Introduction

Surgeons dealing with obese patients face certain challenges. In particular, these are manipulations with extensive subcutaneous fatty tissue of anterior abdominal wall and narrow surgical space for instruments due to enlarged left liver lobe and extensive intra-abdominal fat. Apparently, da Vinci robotic system (Intuitive Surgical, USA) as additional tool for minimally invasive surgeons is ideal for working with such patients [1]. Complex long-term surgeries involving anastomosis, such as Roux-en-Y gastric bypass, are likely to be a more obvious advantage of robotic system over standard laparoscopy [2]. Robotic surgery differs from laparoscopic surgery in distant control of camera and instruments. Ergonomics of robotic platform leads to less fatigue for surgeons compared to laparoscopic techniques [3]. 3D imaging and instruments under the wrist increase freedom of movements and manual dexterity for surgical objectives such as intracorporeal sutures [4, 5]. Lost haptic feedback is partially compensated by visual image [6]. Another disadvantage of robotic surgery is higher duration of intervention due to necessary docking of robotic system. Da Vinci robotic surgical systems require greater costs for complex maintenance and consumables. Cost-effectiveness of robotic system for bariatric procedures is still unclear [7].

“Sleeve gastrectomy” may be ideal for introduction of robotic system into bariatric surgery. Indeed, this standardized procedure is recognized by experts as a teaching procedure for robotic surgery [8-10]. Sleeve gastrectomy as a single-quadrant surgery allows the surgeon to become accustomed to robotic platform and tissue processing by various robotic instruments without haptic feedback. Operating theatre and patient layout for robotic sleeve gastrectomy may also be applicable to other upper gastrointestinal surgeries such as gastric bypass, hiatal hernia repair (fundoplication) and interventions for achalasia cardia. Additional procedures such as adhesiolysis and cholecystectomy can further enhance surgical experience in case of robotic sleeve gastrectomy.

There are various national studies devoted to robotic technologies in abdominal surgery, in particular, pancreatic surgery [11, 12], rectal surgery [13] and surgical oncogynecology [14]. However, bariatric robotic surgery is still less studied direction.

Therefore, the purpose of this study was to demonstrate safe introduction of a new technology (Da Vinci robotic system) into laparoscopic bariatric practice.

Material and methods

We retrospectively analyzed a prospectively maintained database. The first 15 robotic sleeve gastrectomies were performed between March 2020 and February 2023 by the same surgical team (console operator and assistant surgeon). All patients were assessed preoperatively by a multidisciplinary team (surgeon, gastroenterologist-nutritionist, endocrinologist, sleep specialist and psychologist). Body mass index (BMI) was >40 kg/m² or >35 kg/m² with obesity-related comorbidities. These patients underlie the present analysis.

Preparing for surgery

Operating theatre is presented in Fig. 1. The patient is placed in reverse Trendelenburg position (beach chair position). The left arm is extended to the side, and the right arm is fixed in the armrest.

Fig. 1. Patient position on the operating table relative to robotic console.

Docking

Baseline abdominal access was made 16 cm below the xiphoid process in the midline using an extended Veress needle. The first 12-mm trocar with da Vinci camera 30° was installed. CO2 insufflation was carried out to achieve intra-abdominal pressure about 12–14 mm Hg. Ports and Strong Arm Nathanson Hook hepatic retractor (Mediflex Surgical Products, USA) were installed as shown in Fig. 2. After that, we brought the console towards the patient's left shoulder (Fig. 1) and performed docking.

Fig. 2. Trocar arrangement on anterior abdominal wall.

Surgical technique

The first surgical stage was mobilization of the greater curvature of the stomach by a Harmonic ultrasonic robotic scalpel. We initiated dissection 2-3 cm proximal to the pylorus (Fig. 3) until the left crus of the diaphragm (Fig. 4). Hiatal hernia in some cases required crurorrhaphy.

Fig. 3. Mobilization of pyloric segment.

A — pylorus; B — area of mobilization (3 cm from the pylorus).

Fig. 4. Mobilization of esophageal-gastric junction.

A — left crus of the diaphragm; B — esophageal-gastric junction.

After that, the anesthesiologist passed a gastric tube 36 Fr towards the pylorus under visual and objective control. Stomach suturing and transection was performed through the assistant's port using Echelon Flex 60-mm electric reticular linear stapler with open staple height of 4.1 mm (green cassette) for all sutures (Fig. 5). Each suturing required preliminary 60-sec compression. Stapler position was “loose” on the probe, and the last suturing was directed towards the left crus of the diaphragm. It was necessary for capture of the entire fundus of the stomach 1 cm away from gastroesophageal junction.

Fig. 5. Stomach cutting by a linear stapler.

Stapler suture line was closed by absorbable sutures in all cases (V-lock 180 3.0, 30 cm) (Fig. 6).

Fig. 6. Suturing the stapler suture of the stomach.

Surgeon extracted the resected stomach through the assistant's port, and drainage tube was installed into postoperative area. Aponeurosis within the sites of assistant and optical trocar access was sutured using a Berci needle.

Postoperative period

On the first day after surgery, patients underwent contrast-enhanced X-ray examination of gastrointestinal tract (Fig. 7) and started oral nutrition (liquid food). Drainage tube was removed. All patients were discharged after 3 postoperative days.

Fig. 7. Postoperative contrast-enhanced X-ray examination of the stomach.

Before discharge, patients received infusion therapy (15–20 ml/kg), fraxiparine 0.6 ml subcutaneously in the evening and rabeprazole 40 mg daily (intravenous injections followed by oral intake). Rabeprazole therapy was continued for at least 1 month after surgery. Liquid diet was recommended throughout the first postoperative month, blended food — throughout the second month, pureed food diet — throughout additional 2 weeks. Usual diet with normal consistency was allowed in 3 months after surgery.

Baseline data

Preoperative variables included demographic characteristics (age, sex, height, weight and BMI).

Intraoperative data included surgery time (between surgical incision and successful docking, overall time of surgery between incision and skin closure), blood loss > 200 mL and simultaneous interventions (left renal cyst excision, intraoperative ultrasound, esophagogastroduodenoscopy).

Postoperative variables included length of hospital-stay and postoperative complications. We examined our patients throughout hospital-stay, after 1, 3 and 6 postoperative months. Postoperative follow-up included assessment of body weight (kg) and any complications.

Statistical analysis

Statistical analysis was performed using the SPSS 23.0 software (IBM, USA). Final data were presented as median and percentiles — Me [25%; 75%].

Results

There were 7 men and 8 women. Mean age was 50 [42.5; 56] years, mean BMI — 42 [39.4; 44.6] kg/m². There were no intraoperative bleedings (>200 ml) or perioperative complications. BMI, surgery time and additional procedures are presented in Table.

Patient data

Surgery time

Overall surgery time was 194 [173.5; 241] min, docking time — 35 [30; 36] min. Prolonged docking time was due to insufficient surgical field, external collisions of robotic arms, difficult positioning of robotic manipulators over the patient with BMI near 50 kg/m². Minimal docking time was 25 min.

Postoperative period

Postoperative hospital-stay was 3 days, excess weight loss after 6 months — 37.55% [29.5; 51.2], absolute weight loss — 19.5 [17; 21.75] kg.

Discussion

Robotic sleeve gastrectomy is potentially safe if surgical team works on this platform. This is the first Russian experience of robotic bariatric surgery. Preoperative safety precautions included previous laparoscopic experience, training in robotic technology, permanent surgical team, competent organization and control over the first three surgeries (supervising).

“Sleeve gastrectomy” can be safely performed in a robotic manner before other bariatric procedures such as Roux-en-Y gastric bypass. The advantage of robotic system over standard laparoscopy may be more obvious in the last case [8]. To date, there is certain interest in establishing methodology and overcoming the learning curve among some bariatric centers. Ecker B.L. et al. [10] have recently emphasized the role of robotic technology in everyday practice. The authors revealed that robotic sleeve gastrectomy could be safely used with educational purposes. In this sample, we described the first 15 cases in detail. Data of other groups show that this number refers to active learning phase of the procedure [9, 15]. Usual surgical experience requires about 25 surgeries [16]. The learning curve for docking involves the entire surgical team. Therefore, participants and coherence of team are very important [9]. Median of surgery time for the first 15 consecutive robotic sleeve gastrectomies was 194 min. This value is quite acceptable when compared with other data (78-135 min) [8, 9, 17].

No haptic feedback and learning curve may be associated with increased incidence of visceral injuries in robotic surgeries [18, 19]. Therefore, our results are encouraging as they demonstrate acceptable surgery time and favorable postoperative results even at the early stages. Robotic sleeve gastrectomy is more expensive (cost was not addressed in this study) and takes longer than laparoscopic procedure despite similar results [8, 16, 20]. Apparently, robotic Roux-en-Y gastric bypass will have time and cost benefits, especially considering reduced learning curve for this procedure [21].

Bell S. et al. [22] described similar safety measures in establishment of robotic colorectal surgery program in Australia although the proctors were not specialized in this issue. Proctor’s role is to inform the administration whether the surgeon is competent enough to obtain temporary privileges for permanent work with robotic system. Proctor gives some passive instructions, although surgical team is finally responsible for surgical treatment. Proctoring of the first cases is considered a safety control point when introducing new techniques [23].

Simultaneous interventions included laparoscopic and robot-assisted adhesiolysis. Excision of the left renal cyst was also performed in another quadrant that was possible for this robotic system. Surgery time was longer in these cases without additional complications. Intraoperative gastroscopy was performed in 1 case for control of stapler suture integrity. Despite different arrangement of robotic ports, robotic system for sleeve gastrectomy will be applicable to other robotic surgeries. Weight loss in short-term postoperative period is comparable to 6-month weight loss after laparoscopic sleeve gastrectomy [16, 20]. We are awaiting for long-term data on weight loss.

Conclusion

Thus, we found no similar experience of robotic bariatric surgery in available national literature. This study demonstrates safe introduction of a new technology to prepare the bariatric team for more complex surgical interventions in the future.

Author contribution:

Concept and design of the study — Vyborniy M.I., Kolygin A.V.

Collection and analysis of data — Vyborniy M.I., Petrov D.I., Bolshakov G.V.

Statistical analysis — Petrov D.I.

Writing the text — Petrov D.I.

Editing — Vyborniy M.I., Kolygin A.V., Bolshakov G.V.

The authors declare no conflicts of interest.