Clinical Challenges in Robotic Bariatric Surgery: The Robot is Here to Stay!

Join us as we dissect the use of robotics in bariatric surgery – where precision meets programming, and the scalpel gets a software upgrade. Video Clip Link: https://app.behindtheknife.org/video/clinical-challenges-in-robotic-bariatric-surgery-the-robot-is-here-to-stay This videos includes: - Robotic RYGB - Robotic Sleeve Gastrectomy - SADI: Single Anastomosis Duodenoileostomy Hosts: - Matthew Martin, trauma and bariatric surgeon at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California) - Adrian Dan, bariatric and MIS surgeon, program director for the advanced MIS bariatric and foregut fellowship at Summa Health System (Akron, Ohio) - Crystal Johnson Mann, bariatric and foregut surgeon at the University of Florida (Gainesville, Florida) - Katherine Cironi, general surgery resident at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California) Learning objectives: Strengths of the robot: Surgical robots are at the forefront of technology and continue to improve with detailed, precision cameras and the ability to remove baseline tremors Allows for smooth movements, fine dissection, and precise tissue handling Ergonomics are more advantageous to the surgeon when compared to laparoscopy Weaknesses of the robot: The loss of haptic feedback can be challenging for surgeons early in their learning curve Emphasis on surgical robots means some trainees may be losing exposure to laparoscopic techniques Longer operative time when working robotically, and more time under anesthesia for the patient Increased cost for robotic surgery Outcomes data: Mixed data from the MBSA QIP database (metabolic and bariatric surgery accreditation and quality improvement program) The most recent study looked at 824,000 patients from 2015-2022 who had a sleeve gastrectomy or RNY gastric bypass, either laparoscopically (lap sleeve 61%, lap RYGB 24%) or robotically (robo sleeve 11%, robo RYGB 4%). Robotic sleeves were reported to have higher complication rates compared to laparoscopy, seen as higher overall morbidity and an increased rate of leaks While the robotic RYGBs have lower overall complications, including decreased morbidity and bleeding. Robotic RYGB can be especially advantageous with revisional surgeries when compared to lap. Setting up for success Train your eyes to determine tension on tissue, since there is no haptic feedback Learn how to assist yourself (manipulating the camera and effectively utilizing the fourth arm) Understand how techniques of the surgery change when doing it robotically, as compared to laparoscopy Experienced operating room team When learning, recommend putting all cases feasible on the robot (including easier cases), to master the straightforward cases before moving to technically challenging revision cases. Don’t hesitate to add an additional trocar or assistant port when needed Education in Robotic learning Learning by observation/mirroring – ex: robotic bilateral inguinal hernia (mirroring the attending/instructor) Easy for the attending/instructor in the case to switch instruments seamlessly, then give them back intermittently at the appropriate time Helpful when the attending annotates the screen to depict where to go Data-driven teaching tools on the Davinci system Tips for robotic sleeve gastrectomy: Of the robotic bariatric surgeries, sleeve gastrectomy is most similar to its laparoscopic procedure 30-40 degrees of reverse Trendelenburg Liver hammock stitch instead of a liver retractor (one less trocar), which makes a total of 4 trocars needed for the case Green staple load for the first firing, then the rest are typically blue loads Mixed opinions on reinforced staple loads versus non-reinforced staple loads and oversewing the staple line (discussed cost-benefit) Tips for robotic gastric bypass: Watch videos from colleagues to learn what they do Gastric bypass is a multi-quadrant surgery; thus, you must set yourself up for success so that your arms are not fighting when moving through different quadrants A size 12 trocar on the left can make the formation of the gastric pouch easier GJ and JJ anastomosis formed with a linear fire, then a two-layer closure with absorbable barb suture Don’t forget to close the mesenteric defect (non-absorbable braided suture) Tips for robotic DS and SADI: If doing a duodenal anastomosis hand-sewn, then recommend planning the exact number of sutures and locations of each for ease Hand-sewn anastomosis can have less bleeding and fewer strictures for patients, and is completed in a much more seamless fashion with the robot Future of Robotics Haptic feedback Integrated visual overlays to identify anatomical structures/serve as an intraoperative map Artificial intelligence integration Telesurgery – ex, small surgical robot deployed to space Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more. 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