Controversial Role of Robot in Primary and Revisional Bariatric Surgery Procedures: Review of the Literature and Personal Experience

Abstract

Laparoscopy is the surgical standard of care for bariatric procedures; however, during the last two decades, the robotic approach has gained increasing interest. It is currently considered a safe and effective alternative to laparoscopy. This literature review investigates the role of the robotic approach for primary and revisional bariatric procedures, with the particular aim of comparing this technique with the standard-of-care laparoscopic approach. The feasibility of robotic dissection and suturing could have potential advantages: robotics may prevent the risk of leak and bleeding and other surgical complications, determining potential benefits in terms of operative time, length of hospital stay, and learning curve. Considering primary procedures, the literature reveals no advantages in robotic versus the laparoscopic approach for adjustable gastric banding and sleeve gastrectomy. Robotic Roux-en-Y gastric bypass is associated with a longer operative time and a shorter hospital length of stay than laparoscopy. The robotic approach in revisional surgery has been proven to be safe and effective. Despite the longer operative time, the robotic platform could achieve a lower bleeding rate compared with laparoscopy. The surgeon’s selection criteria related to referrals to the robotic approach of difficult-perceived cases could represent a bias. In conclusion, robotic surgery can be considered a safe and effective approach in both primary and revisional bariatric surgery, despite the lack of evidence to support its routine use in primary bariatric surgery. However, in revisional bariatric surgery and in surgical complex procedures, the robotic approach could have potential benefits in terms of surgical complications and learning curves.

Feasibility of Roux-en-Y Gastric Bypass with the novel robotic platform HUGO™ RAS

“…In our centre, since performing the first robotic bariatric procedure in 2013, we have performed more than 4,177 bariatric procedures in total, but only approximately 90 cases (≈2%) were scheduled for robotic approach, half of them being RYGB and the remaining single-anastomosis duodenal switch operations (SADI-S, single anastomosis duodeno-ileal bypass with sleeve gastrectomy) ( 24 , 25 ). The main limitations in further application being robotic operative room availability and economic concerns, forcing us to conserve the robotic-approach predominantly for more challenging procedures and/or patients (super-obese, revisional surgery, RYGB, SADI-S) ( 24 , 26 ). Thus, the opportunity to introduce the Hugo™ RAS platform, in an already established robotic bariatric program, was met with guarded enthusiasm in our Institution.…”

Robotic-assisted Roux-en-Y gastric bypass with the novel platform HugoTM RAS: preliminary experience in 15 patients

“…However, the main limitations of further RAS diffusion have been repeatedly associated with increased costs, longer operative times, and lack of platform accessibility. Published individual studies and meta-analyses have failed to systematically yield superior results of robotic-assisted RYGB in comparison to the laparoscopic conventional approach, thus associating robotic-assisted RYGB with reduced cost-effectiveness [ 9 , 10 , 27 ]. However, included studies were not randomised, varied in surgical techniques applied, and surgeons’ expertise in robotic procedures.…”

“…However, the main costs are associated with the initial capital invested in platform purchase, the limited life span of instruments used, and annual maintenance. It has been thus estimated that to address and rationalise the increased costs of robotics with the Da Vinci platform, at least 250 procedures/year are necessary to be performed in a medical centre [ 27 , 35 ]. It has been proposed that the financial burden of robotics may be alleviated by reducing the complications rates, readmissions, and operative times in the future, especially in revisional and challenging operations.…”

Robotic vs laparoscopic approach for single anastomosis duodenal-ileal bypass with sleeve gastrectomy: a propensity score matching analysis

“…In such a group of challenging patients, the robotic approach would facilitate the single step procedure. Since single step procedure seems to have a beneficial effect in terms of %EWL and comorbidity resolution [ 5 , 6 , 9 ]; the robotic approach could ultimately result in a better postoperative outcome and, probably, a reduction of the overall cost, eliminating the need for a second hospitalization and a second surgical procedure [ 49 ]. It is clear that such theoretical advantages should be explored and evaluated in larger comparative studies.…”