|Year : 2017 | Volume
| Issue : 2 | Page : 96-102
Robotic Roux-en-Y gastric bypass: Our centre's technique with short-term experience
Mohit Bhandari, Winni Mathur, Arun Kumar Mishra, Daksha Chandorkar
Department of Bariatric and Metabolic Surgery, Mohak Bariatrics and Robotics, Indore, Madhya Pradesh, India
|Date of Submission||09-May-2016|
|Date of Acceptance||19-Nov-2016|
|Date of Web Publication||9-Mar-2017|
Mohak Bariatrics and Robotics, SAIMS Campus, Indore-Ujjain Highway, Near MR 10 Crossing, Indore, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Background: Roux-en-Y gastric bypass (RYGB) is one of the most widely performed bariatric surgeries in the world. Performing an RYGB by a Da Vinci Surgical System is a new advancement. The aim of this study is to describe single docking-single quadrant technique and its short-term results. Materials and Methods: Between January 2013 and December 2013, 140 robotic RYGB were performed. The RYGB was performed through single docking, single quadrant approach. The data were analysed retrospectively. Intra- and post-operative details of every patient were documented. Follow-up was done as per protocol at 6 months; 1 and 2 years. In total, 120 patients completed the follow-up protocol as per our database. Results: Mean age of the patients was 42.7 ± 12.11 years. Ratio of males: females were equal. The mean operative time was 97.48 ± 23.79 min. Early mortality was seen 7 days post-surgery. Two late complications were documented with no late mortality. The average length of stay was 2.89 ± 1.06 days. Average blood loss was 55.79 ± 11.91 ml. There was no hospital re-admission after the surgery. Conclusion: Single docking-single quadrant technique is simple, effective and time saving without having complicated port position, multiple docking with minimal complications.
Keywords: Console time, docking time, morbid obesity, robotic gastric bypass, single quadrant, weight loss
|How to cite this article:|
Bhandari M, Mathur W, Mishra AK, Chandorkar D. Robotic Roux-en-Y gastric bypass: Our centre's technique with short-term experience. J Min Access Surg 2017;13:96-102
|How to cite this URL:|
Bhandari M, Mathur W, Mishra AK, Chandorkar D. Robotic Roux-en-Y gastric bypass: Our centre's technique with short-term experience. J Min Access Surg [serial online] 2017 [cited 2017 Jul 20];13:96-102. Available from: http://www.journalofmas.com/text.asp?2017/13/2/96/201728
| ¤ Introduction|| |
Obesity has been labelled as global epidemics by WHO and reached to alarming situation in India as about 5% of country's population is affected by morbid obesity. Long-term weight loss with caloric restriction alone or coupled with exercise have not promising results. Bariatric surgery has evolved as a boon for morbidly obese patients who have failed every attempt to achieve their target weight loss simply by diet and exercise. One of the most commonly performed bariatric procedures is Roux-en-Y gastric bypass (RYGB), which is now considered as gold standard for weight loss. Recent development in the field of bariatric surgery is the introduction of Da Vinci Robotic Surgical System. Robotic Surgery has added newer paradigm in the minimal access surgery.
Bariatric surgery essentially involves a procedure to be done in multiple quadrants. A procedure like gastric bypass or a mini gastric bypass has a gastric component and an intestinal component. In robotic surgeries working in multiple quadrants will involve complicated port positions with change in position of the patient multiple times, with multiple docking of the robotic arms thereby wasting a lot of precious time under anaesthesia. Most of the gastrointestinal (GI) surgeries are performed robotic-assisted through multiple quadrant approach. It amounts to a waste of time and effort on the part of the surgeon and the team. Anaesthesia time in bariatric surgery is very critical in morbidly obese patients, as they have increased risk of developing pulmonary complications postoperatively. Robotic RYGB in a single quadrant by single docking without putting additional ports reduces the surgical time as it abates the need to change the position of the patient multiple times during the procedure. In this study, we describe and elucidate short-term results of robotic RYGB using single docking-single quadrant technique.
| ¤ Materials and Methods|| |
Robotic RYGB was performed on 140 patients from January 2013 to December 2013. Single docking-single quadrant technique was used for RYGB surgery. Written Informed consent was taken from each patient.
An 8 mm port was placed as an optical port in supraumbilical position. Another 12 mm port was placed at right mid clavicle line and parallel to optical trocar. This non-docking port was used for assistance and staplers were fired across from this port. Furthermore, if any special instrument is to be introduced which is non-robotic then, it is done by this port. Further, two 8 mm robotic ports were placed one on the left side in mid axillary line and the other on the right side in mid clavicular line below rib margins for docking of 2nd (right side) and 3rd (left side) robotic arm. Another 8 mm trocar was placed in left mid-clavicular line exactly parallel to optical trocar. Finally, Nathanson liver retractor (Cook Medical, USA) was placed just below the xiphisternum before docking. The minimum distance in between the trocars should be 8 cm [Figure 1].
The complete robotic technique is divided into two parts: (a) Laparoscopic part and (b) Robotic part.
The first step in a robotic RYGB is the division of the greater omentum [Figure 2]. The patient was kept in supine position. After a diagnostic laparoscopy to access the bowel and hiatus, the omentum was divided starting from the base of the transverse colon till the left subtotal angle. The ligament of treitz was identified when the transverse colon is raised [Figure 3]. Marking of the biliopancreatic and alimentary limb of the bowel by a black silk thread marking stitch was done. The biliopancreatic limb was marked at 80 cm, and alimentary limb was marked at 120 cm. This was standard limb length for all our robotic and conventional gastric bypass cases.
The biliopancreatic limb was clipped with the thread to the left subtotal area so that it does not fall down after giving a steep head up position before docking. The position of the patient was maintained supine at this stage [Figure 4].
The robotic part requires re-positioning of the patient. The patient was put up in steep head up a position at 45° elevation. This position was remains constant till the end of the procedure [Figure 5]. The docking was done in the steep head up position.
Docking of the robot
The robotic docking process was streamlined with the help of the assistant team, which need not to be scrubbed for the procedure [Figure 6].
The first step in robotic RYGB is making the pouch. The essence of a gastric bypass for morbid obesity is a micro pouch. The pouch was made by dividing the gastric omentum just below the left gastric pedicle [Figure 7]. The pars flaccida approach is most commonly done to make a gastric pouch at our centre. After entering into the lesser sac, we use a blue load of 6 cm to make a horizontal fire [Figure 8]. The 36 Fr bougie was used to calibrate the pouch, and two vertical firings were made with blue reloads of 60 mm and gastric pouch of size approximately 30 ml was made [Figure 9]. Once the pouch was made, the loop of bowel was clipped at the subcostal area at 80 cm of its length. The anastomosis was made between the loop and the gastric pouch. This was done with a fourth layer taking antimesenteric part of the bowel with posterior wall of stomach pouch [Figure 10]. Gastrostomy was made with a hook to create a defect of size 2.5 cm and an enterotomy of size 2.5 cm [Figure 11]. The third layer was taken to incorporate mucosa of both gastric and enteric wall. The second and a final layer were taken to completely close the gastrostomy enterotomy defect.
A 3.0-barbed suture (Quill, Angiobiotech, USA) for closure of gastrostomy enterotomy defects was used [Figure 12]. After the loop pouch jejunal anastomosis; the loop was divided close to the anastomosis avoiding a candy cane [Figure 13]. An enterotomy was made at the alimentary limb of size 2 cm and also at the biliopancreatic limb. A linear cutter stapler was used for making an anastomosis of size 6 cm and enterotomy defects were closed [Figure 14]. The internal hernia defect was then closed with a non-absorbable silk 2.0 (Ethicon Biosurgery, Jhonson and Jhonson, India) and finally the petersons space was closed with the same suture. Drains were usually not kept in patients [Figure 15]. Perioperative and post-operative antibiotic course for 3 days was given to patients.
|Figure 14: Stapler is used for making an anastomosis and the enterotomy defects were closed|
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Rationale for laparoscopy
The laparoscopy was done in the initial part of the procedure to perform basic steps such as division of omentum, performing a diagnostic laparoscopy, arranging the bowel and marking the bowel. These steps can also be performed using the Robot but to simplify the procedure and to avoid the waste of time, these steps were done laparoscopically.
The amount of blood loss, duration of surgery and other parameters were documented intraoperatively. Patients were followed up and documentation of weight loss, body mass index (BMI) change at 6 months and 12 months postoperatively was done.
Early and late complications were recorded. The early and late complications were defined by standardised classification by Clavien et al. in which the time <3 months after surgery is used to define as early complications and complications later than 3 months are documented as late. Any complication requiring surgical intervention is regarded as major.
| ¤ Results|| |
Out of 140 patients who underwent robotic RYGB using single docking-single quadrant technique, follow-up till 1 year could be made in 120 patients whereas 20 patients were lost to follow-up.
Out of 120 patients, 49.16% (59) of patients were male and 50.83% (61) were females. The mean age of all the patients was 42.7 ± 12.11 years. The mean pre-operative weight of 117.41 ± 27.14 kg and the mean BMI was 43.75 ± 8.01 [Table 1]. The total mean operative time, including the laparoscopic, robotic and console time for the complete procedure, was 97.48 ± 23.79 min. As the complete procedure consists of laparoscopic and robotic part; the mean laparoscopic time was 19.61 ± 5.50 min, docking time of 7.53 ± 5.40 min and mean console time of 70.37 ± 14.76 min.
In our first seven cases, it was documented that the docking time was higher which ranged from 20 to 30 min (mean 24.28 min) of docking but there was gradual decreasing trend in docking time and finally reduced to just 4–7 min [Figure 16]. The average docking time for the all the cases was 7.53 ± 5.40 min. The docking was done with four robotic arms one of which was used for the optical port. The length of stay at the hospital averaged to 2.89 ± 1.06 days. The average blood loss was 55.79 ± 11.91 ml.
It was found that there was only one early minor complication of minor wound infection with no early major complication. One case of mortality was documented 7 days post-surgery with a suspected cause of pulmonary embolism. Two cases of late complication of stoma stenosis at 9 months post-operative in one case and 11 months post-operative in other case were documented on upper GI endoscopy. They were both managed conservatively by two sittings of serial dilatation. There was no case of late mortality [Table 2].
Weight loss patterns of all the patients were observed at 6 months and 1-year post-surgery. The mean weight at 6 months was 87.83 ± 14.32 kg, with a mean BMI of 32.75 ± 3.19 kg/m 2 and at 1 year mean weight was 83.86 ± 143. 40 kg with mean BMI of 31.04 ± 3.91 kg/m 2 [Table 3].
Mean excess body weight loss at 6 and 12 months of follow-up was 58.1 ± 4.5 and 66.8 ± 5.1 kg.
| ¤ Discussion|| |
RYGB is the most effective treatment for morbid obesity. The robotic surgery has evolved as the newer paradigm in minimal access surgery  and it envisages the advantage of having a three-dimensional vision with articulating instruments. The surgeon sits on the console in the most comfortable way without stress on his shoulders and torque on arms even on most super obese patients. Usually, in laparoscopy there is huge torque on hands of surgeon that makes suturing difficult and inaccurate. Robotic surgery has become the gold standard treatment of prostate cancer. The major reason why this has happened is the accuracy with minimal damage to surrounding tissue specifically the prostatic nerve plexus. This helps in avoiding many complications such as erectile dysfunction, incontinence and premature ejaculation.
Robotics in bariatric surgery has still not come into the mainstream, and the major reason for that is the cost of equipment and cumbersome procedure involving multiple dockings and complicated port position. Most of the studies published comparing the cost between a robotic bariatric procedure to a laparoscopic procedure reveal that the cost involved in the robotic bariatric procedure is more although the return to activity is faster. As oppose to this Hagen et al. reported the issue of material cost in robotic gastric bypass. The robotic surgery cost as per them is 5427 USD and that of laparoscopic is 5494 USD. This is possible according to them because of the lesser use of costly staplers while doing a robotic gastric bypass where suturing can abate the use of staplers in anastomoses.
Cirocchi et al. done a meta-analysis and included 22 studies in the quantitative analysis of robotic bariatric surgery. This study includes one randomised control trial, 9 clinical control trial and 12 case series. The leak rates in this analysis were 0.29% gastro jejunostomy and 0.05% of jejunojejunostomy. In the major outcomes, they have reported 4.26% major complications. Pulmonary embolism rates were 0.71% in RYGB series. The 30-day readmission rates were 4.84%. 15 cases out of 1873 RYGB had anastomotic site bleeding. Gastro jejunostomy stricture rate was 1.23%. The post-operative small bowel obstructions were 1.17% in RYGB. The hospital stay was between 2.72 and 7.4 days. The operative time ranged from 95 to 135 min.
Fourman and Saber  have described in their meta-analysis that in a total of 6 studies, 684 patients with a mean pre-operative BMI of 47.8 kg/m 2 underwent Robotic RYGB. The mean operative time was found to be 194.9 min. In this analysis, the studies had both completely robotic and robotic assisted procedures. The mean reported follow-up time in 4 of 6 studies was 10.5 months. The overall reported complication rate in this study was 10.2%. The major complications that they documented were gastrojejunal strictures, marginal ulcers, anatomic leak, bleeding, myocardial infarction, Clostridium difficile ection, bowel perforations and internal hernia. Bindal et al. have performed a review of contemporary role of robotics in bariatric surgery. They have concluded that out of a total of 3337 patients in 9 studies, 1382 were kept in the robotic arm and 1956 in laparoscopic arm. The mean operative time in robotic arm was 211.9 min and in laparoscopic arm was 185.1 min. However, in their analysis, they found out three studies with a significantly lower operating time for robotic gastric bypass. The length of stay was 5 days for robotic surgery and 7.1 days for laparoscopic surgery. The overall complication rate was 12.2% in robotic group and 13.3% in laparoscopic group.
If we compare our results with these previous reports, we have a significantly lower rate of complications with just one early minor wound infection and two gastro jejunostomy stricture which did not require any surgical treatment but were managed by endoscopic dilatation. The mean operative timing in our case was 97.48 ± 23.79 min. Lower mean operative time was achieved in our series of patients as we do not change the position of the patient and ports after docking is done. As compared previous reports , complication rates were very low in present series. The length of stay in their case series ranged from a minimum of 2 days to 4 days that is comparable with our experience.
The present study has focused more on technique and the simplification rather than comparison of robotic gastric bypass with our conventional bypass. Mohr et al. have described the technique of totally robotic gastric bypass. They have essentially used 6 ports and similar port position but the technique required a median operating time of 169 min. They have compared this time with their conventional gastric bypass timing and it has turned out to be significantly lesser in robotic. They have attributed this to effective suturing and anastomosis in robotic surgery.
The standard 5-port technique utilised by us for robotic gastric bypass envisages the benefit of avoiding multiple dockings and complicated port positions. The lesser operative time, and lower complications rate in our series is attributed to our simplified technique.
The average docking time for the all the cases was 7.53 ± 5.40 min. This is comparable with most existing studies. As mentioned in other studies, the average docking time and console time has shown a decreasing trend with passage of time.
The shortcoming of our study is that we did not compare our clinical outcomes of robotic gastric bypass with our laparoscopic gastric bypass performed during the same time.
Robotic RYGB is a safe and feasible technique. With the single quadrant, single docking approach as performed at our centre, we have eliminated wastage of time and decreased over all operative time and time under anaesthesia.
| ¤ Conclusion|| |
RYGB when done with da Vinci Robotic Surgical System has proven to be safe and effective procedure. Most of the studies and analysis have expressed satisfactory results with robotic platform. Single docking-single quadrant technique shows a lesser mean operative time with minimal complication rate. The cost of the equipment and disposable restricts its use in the mainstream. Robotic bariatric surgery is still not for the prime time but with several innovations and rapid developments to follow it might get more popular and cost-effective.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ¤ References|| |
Chin SH, Kahathuduwa CN, Binks M. Physical activity and obesity: What we know and what we need to know. Obes Rev 2016;17:1226-44.
Lee WJ, Yu PJ, Wang W, Chen TC, Wei PL, Huang MT. Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbid obesity: A prospective randomized controlled clinical trial. Ann Surg 2005;242:20-8.
Jung M, Morel P, Buehler L, Buchs NC, Hagen ME. Robotic general surgery: Current practice, evidence, and perspective. Langenbecks Arch Surg 2015;400:283-92.
Lim RB, Blackburn GL, Jones DB. Benchmarking best practices in weight loss surgery. Curr Probl Surg 2010;47:79-174.
Lotia S, Bellamy MC. Anesthesia and morbid obesity. Contin Educ Anaesth Crit Care Pain 2008;8:151-6.
Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al.
The Clavien-Dindo classification of surgical complications: Five-year experience. Ann Surg 2009;250:187-96.
Celio AC, Wu Q, Kasten KR, Manwaring ML, Pories WJ, Spaniolas K. Comparative effectiveness of Roux-en-Y gastric bypass and sleeve gastrectomy in super obese patients. Surg Endosc 2016; [Epub ahead of print].
Szabó FJ, Alexander de LT. Robotic surgery-the modern surgical treatment of prostate cancer. Magy Onkol 2014;58:173-81.
Fourman MM, Saber AA. Robotic bariatric surgery: A systematic review. Surg Obes Relat Dis 2012;8:483-8.
Hagen ME, Pugin F, Chassot G, Huber O, Buchs N, Iranmanesh P, et al.
Reducing cost of surgery by avoiding complications: The model of robotic Roux-en-Y gastric bypass. Obes Surg 2012;22:52-61.
Cirocchi R, Boselli C, Santoro A, Guarino S, Covarelli P, Renzi C, et al.
Current status of robotic bariatric surgery: A systematic review. BMC Surg 2013;13:53.
Bindal V, Bhatia P, Dudeja U, Kalhan S, Khetan M, John S, et al.
Review of contemporary role of robotics in bariatric surgery. J Minim Access Surg 2015;11:16-21.
Mohr CJ, Nadzam GS, Curet MJ. Totally robotic Roux-en-Y gastric bypass. Arch Surg 2005;140:779-86.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]
[Table 1], [Table 2], [Table 3]