Robotic Bariatric Surgery
Robotic Surgery was first introduced in 1985 when a robotic surgical arm was used in a neurosurgical biopsy. Shortly thereafter, in 1987, the first robotic gallbladder surgery was performed. Over the next three years, the robot’s umbrella expanded to include other operations and with different competing robotic systems.
In 1990 the FDA approved the first robotic endoscopic procedure, and in 2000 the first robot was FDA approved for laparoscopic surgery. Since its expansion, the robot has changed with regard to the number of arms, precisions of arm movements, docking ability, and picture quality including three dimensional screens.
In terms of bariatric surgery, the robot was first used in 1998 to place a gastric band. Since the advent, its use has expanded to all forms of bariatric surgery including sleeve gastrectomy, gastric bypass, and duodenal switches. Studies have even demonstrated efficacy of robotic revisions bariatric surgery. Robotic assisted bariatric surgery is performed under general anesthesia and usually requires overnight observation in the hospital with discharge the follow day.
Bariatric surgery is the result of approximately 50 years of improvement in surgical practice. The first bariatric operation was a jejunoileal bypass performed in 1956, but due to severe comorbidities such as dehydration and malabsorption, this practice was abandoned for the gastric bypass (gastroplasty w/ loop gastro-jejunostomy) procedure in 1960’s by Edward Mason.
The exact mechanism of bypassing the stomach was changed multiple times over the course of the late 20th century, but the concept of bypassing the stomach has held true and is one of the accepted standards today for bypass surgery.
Most surgeons today perform a variation of a Roux-En-Y bypass which consist of a gastoplasty (reduction of stomach size) and a gastrojejunostomy (connection of the newer smaller stomach to small intestine further down the digestive tract). Other procedures commonly performed include gastric sleeve, gastric band (both reduce the overall active stomach size), and gastric stimulators.
Obesity is characterized by excess adipose tissue and defined by using the body mass index (BMI) based on world heath organization definitions (BMI > 30). Obesity is classified into mild (30-34.9), moderate (35-39.9), and severe (40 or greater). While we have documentation of obesity prior to the current millennium, obesity has become increasingly prevalent. During the last census in 2010, the CDC reported that 36% of American adults and 17% of American children were obese.
While we know that metabolic disease arises in adipose tissue, the link between obesity and metabolic disease is still not well understood, being complex and multifactorial. Obesity is associated with multiple medical comorbidities including metabolic disorder, hypertension, hyperlipidemia, atherosclerosis, hepatic steatosis, sleep apnea, and depression. While the first line of treatment for obesity is lifestyle modifications—such as dieting and exercise—by far the most efficacious is bariatric surgery.
The Da Vinci by Intuitive has shown to be a reliable tool in minimally invasive bariatric surgery. It allows the surgeon to operate in patients with large body habitus that can be difficult to perform surgery on using standard laparoscopic surgery. It has been shown to offer more precision and better ergonomics, reducing surgeon fatigue and allowing for delicate maneuvers.
The Da Vince robot consists of a surgeon cart, patient cart, and vision cart (which communicates between the former two carts). Currently there are two models in use for bariatric surgery X and XI. The other two Da Vinci models include the S which is being phased out and the SP which is only FDA approved for single port site surgery. The use of the Da Vinci robot in robot assisted bariatric surgery has decreased overall operative time, hospital stay, and overall post operative complications.
When using the Da Vinci Robot, the initial entry into the abdomen is performed by the surgeon who then docks the patient cart at the bedside, the surgeon then leaves the bedside and performs the surgery at the surgeon cart, while an assistant is at the bedside with the patient cart.