by the significant decrease in the rate of OSI, readmissions, and interventions at 30 days.

A Review of the Role of Robotics in Bariatric Surgery: Finding Our Future?

Introduction: Obesity rates continue to rise in America and around the World. Numerous studies show the benefit of bariatric surgery on all-cause mortality in obese patients. Given its substantial role in the future of patient care, we continue to search for the most beneficial ways to optimize patient outcomes and procedural costs in bariatric surgery. Much like laparoscopy was found to greatly improve the morbidity of weight loss surgery, we seek to evaluate the role of robotic surgery in bariatric procedures. Methods: We critically reviewed the available literature accessed through PubMed on the use of robotics in bariatric surgery. We aim to provide an overview of the conclusions from the most recent publications with commentary by the authors. Results: Although the outliers exist, it would appear that the majority of cases point to robotic surgery increasing operating room time and cost without providing significant generalizable improvements in patient outcomes. Promise exists in the use for special groups such as super obese patients or revisional bariatric procedures, however current studies in this subset are equally variable in their outcomes. Conclusion: Despite the current assumptions, we believe there is a future in bariatric surgery for robotics. This may inevitably be seen in the more demanding and difficult cases or in the advancement of the available technology. Likely, as robotics continues to mature, applied artificial intelligence will provide enhanced cues during surgery that augment the surgeon's judgment and skill and result in unanimously improved patient outcomes.

Robot-assisted versus laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy: a propensity score-matched comparative analysis using the 2015-2016 MBSAQIP database.

BACKGROUND: Robotic-assisted bariatric surgery is part of the armamentarium in many bariatric centers. However, limited data correlate the robotic benefits to with clinical outcomes. This study compares 30-day outcomes between robotic-assisted and laparoscopic procedures for Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). METHODS: Using the 2015-2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, patients between18- and 65-year-old were included. To adjust for potential confounders, 1:1 propensity-score matching (PSM) was performed using 22 preoperative characteristics. Second PSM analysis was performed adding operative time and conversion rate. RESULTS: 269,923 patients underwent SG (n = 190,494) or RYGB (n = 79,429). The operative time was significantly longer in the Robotic-assisted compared to laparoscopic approach either for SG (102.58 ± 46 vs. 73.38 ± 36; P < 0.001) or for RYGB (158.29 ± 65 vs. 120.17 ± 56; P < 0.001). In the SG cohort (12,877 matched cases), the robotic approach showed significant reduction of postoperative bleeding (0.16% vs. 0.43%; P < 0.001) and strictures (0.19% vs. 0.33%; P = 0.04) with similar results in the other 30-day outcomes in both analyses. Similarly, for the RYGB cohort (5780 matched cases), the robotic approach showed significantly fewer requirements for blood transfusions (0.64% vs. 1.16%; P = 0.004) with no statistically different results for the other's outcomes. Conversely, when adding operative time and conversion rate to the PSM analysis, the robotic platform showed significantly shorter length of stay (2.12 ± 1.9 vs. 2.30 ± 3.1 days; P < 0.001), reduction of anastomotic leak (0.52% vs. 0.92%; P = 0.01), renal complications (0.16% vs. 0.38%; P = 0.004), and venous thromboembolism (0.24% vs. 0.52%; P = 0.02). CONCLUSIONS: Our findings show that postoperative bleeding and blood transfusion are significantly reduced with the robotic platform, and after correcting for all factors including operative time, the robotic-assisted approach is associated with better postoperative outcomes especially for RYGB.

Totally robotic gastric bypass: approach and technique.

Despite the advantages of the da Vinci robotic system in the performance of abdominal surgery (Maeso et al. Ann Surg 252:254-262, 2010), there has been limited application of this technology to bariatric surgery. The robotic platform may be ideal for performance of Roux-en-Y gastric bypass (RYGB), providing significant ergonomic advantage and greater ability to maneuver more precisely in limited spaces. However, there has been slow adoption of robotic technology for the performance of the RYGB procedure due, in part, to the perceived difficulty of conversion from laparoscopic to totally robotic procedures and the associated initial increase in operative time. In this report, we describe our approach to developing a standardized totally robotic technique with focus on patient safety and attention to operative times, the technique itself, and surgery outcomes of nearly 300 RYGB cases. Our findings show that totally robotic RYGB can be safely approached through systematic stepwise progression with minimal complications and comparable operative times.