Introduction
Bariatric surgery represents a field in which one operation can “cure” a patient of numerous medical comorbidities and is the only proven method that results in long-term weight loss for patients. Since its inception, the field has undergone continuous improvements in operative technique, with the most recent advancement being the adaptation of the procedures to facilitate robotic-assisted surgeries. It is estimated that there were approximately 25,000 robotic bariatric surgeries performed in the United States in 2017.
The concept of surgical weight loss procedures came about in the 1950s at the University of Minnesota. Bariatric surgery has undergone multiple iterations, leading to improved patient outcomes. In 1954, the first jejunoileal bypass surgery was performed in which the proximal jejunum was anastomosed to the distal ileum. , Although this procedure was associated with weight loss and decreased lipid levels for patients, it was rife with complications, including diarrhea, dehydration, vitamin deficiencies leading to night blindness and osteoporosis, protein-calorie malnutrition, kidney stones, and toxic overgrowth of bacteria in the bypassed intestine. , Throughout the 1960s and 1970s, several modifications to the technique were attempted but ultimately were unsuccessful.
Many bariatric procedures, namely the mason bypass, vertical banded gastroplasty, Roux-en-Y gastric bypass, laparoscopic gastric band, sleeve gastrectomy, biliopancreatic diversion with and without duodenal switch, and single anastomosis duodenal switch were developed and implemented with success. Starting in the 1990s, these procedures were able to be accomplished laparoscopically. The world’s first robotic obesity surgery, a gastric band placement, was successfully performed in 1999. Once laparoscopic-assisted surgery was introduced, bariatric surgery procedures were quickly adapted and resulted in lower morbidity than open procedures. Some of the benefits of robotic-assisted bariatric surgery include articulating instruments with reduced torque on the operator’s wrists and fingers, improved visualization, and increased precision in suture placement. For the purpose of this chapter, we shall limit our discussion to the mainstream bariatric surgeries currently performed. This chapter discusses the basic principles and robotic operative techniques for sleeve gastrectomy, Roux-en-Y gastric bypass, and duodenal switch procedures using the Intuitive surgical Xi Platform. It covers all technical aspects in detail, including supplemental videos. Specialty equipment required for these procedures is listed in the box that follows.
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Two Cardiere graspers
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One scissors
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One vessel sealer
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± Suture cutting needle drive
Patient selection and preparation
The American Society for Metabolic and Bariatric Surgery (ASMBS) published guidelines detailing qualifications for patients desiring bariatric surgery. The qualifications include: BMI ≥ 40 and BMI ≥35 with at least two obesity related comorbidities, such as: type 2 diabetes, hypertension, sleep apnea and other respiratory disorders, nonalcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, heart disease, and an inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts. These guidelines are echoed by the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), with their guidelines adding in recommendations: age 18 to 65; no drug dependency; a capacity to understand the risks and commitment associated with the surgery; and pregnancy not anticipated within the first year following surgery. The National Institute of Health, American College of Surgeons, and ASMBS also recommend that patients desiring these types of surgery undergo their procedure with a board-certified surgeon specializing in bariatric and metabolic surgery at a center with a multidisciplinary team of experts for follow-up care.
Robot-assisted sleeve gastrectomy
The sleeve gastrectomy was first described in 1993 by Picard Marceau as part of the biliopancreatic diversion with duodenal switch operations. A sleeve gastrectomy is effective for two primary reasons. First, it is restrictive and removes the gastric fundus. In a sleeve gastrectomy, the pylorus is left intact, which creates a narrow lumen that causes early satiety while restricting the maximum quantity of gastric contents. Additionally, by removing the ghrelin producing portion of the stomach, there is a long-term reduction in the hunger feeling, further reducing patient food intake. Sleeve gastrectomy has been demonstrated to be an effective weight loss operation, leading to improvements in obesity-related comorbidities, such as noninsulin dependent diabetes, arterial hypertension, and dyslipidemia, and is capable of inducing desirable changes in inflammatory, kidney, and liver-related biomarkers such as creatinine, C-reactive protein, and uric acid levels. The sleeve gastrectomy procedure is considered by most bariatric surgeons as technically a relatively easier operation compared to other bariatric procedures; however, it is the authors’ opinion that this is an excellent index procedure for bariatric surgeons who wish to incorporate robotic surgery into their practice. In higher BMI patients, robotic assistance is invaluable in getting exposure to the short gastric vessels and accessing the relatively tight space for dissection near the angle of His.
Positioning, trocar placement, and operative steps
Patient should be positioned supine on the operating room (OR) table and prepped and draped in the normal sterile fashion. All pressure points should be padded with gel and foam pads. Patient arms should be extended out just shy of 90 degrees. Ensure that the patient is secured to the OR table with a belt and a footboard in place. The box that follows outlines the key steps of this operation.
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Induce pneumoperitoneum and place trocars as indicated in Fig. 55.1 .
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Dock the robot and complete targeting.
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Visually inspect the hiatus.
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Begin sealing and dividing the gastrocolic and gastrosplenic ligaments.
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Anesthesia places 40 French bougie.
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Begin stapling along the bougie, starting 6 cm proximal to the pylorus.
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Remove remnant stomach.
Pneumoperitoneum can be established using the Veress needle technique. Trocars are then placed under direct visualization. Placement is as outlined in Fig. 55.1 . An 8.5 mm port should be placed 15 cm inferior to the xiphoid and 5 cm left of midline and will be used as the camera port. From there, two additional 8.5 mm ports are placed approximately a hands-width lateral from the camera port. A 12 mm port should then be placed hands width to the right of the camera port, this should be placed to facilitate sleeve creation using the robotic stapler. A 5 mm trocar is placed in the right side, which will be used for liver retraction, facilitating enhanced visualization of the stomach. Alternatively, a port can be placed in the subxiphoid region for liver retraction. The patient should then be placed in 30-degree reverse Trendelenburg position for the procedure.
At this point, docking of the robot can begin. The camera is advanced through the supraumbilical 8.5 mm port and used to finalize placement of the robot arms by completing targeting, using the mid stomach as the target point. The remaining arms are then docked to their respective ports. The liver is retracted to ensure adequate visualization of the stomach. Once this is complete, the console surgeon can step away from the patient and go to the console, leaving the assistant at the bedside.
The first step is a visual inspection of the hiatus to ensure that a hiatal hernia is not present; if one is, it should be dissected free, and a posterior hiatal hernia repair performed. Using two Cardiere graspers and the vessel sealer, the lesser sac is entered at the level of the mid-point of the greater curvature of the stomach. The gastrocolic and gastrosplenic ligaments are taken from approximately 6 cm proximal to the pylorus up to the level of the gastroesophageal junction (GEJ), being aware of the position of the spleen in relation to the dissection. One of the benefits of the robot in this area is the precision it affords the surgeon, helping to avoid injury to the spleen while allowing for adequate visualization and ligation of the short gastric arteries. Once the greater curvature has been appropriately mobilized, the anesthesiologist can advance a bougie to add in the calibration of the sleeve. We recommend use of a 40 French bougie. Using the robotic stapler and starting at the antrum approximately 6 cm proximal to the pylorus, the stapling of the stomach begins. The bougie remains in place and the stapler is fired lateral to the bougie. This is continued to the level of the GEJ, thus freeing the remnant stomach from the remaining gastric sleeve. Care must be taken not to narrow the incisura angularis, and dissection must be adequate to ensure removal of the entire fundus. The remnant stomach can be removed through the right sided 12 mm stapler port after enlarging the port. Hemostasis along the staple line is ensured. For most patients, a blue load stapler is adequate in performing the sleeve gastrectomy; however, occasionally in large male patients with a thick antrum, one may have to upsize to a green load for the stapler if the message that the tissue is too thick to staple is relayed by the robot and repositioning the stapler with the blue load does not work.
A leak test may be performed, as is the practice by individual surgeons, with methylene blue or ICG with Firefly mode on the robot. Our practice has been to perform an upper endoscopy to examine the sleeve creation; we do not perform a leak test. After hemostasis is obtained, the extraction site for the sleeve specimen is then closed with a port closure assist device using permanent sutures.
Roux-en-Y gastric bypass
The Roux-en-Y gastric bypass is a moderately complex, yet technically demanding, operation, making it an excellent procedure to be accomplished robotically. The efficacy of this procedure is due to two primary reasons: (1) the small gastric pouch created allows for increased satiety, thereby reducing the portion size, and (2) by bypassing of the first portion of the small bowel, it initiates a cascade of hormones which facilitate weight loss and improve insulin sensitivity. While there have been multiple adaptations to how the procedure is performed, the traditional and most well described technique involves the creation of a small gastric pouch, a biliary limb of approximately 50 cm and a Roux limb of approximately 75 cm. Multiple studies have demonstrated that performing a Roux-en-Y gastric bypass with robotic assistance has multiple advantages as compared to laparoscopically performing the procedure. The robotic approach is associated with decreased rates of hemorrhage, anastomotic fistulas, and gastrojejunal anastomotic strictures, as well as shorter duration of surgery, shorter hospital stays, and a lower readmission rate. After undergoing a Roux-en-Y gastric bypass, patients will typically lose between 60% and 75% of their excess body weight and are able to maintain greater than 50% excess body weight loss for greater than 15 years. ,
Positioning, trocar placement, and operative steps
The patient should be positioned supine on the operating table and prepped and draped in the normal sterile fashion. All pressure points should be padded with gel and foam pads. Patient arms should be extended out just shy of 90 degrees. Ensure that the patient is secured to the OR table with a belt and a footboard in place. The box that follows highlights the key steps of this operation.
- 1.
Induce pneumoperitoneum and place trocars as indicated in Fig. 55.1 .
- 2.
Dock the robot and complete targeting.
- 3.
Visually inspect the hiatus.
- 4.
Create the gastric pouch.
- 5.
Create gastrojejunal anastomosis with division of the loop on the left side.
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Create jejunojejunal anastomosis with 75 cm Roux limb.
Pneumoperitoneum can be established using the Veress needle technique inserted at the camera port. Trocars are then placed under direct visualization. To ensure adequate working room for the robotic arms, trocars should be placed in a manner that maximizes the horizontal separation of the trocars ( Fig. 55.2 ). An 8.5 mm port should be placed 15 cm inferior to the xiphoid and 5 cm left of midline and will be used as the camera port. From there, two additional 8.5 mm ports are placed approximately a hands-width lateral from the camera port. The left-sided middle trocar can be upsized to a 12 mm trocar if the surgeon feels the need for an additional stapler trocar from the left side for performing the vertical fire of the stapler in creation of the gastric pouch. A 12 mm port should then be placed hands width to the right of the camera port. A 5 mm trocar is placed in the right side; this will be used for liver retraction that facilitates enhanced visualization of the stomach. Alternatively, a port can be placed in the subxiphoid region for liver retraction. The patient should then be placed in 30-degree reverse Trendelenburg position for the procedure ( Figs. 55.3 and 55.4 ).
The procedure can be performed by placing the sutures in the abdomen, before docking the robot, to reduce arm exchanges. Typically, we place a 6-inch Vicryl suture, a 12-inch VLOC absorbable suture, and two 2-0 Ethibond sutures cut to 9 inches. The docking of the robot can then begin. The camera is advanced through the supraumbilical 12 mm port and used to finalize placement of the robot arms by completing targeting, using the midpoint of the greater curvature as the target point. The remaining arms are then docked to their respective ports. The liver is retracted to ensure adequate visualization of the stomach. For this procedure we use two Cardieres, a robotic suture cut needle driver, a robotic scissor, and a vessel sealer. Once this is complete, the console surgeon can step away from the patient and go to the console, leaving the assistant at the bedside.
The first step is a visual inspection of the hiatus to ensure that a hiatal hernia is not present; if one is, it should be dissected free, and a posterior hiatal hernia repair performed. The angle of His is dissected; we then perform a careful perigastric dissection at the level of the second gastric vessel about 5 cm form the GE junction. Once the retrogastric plane is entered and cleared, we perform a horizontal fire to aid creation of the gastric pouch; this is done with a blue load using about 35 mm of the robotic stapler. We then perform two fires of the robotic stapler in the vertical plane using blue load staplers to complete formation of a narrow tubular lesser curve-based pouch. Care is taken to ensure that the fundus is excluded in creating this pouch. A 34 French Ewald tube is placed before performing the last vertical fire to ensure that the GE junction is not compromised. The patient is then placed in a supine position, and this can be accomplished using the table motion function if available; however, the procedure can be done without table motion with the patient being placed in moderate reverse Trendelenburg. We then divide the greater omentum using the vessel sealer if the greater omentum is bulky. This step is strictly done as needed, based on perceived tension after gastrojejunostomy. We then identify the ligament of Treitz, and in proper orientation bring up a loop of bowel that is 50 cm from the ligament of Treitz. A gastrotomy is created with the robotic scissors on the gastric pouch with the Ewald tube in place to provide tension on the pouch. The jejunotomy is created using the robotic scissors. Once this is completed, the gastrojejunal anastomosis is created using a single fire of the robotic stapler with a blue load. The common enterotomy is closed in two layers using the 2-0 V-Loc absorbable suture. A mesenteric window is created on the biliary side of the loop gastrojejunostomy. Then, to create a biliary limb and a Roux limb, the gastrojejunostomy loop is divided on the left side of the anastomosis using a white load of the robotic stapler. An area that is 75 cm on the Roux limb is identified with proper orientation to create jejunotomies on the Roux limb and the biliary limb. This setup is crucial to create a jejunojejunal anastomosis, which is done by using a fire of the robotic stapler with a white load. The common enterotomy can then be closed using a 2-0 Vicryl suture; however, the authors’ preference is to create a bidirectional firing for the jejunojejunostomy, using another white load in the opposite direction, and the common enterotomy is closed transversely to create a wide H-shaped anastomosis. The jejunojejunal mesenteric defect is then closed using a 2-0 Ethibond suture. Petersen’s space is closed using a 2-0 Ethibond suture. An upper endoscopy is performed to ensure hemostasis and that no leak is present; alternatively, a methylene blue or ICG test with Firefly can be done using the indocyanine green (ICG) instilled in the Ewald tube to look for leaks. The 12 mm trocar sites are then closed using a port closure system using permanent suture ( Fig. 55.5 and 55.6 ).
