Robotic Bariatric Surgery?

From Healthwellnesscolorado.com

Robotic bariatric surgery?

Technically "Robot-Assisted Laparoscopic Bariatric Surgery".

Is it just a trend?  Is there any benefit to this method vs. traditional laparoscopic bariatric surgeries?  Is it available in my area?

I looked into those very questions, as we provide access to Robotic surgery for Bypasses and Sleeves. We don't now perform our surgeries exclusively with the Robot, but patients can generally have their surgery performed that way if they want to.  Our experience is overall quite favorable, in terms of post op pain, length of stay, complications, etc.

We are closing in on our 100th case done this way, but I found an article that was helpful to compare the experiences of another established practice that reviewed the results of their first 100 Robotic-Assisted Gastric Bypass cases, contrasting them with a similar group of 100 patients from their practice done through the traditional laparoscopic approach.

History

Traditionally an open procedure started by Dr. Mason, Gastric Bypass operations started to go to the laparoscopic approach in 1994 as performed by  Dr. Wittgrove and his associates.  Within a relatively short amount of time, the experience proved both beneficial to patients, and morbidity and mortality of this operation have decreased substantially to the current very low levels.

The Da Vinci surgical robotic system has been on the surgical scene for the past 5-10 years, and has  beneficial applications to urologic, gynecological, general, and cardiovascular surgeries to name a few.  DaVinci robotic surgery has the benefits of an enhanced 3-D HD surgeon viewer,  improved wrist articulation (extra-anatomical) interaction with the surgical instruments, as well as a remote-centering of the trocars that enhances the surgery as done laparoscopically,  which can result in less post op pain for most patients.

To be honest, robotic application to some surgical procedures makes a huge difference (such as open vs. staying laparoscopic- ex. uterine myomectomy, radical prostatectomy), and/or enables patients to have less pain (and discharge them sooner), and/or reduce the risk of complications (possibly with the prostatectomy) due to the technology used to do these operations.

However, some procedures are aided by the robotic approach, and are able to be done that way, yet don't offer such an overwhelming advantage that comfortably usurps the tried and true approach of the existing standard of a laparoscopic approach.  Bariatrics, specifically Gastric Bypass, likely falls in to this category.

The Study

The group in the study looked at the first 100 Gastric Bypass Robotic cases, and contrasted them with 100 traditional cases done in the same group, of similar demographic and medical makeup.  They looked at both the progression of their robotic cases in terms of complications and duration of the surgery, and how the overall results of the first 100 cases compared with the latter group of 100 standard laparoscopic cases.

What they found was interesting and mimicked our experiences quite closely.

OR case time decreased over the"learning curve" of the robotic timeline, and approached the time of laparoscopic cases.  Stricture rates were a little higher early in the robotic group, but decreased to below their laparoscopic levels by the second 50 cases.  Mortality was at 0% for both groups.  Two patients returned to the OR within 90 days in the robotic group, and only 1 patient required a transfusion for post op bleeding in the robotic group vs. the lapsaroscopic group (5 pts.).

The biggest difference favoring the robotic group was the length of stay, which showed a significant decrease  vs. the laparoscopic group.  Sixty percent of the robotic patients left the hospital after only a 1 night stay, as compared to 4% o patients in the laparoscopic group.

I have to  imagine this was due to less pain (due to no need for fascial closure, and/or the remote centering trocar movement of the robot that can put less torque on the abdominal wall), and perhaps a more rapid transition to PO diet, and a willingness to send them home earlier than the standard 2 days, as we do in our practice fairly routinely.

The "willingness"  I refer to is the comfort level of sending a patient home that meets a general criteria (PO analgesic pain control, ambulation, urination ability, stable VS, tolerating PO satisfactorily, and absence / or control of significant additional comorbidities) as being able to do so.  Perhaps this was skewed to look more closely at the likelihood to DC a patient POD 1 than their contrasted laparoscopic group, but in any event the readmission rate,  or complication rate did not seem to reveal this as an issue.

The paper does note that the two groups were not equivalent, and that is true.  The traditional laparoscopic group represented 7 years of prior experience, and nearly 800 cases performed.  In the robotic series, it was a fresh 100 cases that implied a learning curve during that time.

However,  in a way, with such similar results among the 2 groups, this may be of even more significance in terms of safety and efficacy vs. the laparoscopic standard.  This also speaks to the Robotic approach as not an entirely new entity, but an "add-on" platform to existing technology that can enhance the already excellent standard of surgical approach to Gastric Bypass in this case.

In a practical sense, that is how we approach it in our practice.  The surgeon is able to offer that technique for a patient's choice of surgery, and it has its benefits as well as its logistic issues (namely access to the robot when needed), but it is a more similar than different surgical approach to a Gastric Bypass than the traditional approach.

Moreover, as with technology in all fields, once further advances are made to the the robotic platform, we are ready to keep pace, especially if there is a marked benefit to our patients and to us in performing the surgery.