December 1, 2015

Can Robotics Transform Bariatric Surgery

Author: Paul E. Enochs, MD, FACS, FASMBS

When many of us think about robotics, our minds may very well drift toward thoughts of automobiles and airplanes transforming into fighting defenders to save our world from attacking invaders. Perhaps instead we think about the futuristic world of the Jetsons where our mechanized friends help us get ready in the morning, clean our house, and aid us throughout the day. Yet despite these images, the reality is robotics exist in the present day world and have already started to enter every part of our daily lives. The surgical fields are no exception.

Techniques for bariatric surgery – past

Fifty years ago surgery was done primarily through a large open incision where a surgeon could directly visualize a patient’s internal anatomy, and their hands could directly touch the organs. Three decades ago, a laparoscopic, endoscopic, and videoscopic revolution took place, beginning with gynecology, incorporating general surgery, and eventually spreading to every specialty.

With these new minimally invasive techniques, surgeons were able to utilize small incisions to place a scope through which the patient’s internal anatomy could be viewed on a video monitor, while their hands could control instruments that went through the small incisions to work on the organs. This novel technique rapidly changed the surgical fields due to the decreased morbidity to the patient by allowing for less pain, more rapid recovery, decreased infection risk, shortened hospital stay, and quicker return to normal activity.

In adopting this new procedural approach, surgeons had to develop a new skill set to overcome some of the shortcomings of this new field. Field of view was limited while surgeons had to learn a new method of depth perception and hand-eye coordination to overcome the two dimensional visualization. In addition, new techniques had to be developed to overcome the changes in proprioception, dexterity, and range of motion.

As the years passed and technology developed with better scopes and instruments, these limitations did not go away but were overcome as surgeons developed and grew this new set of skills. Eventually the majority of procedures done in the thoracoabdominal cavity had been attempted, and were being performed primarily through a minimally invasive technique.

Techniques for bariatric surgery – current

In 2000, the FDA approved the da Vinci robotic surgical system for widespread use in general laparoscopic surgery. Prior to this time, robotics had been evaluated for use in the military and cardiac surgery. This new technology allowed surgeons to have three dimensional magnified visualization, as well as increased range of motion due to the ability to have wristed instrumentation.

The surgeon’s hands now controlled robotic arms which, in turn, moved the instruments that went through the small incisions that touched the organs. For the first time in the history of surgery, the need for a surgeon’s hands to be in direct contact with the patient’s organs wasn’t a requirement, but instead separated by an electro-mechanical interface. The result of this advancement in technology has been to allow for more refined and precise movements thereby creating less trauma to the abdominal wall, target organs, and tissues. In addition, single incision technology and remote surgery now became more of a real possibility.

The process of robotics in the surgical fields

All surgical fields did not immediately adopt this new surgical approach. Urology became the first specialty to readily adopt the new robotic technology. By 2009, nearly 80% of all radical prostatectomies were being done through the robotic approach. Gynecology became the next specialty to adopt the robot for use in hysterectomies and other pelvic procedures. Despite the acceptance of this robotic technology by other specialties, the field of general surgery and, by extension, bariatric surgery has been slower to readily accept this new technology and to see its usefulness. The reason for this is varied.

One reason involves the fact that greater than 90% of all bariatric procedures performed today are done through the minimally invasive approach, and as such the majority of bariatric surgeons are quite skilled laparoscopically, and have already mastered advanced laparoscopic maneuvers and techniques. In contrast, when robotic surgery was applied to prostatectomies and hysterectomies over a decade ago, the majority of these procedures at the time were done through an open approach, and as such, a greater benefit could be perceived. In addition, it has not been until recently that much of the vessel sealing and stapling technology integral to most bariatric procedures has become available on the robotic platform. Finally, critics of robotics in the bariatric field point to a myriad of topics from having a new learning curve with longer surgical times to a perceived increase in costs as reasons to avoid change.

Benefit of robotics to bariatric surgery

Understanding the above critiques and perceptions, the question arises as to what the true benefit that robotics provides to bariatric surgery. There are several. It is important to realize that the robotic platform is not a new surgical procedure, but a technology that has the potential to increase feedback and information to the operator, and as a result make a skilled surgeon better. All of the bariatric procedures from gastric banding, vertical sleeve gastrectomy, gastric bypass to duodenal switch have been performed robotically.

A review of the published literature has shown that the use of robotics in these procedures are a safe and reasonable option. In fact, several studies have shown a lower complication rate with the robotic platform including leaks, bleeding, and stricture. Although operator dependent, as with all surgery, this can be attributed to the better three dimensional magnified visualization and increased dexterity associated with the robotic platform.

Another benefit of robotics is better ergonomics and decreased operator fatigue. This can be very beneficial in the higher BMI patients with thicker abdominal walls where the ergonomics of traditional laparoscopy can be physically demanding and lead to surgeon fatigue. In addition, the increased range of motion and improved optics allows for more meticulous, precise dissection and suturing, which can be integral to revisional bariatric cases with their extensive adhesionolysis, and need for difficult intracorporeal sutured anastomoses. In these difficult bariatric procedures, the robotic technology also provides the ability to provide real time assessment of tissue perfusion through the use of fluorescence imaging. Knowledge of the blood supply to a revised anastomosis or gastric pouch can be integral in the prevention of staple line breakdown and leak.

Finally, when evaluating the abilities of the robotic platform in bariatrics, it is imperative to remember that this is an evolving technology. Advancements in laparoscopy over the last couple decades were made possible through improvements in many of the instruments we use today, and robotics is no different. Whether it is single site platforms, natural orifice surgery, telesurgery, real time assessment of tissue thickness and perfusion by the staplers, radiographic image integration into the surgical field, or increased haptic feedback.  Once the fundamental techniques of the robotic platform are learned, it can serve as a foundation upon which these new technologies are built. New technologies over time could provide the exciting vehicle to transform the way we care for our patients in bariatric surgery.

2016, Bariatric Specialists of North Carolina, a part of the EmergeOrtho network
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