Mini Robotic Gastric Bypass Surgery
Vinod Kumar Singhal *1, Vidher V V Singhal 2, Umm Heba Asif 3, Faris Dawood Alaswad 4, Varsha Ojha 5
1. General Surgeon, Prime Hospital, Dubai.
2. University College London, London.
3. Bart NHS Trust, London, UK.
4. General Surgeon, NMC Specialty Hospital, Dubai
5. Gynecologist and Obstetrician, Prime Hospital.
Corresponding Author: Vinod Kumar Singhal, General Surgeon, Prime Hospital, Dubai.
Copy Right: © 2023 Vinod Kumar Singhal, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received Date: March 14, 2023
Published Date: April 01, 2023
Abstract
Background: Robotic gastric mini bypass (RMGB) is one of the most widely performed bariatric surgeries in the world. Performing an RGMB by a Da Vinci Surgical System is a new advancement.
Objective: To describe the procedure and evaluate our robotic mini gastric bypass (RMGB) patients and how safe and feasible it is for extreme and Morbid Obesity.
Methods: Between January 2021 and December 2022, 140 robotic RMGB were performed. The RMGB was performed through single docking, single quadrant approach. The data were analysed retrospectively. Intra- and post-operative details of every patient were documented. Follow-up was done as per protocol at 6 months; 1 years. Written Informed consent was taken from each patient. SPSS was used for analysis.
Results: Out of 140 patients, 39% (66) of patients were male and 61% (74) were females. The mean age of all the patients was 42.4 ± 12.10 years. The mean pre-operative weight of 108.40 ± 7.14 kg and the mean BMI was 38.75 ± 4.0. As the complete procedure consists of laparoscopic and robotic part; the mean time was 19.61 ± 5.50 min, docking time of 7.53 ± 5.40 min. The mean operative was calculated with length of hospital was 2.98 days. Average blood loss is minimal in RGMB 56.78ml which was significant. It was seen there was significant decrease in 6 months and 12 month for weight as compared to pre-operative period. Similarly BMI was also significantly decreased.
Conclusion: RMGB appears to be both safe and successful. Robotic surgery improves surgeon positioning and decreases the bariatric surgery's ergonomic difficulties. Thus, it should be the preferred operation in this population, especially in patients who are extremely obese.
Keywords: robotic gastric bypass, morbid obesity, Console time, docking time, single quadrant, weight loss.
Introduction
Mason & Ito first described gastric bypass in 1967. Using a gastric pouch parallel to a smaller curve and loop, Rutledge first described the mini gastric bypass (RMGB) in 1997. 200 cm (150-300 cm) from Treitz's Ligament, gastroenterostomy. WHO has classified obesity as a global epidemic, and the situation in India is frightening since roughly 5% of the population suffers from morbid obesity. [1] The long-term effects of calorie restriction alone or in combination with exercise are not encouraging. [2] Over time, bariatric surgery has shown to be a lifesaver for individuals who are morbidly obese and have tried unsuccessfully to lose weight with diet and exercise alone. Roux-en-Y gastric bypass (RMGB), one of the most popular bariatric operations, is widely regarded as the gold standard for weight loss. [3]
The advent of the Da Vinci Robotic Surgical System is a recent advancement in the field of bariatric surgery. The minimal access surgery has a new paradigm thanks to robotic surgery. [4] In essence, bariatric surgery entails a procedure that must be completed in numerous quadrants. [5] There is a gastric component and an intestinal component to procedures like gastric bypass or a small gastric bypass. Working in various quadrants during robotic surgery requires complex port configurations, many patient position changes, and multiple dockings of the robotic arms, which wastes a significant amount of anesthetic time. The majority of gastrointestinal (GI) procedures are carried out using a multiple quadrant technique and robotic assistance. The surgeon and the crew have essentially wasted their time and effort. Because morbidly obese individuals have a higher chance of developing pulmonary problems after surgery, anesthesia time is crucial in bariatric surgery. [6]
Materials and Methods
Robotic RMGB was performed on 140 patients from January 2021 to December 2022. Single docking-single quadrant technique was used for RMGB surgery. Written Informed consent was taken from each patient.
Methodology
Laparoscopic and robotic components make up the entirety of the robotic approach
Part laparoscopic- The division of the larger omentum is the first step in a robotic RMGB. The patient was kept lying on his back. The diagnostic laparoscopy was followed by a division of the omentum from the base of the transverse colon to the left subtotal angle in order to access the bowel and hiatus. When the transverse colon is elevated, the Treitz ligament can be seen. The alimentary and biliopancreatic limbs of the bowel were marked using a black silk thread marking stitch. The alimentary limb was marked at 120 cm, while the biliopancreatic limb was marked at 80 cm.[6]
The patient must be moved for the robotic component. The patient was elevated 45 degrees above the ground in a steep head-up position. The procedure ended with this position remaining the same. The docking procedure involved a severe head-up angle. Getting the robot docked with the assistance of the assisting team, which did not need to be scrubbed for the procedure, the robotic docking process was simplified.
Surgical Technique
The creation of the bag is the initial step in robotic RYGB. A micro pouch is the fundamental component of a gastric bypass for severe obesity. Just below the left gastric pedicle, the gastric omentum was divided to create the pouch. At our facility, creating a gastric pouch is most frequently done using the pars flaccida technique. We utilize a blue load of 6 cm to generate a horizontal fire after entering the lesser sac. The pouch was calibrated using the 36 Fr bougie, and a gastric pouch of around 30 ml sizes was created after two vertical firings with 60 mm blue reloads. The bowel loop was cut in the subcostal region at 80 cm of its length after the pouch had been formed. The loop and stomach pouch underwent an anastomosis. This was accomplished using a fourth layer that combined the stomach pouch's posterior wall with the antimesenteric portion of the colon. A 2.5 cm defect and 2.5 cm enterotomy were produced by performing a gastrostomy using a hook. The mucosa of the intestinal and stomach walls was included in the third layer. In order to completely close the gastrostomy enterotomy defect, the second and final layer was applied.
For the closure of gastrostomy enterotomy defects, a 3.0-barbed suture (Quill, Angiobiotech, USA) was employed. Following the jejunal anastomosis of the loop pouch, the loop was separated just outside of the anastomosis to prevent a candy cane. Both the biliopancreatic limb and the 2 cm long alimentary limb underwent enterotomies. Enterotomy flaws were repaired by creating a 6 cm anastomosis with a linear cutter stapler. The peterson's space was then stitched shut with the same suture after the internal hernia defect was repaired with a non-absorbable silk 2.0 (Ethicon Biosurgery, Jhonson and Jhonson, India). Patients typically did not have drains. Patients received a 3-day regimen of pre- and post-operative antibiotics.[6,7]
The length of the hospital stay, ergonomic difficulties, docking time (DT), total operative time (OT), problems (intraoperative and postoperative: early and late), and complications were all examined.
Statistical Analysis
The statistical analysis was performed using SPSS for windows version 22.0 software (Mac, and Linux). The findings were present in number and percentage analyzed by frequency, percent, and Chi?squared test. Chi?squared test was used to find the association among variables. The critical value of P indicating the probability of significant difference was taken as <0.05 for comparison.
Results
As per table 1 out of 140 patients, 39% (66) of patients were male and 61% (74) were females. The mean age of all the patients was 42.4 ± 12.10 years. The mean pre-operative weight of 108.40 ± 7.14 kg and the mean BMI was 38.75 ± 4.0. As the complete procedure consists of laparoscopic and robotic part; the mean time was 19.61 ± 5.50 min, docking time of 7.53 ± 5.40 min and mean console time of 70.37 ± 14.76 min. It was documented that the docking time was higher which ranged from 20 to 30 min (mean 24.28 min) of docking but there was gradual decreasing trend in docking time and finally reduced to just 4–7 min. The docking was done with four robotic arms one of which was used for the optical port.
As per table 2 the mean operative was calculated with length of hospital was 2.98 days. Average blood loss is minimal in RGMB 56.78ml which was significant. There were negligible complication and 1 case died due to pulmonary embolism. Stoma stenosis was managed by serial dilatation.
As per table 3 a comparative analysis done pre-operative and 6 months after RGMB and 12 month follow up. It was seen there was significant decrease in 6 months and 12 month for weight as compared to pre-operative period. Similarly BMI was also significantly decreased. The percentage of weight loss was 59% in 6 months and 61% in 12 months follow up period which was also significant. (p<0.05)*
Discussion
The best treatment for morbid obesity is RMGB. [8] The robotic surgery paradigm has emerged as the more recent one in minimal access surgery [4] and it envisions the benefit of having articulating devices and a three-dimensional view. Even with the majority of extremely obese patients, the surgeon sits on the console in a posture that is most comfortable for him, putting no strain on his shoulders or his arms. The surgeon's hands are typically subjected to great torque during laparoscopy, which makes suturing challenging and imprecise. The preferred method of treating prostate cancer is robotic surgery. [9] The accuracy with little harm to the surrounding tissue, particularly the prostatic nerve plexus, is the main cause of this. This aids in preventing a number of issues, including erectile dysfunction, incontinence, and early ejaculation.
The main reasons why robotics in bariatric surgery hasn't become widely used are the high expense of the necessary equipment and the laborious operation requiring numerous dockings and complex port positions. The majority of published research comparing the costs of robotic bariatric surgery with laparoscopic surgery shows that although the robotic bariatric surgery has a quicker return to activity, the cost is higher. Hagen et al.[11] discussed the issue of material cost in robotic gastric bypass in contrast to this. According to them, laparoscopic surgery costs 5494 USD, while robotic surgery costs 5427 USD.
22 papers were included in Cirocchi et al.'s[12] meta-analysis of the quantitative study of robotic bariatric surgery. Twelve case series, nine clinical control trials, and one randomised control trial are all included in this study. In this investigation, there were 0.29% gastrojejunostomy leaks and 0.05% jejunojejunostomy leaks. They reported 4.26% serious problems in the major outcomes. In the RYGB series, pulmonary embolism rates were 0.71%. The readmission rates after 30 days were 4.84%. 1873 RYGB cases exhibited anastomotic site hemorrhage in 15 of those instances. The rate of gastrojejunostomy stricture was 1.23%. In RYGB, the post-operative small bowel obstruction rate was 1.17%. The patient spent 2.72 to 7.4 days in the hospital. The surgery took between 95 and 135 minutes.
In their meta-analysis, Ourman and Saber[10,11] noted that 684 patients with a mean pre-operative BMI of 47.8 kg/m2 received robotic RYGB over a total of 6 investigations. 194.9 minutes was discovered to be the average operating time. The research included in this analysis used both fully robotic and robotically assisted procedures. In four out of six trials, the average reported follow-up period was 10.5 months. This study's reported total complication rate was 10.2%. Gastrojejunal strictures, marginal ulcers, anatomic leaks, bleeding, myocardial infarction, Clostridium difficile infection, bowel perforations, and internal hernias were the main problems that they noted.
If we compare our results to these earlier studies, we find that our risk of complications is substantially lower, with only one early minor wound infection and two gastrojejunostomy strictures that were treated endoscopically rather than surgically. In our case, the average operation lasted 97.48 23.79 min. Because we leave the patient and ports in their current positions once docking is complete, our series of patients saw shorter mean operating times. The present series' complication rates were incredibly low when compared to earlier reports [12,13]. Their case series' length of stay, which was between 2 and 4 days on average, was comparable to ours. The completely robotic gastric bypass approach has been described by Mohr et al. They essentially employed 6 ports with similar port positions, but the technique needed 169 minutes on average to operate. This time was contrasted with their traditional gastric bypass timing and found to be much shorter in the robotic procedure.[14] They have linked this to the successful anastomosis and suturing used in robotic surgery. For all cases, the average docking time was 7.53 5.40 minutes. This compares with the majority of recent studies. The average docking time and console time have decreased with time, as has been reported in earlier studies.
Conclusion
If the surgical team has sufficient experience performing the treatment, RMGB appears to be both safe and successful. Robotic surgery improves surgeon positioning and decreases the bariatric surgery's ergonomic difficulties. Thus, it should be the preferred operation in this population, especially in patients who are extremely obese. Moreover, MGB has benefits such as excellent weight reduction, no need for roux legs, low complication rates, a minimal risk of internal herniation, a quick recovery period, and other metabolic impacts.
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