Robotic Roux-en-Y Gastric Bypass (RYGB) for Treatment of Morbid Obesity

Abstract

Robotic surgery as an approach for Bariatric surgery has been a subject of debate for at least two decades since the platform passed FDA approval. One could argue that the exponential growth of robotics in surgery could end such a debate. The robotic platform offers several advantages that are always advertised, but in the morbidly obese population it offers an added advantage. It is arguable that with the advanced ergonomics, superior visual tools, and wristed instruments the robotic platform is superior in its offerings to the surgeon and enables a wider variety of surgeons with variable skill set to adopt minimally-invasive surgery (MIS), especially in bariatrics. The gastric bypass is a technically demanding operation with a variety of steps that require superior technical skills and can be challenging for trainees and young surgeons. In our experience, the robotic platform allows easier adoption and teaching of these technically challenging steps.¹

Keywords

Robotic gastric bypass; Roux-en-Y gastric bypass; robotic bariatric surgery.

Case Overview

Background

Minimally-invasive bariatric surgical procedures have been the standard practice for several decades. Laparoscopy is currently considered the standard of care as an approach for different bariatric procedures.²

RYGB was initially thought to result in weight loss both by a restrictive and malabsorptive mechanism. However, the mechanism in which the operation works is quite complex, including an increase in energy expenditure and alteration in the hormonal network, gut microbiota, and metabolic efficiency.³

Focused History of the Patient

The patient is a 33-year-old female with a BMI of 42 Kg/m². Her comorbidities include obstructive sleep apnea and a previous history of provoked deep venous thrombosis. The patient had tried several methods to achieve her desired weight loss and reduce her risk of worsening or developing new comorbidities but was unsuccessful. As such she opted to present to our weight management program for surgical weight loss.

Physical Exam

This was largely unremarkable.

Imaging

Upper GI study performed routinely preoperatively. Did not show any evidence of a hiatal hernia.

Options for Treatment

Different surgical procedures are usually discussed with the patient including pros and cons of each, specifically for the gastric bypass, long-term complications are discussed including nutritional deficiencies, marginal ulcer, as well as internal hernia risk. In this case, the patient chose to pursue a gastric bypass versus a sleeve gastrectomy. Unless the patient has a certain preference for a procedure, usually, we recommend the gastric bypass mainly for patients who suffer from diabetes mellitus (DM) and or gastroesophageal reflux disease due to the marked improvement of these comorbidities after the gastric bypass.

Rationale for Treatment

The goal is to achieve meaningful weight loss of at least 60–70% excess weight loss and to help resolve the current medical comorbidities and furthermore prevent development of future comorbidities should the patient maintain her current weight.

Special Considerations

As mentioned above for the group of patients who suffer from DM and or reflux disease, the gastric bypass procedure offers a superior benefit over other procedures based on several studies. Some of the relative contraindications for Roux-en-Y gastric bypass (RYGB) is Crohn’s disease and multiple abdominal surgeries that prevent safe dissection of the small bowel. We carefully consider patients on immunosuppression for this procedure, especially if on steroids as it increases the risk of marginal ulcer significantly.

Discussion

We present a relatively straightforward case of robotic RYGB in a young patient with a reasonable BMI. The goal was to show the main steps, tips, and tricks for surgeons adopting robotic techniques to perform this procedure. We also showed in this case the advantages of using the robotic platform including but not limited to the wristed instruments, superior vision, as well as sensitivity of the leak test using ICG.

RYGB has been standard in metabolic and bariatric surgery for several decades, and the outcomes and safety profile are well known and are beyond the context of this article.

• Patients who undergo RYGB are typically reported to experience approximately 60–70% excess body weight loss, with over 75% control of comorbidities. In a study published in NEJM looking at 12-year weight and metabolic outcomes after gastric bypass, the adjusted mean change from baseline body weight in surgical group was -45.0 kg, -36.3 kg, and -35.0 kg at 2, 6, and 12 years, while that in the two nonsurgical groups (1: no surgery due to insurance reasons; 2: did not seek surgery) at 12 years was -2.9 kg and 0.0 kg, respectively. Similarly, higher rates of remission in the surgical group when evaluating preoperative comorbidities: type 2 diabetes (51% at 12 years), hypertension, and hyperlipidemia.⁴
• It is, however, important to mention and explore if the shift in paradigm towards robotic bariatric surgery has contributed to improved outcomes for these procedures.
• There are several studies as mentioned in the introduction that looked at this, and so far it has been demonstrated that the outcomes are comparable to the laparoscopic approach, especially after the surgeon moves past their learning curve.
• It is arguable that with the advanced ergonomics, superior visual tools, and wristed instruments the robotic platform is superior in its offerings to the surgeon and enables a wider variety of surgeons with variable skill set to adopt minimally-invasive surgery (MIS), especially in bariatrics.
• The gastric bypass is a technically demanding operation with a variety of steps that require superior technical skills and can be challenging for trainees and young surgeons. In our experience the robotic platform allows easier adoption and teaching of these technically challenging steps.
• In addition, the marked increase in market share for robotic bariatric surgery is a sign that the technology is here to stay and is well sought by surgeons as well as patients.

Total operative time was 90 minutes, and the patient was discharged home on postoperative day 1. No complications noted on follow up.

Equipment

Nothing special apart from the robotic instruments and sutures used and mentioned in the video.

Disclosures

1. Proctor and consultant for Intuitive Surgical Inc.
2. Shareholder at IHC Inc.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Acknowledgments

I would like to acknowledge Dr. Karan Chabra and Kendal Towle, ARNP for assisting and participating in this procedure, as well as the OR staff at Wentworth-Douglass Hospital.