Robotic Sleeve Gastrectomy for Treatment of Morbid Obesity

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 Sleeve gastrectomy is technically a straightforward procedure to perform and is easier to learn for trainees and novel surgeons. It could, however, pose some challenges especially in patients with increased BMI, which is a huge advantage for the robotic platform in our experience as it allows easier exposure and comfort during the operation.

Robotic sleeve gastrectomy; sleeve gastrectomy; robotic bariatric surgery.

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.¹

Sleeve gastrectomy was initially thought to be a purely restrictive operation; however, caloric restriction cannot account for the sustained weight loss and improved glucose metabolism seen following sleeve gastrectomy. Other mechanisms, including changes in gastrointestinal hormone secretion, rearrangement of hypothalamic and vagal control, alteration in energy expenditure, and reregulation of bile acid metabolism and the intestinal flora environment are thought to contribute to the postoperative benefits.²

Current evidence indicates that robotic sleeve gastrectomy generally involves longer operative times and is associated with higher postoperative morbidity, including leaks and surgical site infections, compared to laparoscopic sleeve gastrectomy. Additionally, robotic sleeve gastrectomy patients are more likely to experience conversions to open procedures, longer postoperative stays, readmissions, and higher overall costs. Despite these challenges, robotic sleeve gastrectomy remains a viable option with potential benefits, particularly as technology advances and surgical techniques improve. It will take some time for the robotic technology to be fully adopted and mastered technically by surgeons, which could further enhance its effectiveness and safety.^4,5

The patient is a 56-year-old male with a BMI of 44.5 Kg/m². His comorbidities include obstructive sleep apnea and hyperlipidemia and first degree AV block. The patient had tried several methods to achieve his desired weight loss and reduce his risk of worsening or developing new comorbidities but was unsuccessful. As such he opted to present to our weight management program for surgical weight loss.

This was largely unremarkable.

Upper GI study performed routinely preoperatively. In this case, it was questionable for a hiatal hernia; however, this was not identified intraoperatively.

Different surgical procedures are usually discussed with the patient including pros and cons of each, specifically for the sleeve gastrectomy long-term complications are discussed including worsening reflux disease. In the short term, usually the sleeve gastrectomy is associated with more postoperative nausea; furthermore, leaks after sleeve gastrectomy, although rare, can be much harder to manage due to the high intraluminal pressure. All of this was discussed with the patient, and since he did not have symptomatic reflux or diabetes he opted to pursue a sleeve gastrectomy.

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 his current weight.

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 the sleeve gastrectomy based on several studies. Some of the relative contraindications for the sleeve gastrectomy is severe reflux disease and Barrett’s esophagus, which some may consider an absolute contraindication.

We present a relatively straightforward case of a robotic sleeve gastrectomy 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 the utility of ICG in checking the blood supply of the sleeve, especially at the gastroesophageal (GE) junction.

There are several reviews that compared the outcome of sleeve gastrectomy versus other procedures, and it may be concluded that in terms of excess weight loss, long-term results are generally satisfying. Results on the resolution of comorbidities vary among the studies available today, so the procedure’s performance in this area cannot be evaluated irrefutably at this point.

However, there is no consensus among authors concerning the issues of GERD and Barrett’s esophagus. Authors argue whether sleeve gastrectomy is able to improve symptomatic reflux and reduce the risk of developing Barrett’s metaplasia or, on the contrary, if it actually promotes these issues. Thus, the question whether GERD and Barrett’s esophagus should be treated as relative contraindications to sleeve gastrectomy may not be clearly answered at this point. In terms of hiatal hernias, authors have reported good results combining sleeve gastrectomy with hiatoplasty. An intraoperative visualization of the hiatus to detect hiatal hernias and adding hiatoplasty to sleeve gastrectomy if necessary thus seems recommendable.

Review of long-term studies was also able to show that conversion rates after sleeve gastrectomy are quite high due to different reasons. Roux-en-Y gastric bypass (RYGB) as a conversional procedure is considered most successful for patients with reflux in literature. Patients with weight regain are suggested to benefit from a procedure with a stronger malabsorptive element.

Total operative time was 45 minutes, the patient was discharged home on postoperative day 1, and no complications were noted on follow up.

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

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

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.

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.