Robotically assisted bariatric surgery

Transcription

1 The American Journal of Surgery 188 (Suppl to October 2004) 38S 44S Robotically assisted bariatric surgery Federico Moser, M.D., Santiago Horgan, M.D.* Minimally Invasive Surgery Center, University of Illinois, 840 South Wood Street, Room 435 E, Chicago, Illinois 60612, USA Abstract Obesity is a serious health problem in the United States today, and surgical treatment is recognized as long-term effective therapy. Minimally invasive techniques are becoming the gold standard approach to the treatment of disease, and robotic surgery has the potential to advance the use and development of minimally invasive procedures. In this article, we report our experience using robotically assisted technology to perform bariatric surgery. From mid 2002 to early 2004, 110 robotically assisted Roux-en-Y gastric bypass and 32 robotically assisted gastric banding procedures were performed at our institution. The mean preoperative body mass index was 46 for the patients receiving Roux-en-Y gastric bypass and 49 for the patients receiving gastric banding. The mean length of stay was 2.1 days and 1 day for patients in the 2 respective groups. There were 3 strictures in the Roux-en-Y group and 1 marginal ulcer in the gastric banding group; no leaks were observed in any patients in either group. There was 1 conversion to a laparoscopic procedure in the Roux-en-Y gastric bypass group. We conclude that robotically assisted bariatric surgery will allow more surgeons to offer patients the same safety and successful outcomes currently available through open techniques but without the significant morbidities of large surgical wounds Excerpta Medica, Inc. All rights reserved. Obesity is a serious public health problem in the United States. The prevalence of obesity is growing every year, not only in adults but also in the pediatric population [1]. Obesity is now the second leading cause of death in the United States after tobacco-related disease, and 400,000 Americans died of obesity-related causes in 2000 [2]. It is well known that obesity contributes to such comorbidities as noninsulindependent diabetes mellitus, hypertension, and hypertriglyceridemia or hypercholesterolemia. Surgical treatment of morbid obesity is recognized as long-term effective therapy, and its goal is to limit or eliminate these comorbidities [3,4]. Robotically assisted surgery s most notable contributions are reflected in its ability to extend the already well-established benefits of minimally invasive surgery to procedures not routinely performed using minimal access techniques (ie, total esophagectomies, coronary artery bypass grafting, and radical prostatectomies). This technology may ultimately increase the number of physicians who are able to provide the benefits of minimal access surgery to their patients without the increased risks of complications associated with initial learning curves. We believe that the progress and development of robotic surgery will eventually provide all bariatric surgeons with the option of a minimally * Corresponding author. Tel.: ; fax: address: shorgan@uic.edu invasive approach. As more patients become aware of the clinical outcomes from minimally invasive surgical treatment for morbid obesity, they will actively seek a bariatric surgeon skilled in these techniques. The additional advantages afforded by the use of minimally invasive surgical techniques, coupled with the desire to retain the natural ergonomics and visual advantages of open surgery, have propelled the development and progression of robot-assisted surgery. Current robotics systems have already begun to return the natural feel of open access afforded by laparotomy to minimally invasive surgeons. Here, we examine the current use of robotics in bariatric surgery as well as its potential advantages and disadvantages. Current applications of robotically assisted bariatrics A survey of surgeons in 2003 revealed that only 11 surgeons in the United States were currently using a robotic surgical system for bariatric surgery [5]. This statistic can be explained by the small number of bariatric cases performed laparoscopically and by the limited number of institutions with a robotics system available for use. The first robotassisted adjustable gastric banding was reported in 1999 [6], and the first robot-assisted gastric bypass was done in September 2000 by our group [7]. There have also been several abstracts submitted at national meetings detailing biliopan /04/$ see front matter 2004 Excerpta Medica, Inc. All rights reserved. doi: /j.amjsurg

2 F. Moser and S. Horgan / The American Journal of Surgery 188 (Suppl to October 2004) 38S 44S 39S Fig. 1. Trocar placement for robotically assisted Roux-en-Y gastric bypass. creatic diversion, with duodenal switch being performed with robotic assistance [5]. The results of laparoscopic and robotically assisted surgery comparisons will be subtler than comparisons of open and laparoscopic techniques. Robotically assisted Roux-en-Y gastric bypass The procedure that benefits most from robotic assistance in the field of bariatric surgery is gastric bypass. Gastric bypass is an effective modality in the surgical treatment of morbid obesity. Laparoscopic Roux-en-Y gastric bypass is becoming an increasingly popular variation of this surgical approach and has been deemed safe and effective. Surgical technique The patient is placed in the low lithotomy position with the legs and arms open; a beanbag is placed under the patient to support the steep reverse Trendelenburg position during the operation. A single dose of preoperative prophylactic antibiotics (first-generation cephalosporin) is given. Thigh-length antiembolic stockings and a sequential pneumatic compression device are placed on both lower extremities before induction of anesthesia. A single dose of 5,000 U subcutaneous heparin is given for prophylaxis against venous thrombosis. After general anesthesia is achieved, an NG tube is placed in the stomach and a Foley catheter is put in position. The trocar placement for robotically assisted Roux-en-Y gastric bypass is shown in Figure 1. The procedure starts by dividing the small bowel approximately 50 cm below the angle of Treitz using a vascular stapler; the mesentery of the bowel is also divided using a vascular stapler. After creating a 150-cm limb, a jejunojejunal anastomosis is performed using 2 reloads of vascular staplers. The bowel opening is closed using an endo-needle holder with interrupted stitches of 3-0 silk. The defect between the mesentery is closed using a 3-0 silk suture. At this time, the patient is placed in a reverse Trendelenburg position; the omentum is mobilized and sectioned using the harmonic scalpel. Next, beginning at the lesser curve (approximately 5 cm from the gastroesophageal junction), the retrogastric tunnel is created using the harmonic scalpel. Several firings of the surgical stapler are performed to create an approximately 30-cm 3 gastric pouch; following completion, the distal portion of the ileum is brought up for creation of the gastrojejunostomy. At this time, the surgical arm cart of the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) is positioned (Fig. 2). To perform the gastrojejunal anastomosis, a Cadière forceps is attached to the right arm and a needle holder to the left arm. The posterior layer of the gastrojejunal anastomosis is performed with 3-0 silk. Then, using electrocautery, a 1.5-cm opening is created in both the jejunum and the gastric pouch; for the opening, the cautery is hooked to the left arm. Once the bowel and the stomach are opened, we start the handmade anastomosis using the robot. A running suture is placed to the right and left of the anastomosis using 3-0 absorbable suture (Fig. 3). The anterior serosa-serosa layer of the gastrojejunal anastomosis is closed using 3-0 silk.

3 40S F. Moser and S. Horgan / The American Journal of Surgery 188 (Suppl to October 2004) 38S 44S Fig. 2. Operating room setup for gastric bypass and gastric banding. Once the anastomosis is finished, the robotic surgical cart is removed from the patient. The NG tube is passed down into the gastric pouch. The distal limb of the ileum is clamped, and 60 ml of methylene blue is introduced to rule out the presence of leak. Patients are encouraged to ambulate on the same operative day. On postoperative day 1, patients undergo a gastrograffin swallow to evaluate the status of the gastrojejunal anastomosis. Following this, they start a clear liquid diet. On postoperative day 2, if no complications are experienced, they are discharged home. Results According to a survey conducted in 2003, 11 surgeons in the United States were using robotics to perform bariatric procedures. A total of 107 cases were reported [5]. In this series of combined experience, the leak rate was 0%. One stricture that required dilatation was reported. Four additional complications were related to the robotic portion of the procedure, including improper port placement in 2 cases, a problem with imaging system in 1 case, and a mechanical difficulty in robotic arm movement in 1 case. At our institution, the average length of stay was 2.1 days for 110 cases performed from mid 2002 until early The body mass index (BMI) of these patients averaged One case was converted from robotic to open in the first 6 months of our experience, but no case since that time has required conversion. There were 3 incidences of complications possibly related to implementation of robotic technology, including 3 strictures and 1 marginal ulceration at the

4 F. Moser and S. Horgan / The American Journal of Surgery 188 (Suppl to October 2004) 38S 44S 41S Fig. 3. Robotic gastrojejunostomy anastomosis for gastric bypass. gastrojejunal anastomosis. One patient required a blood transfusion. No anastomotic leaks occurred in this group. Robotically assisted adjustable gastric banding Robotically assisted adjustable gastric banding is also performed. Three of 11 surveyed bariatric surgeons in the United States were using the da Vinci System for adjustable gastric banding in 2003 [5]. Surgical technique The patient is placed in the low lithotomy position with the legs and arms open. The surgeon operates between the patient s legs, with the assistant at the patient s left side. Prophylactic antibiotics (first-generation cephalosporin) as well as 5,000 U subcutaneous heparin are given to the patient during the anesthesia induction. Four trocars are used. The first is a 10- to 12-mm bladeless trocar (Ethicon Endo-Surgery, Inc., a Johnson & Johnson Company, Cincinnati, OH), which is inserted under direct vision 15 to 20 cm from the xyphoid process using a 10-mm, 0-degree scope. Pneumoperitoneum is then achieved to 20 mm Hg. The rest of the trocars are placed under direct vision using a 30-degree scope. An 8-mm trocar (robotic arm) is placed immediately below the left rib cage in the mid clavicular line. An 18-mm trocar is then placed on the left flank at the same level as the camera. At this point, the patient is placed in the reverse Trendelenburg position, which allows for better visualization of the gastroesophageal junction. A 5-mm incision is made below the xyphoid process to facilitate introduction of a Nathanson liver retractor. The last 8-mm trocar (robotic arm) is placed approximately 8 cm below the right rib cage, depending on the position of the liver edge. The Cadière forceps are attached to the right arm and the harmonic scalpel to the left arm. The first step of the operation consists of detaching the phrenogastric ligament in order to expose the left crura. Then, the gastrohepatic ligament is opened. The caudate lobe of the liver, the inferior vena cava and the right crura are subsequently exposed. Having identified these structures correctly, we create a retrogastric tunnel using blunt dissection. We start the dis-

5 42S F. Moser and S. Horgan / The American Journal of Surgery 188 (Suppl to October 2004) 38S 44S Fig. 4. Robot-assisted adjustable gastric banding. section between the edge of the right crura and the posterior wall of the stomach, and it is continued until the articulated tip of the robotic instrument is visualized at the other side of the stomach, at the angle of His. At this time, and using the 18-mm trocar, the band is placed inside the abdomen. Following this, the tip of the tubing is placed between the jaws of the Cadière forceps, attached to the left arm, and the band is threaded around the stomach (Fig. 4). Since the tip of the instrument is articulated, there is no need to use the band passer. Then the tip of the tubing is inserted into the band buckle and locked. With the band closed and in position, a wrap is fashioned out of the stomach to secure the band in place. We place 3 (or 4 if necessary) nonabsorbable seromuscular sutures during the creation of this wrap (Fig. 5). The first is placed in the left lateral aspect of the gastric pouch, and 2 more are placed in the anterior aspect. Once the band is in position, the port is then secured using 4 Prolene 2-0 sutures (Ethicon Endo-Surgery, Inc.). Results A total of 32 robotically assisted LAP-BAND (INAMED Development Co., Carpenteria, CA) placements were done at University of Illinois at Chicago. The mean age was 43 years (range, 28 to 63 years). The mean BMI was 49.2 (range, 37 to 82). The mean weight was 301 lb (136.5 kg) (range, 217 to 402 lb [98.4 to kg]). The mean operative time was 105 minutes (range, 60 to 150 minutes), and the mean length of stay was 1 day (range, 0.2 to 6 days) [5]. We compared 32 of 220 adjustable gastric bandings for conventional laparoscopic versus robotically assisted technique. A total of 50 patients were randomized. Patients in both groups experienced similar outcomes in terms of length of hospital stay and weight loss, although the operative time in the robotic group was significantly longer [5]. Robotically assisted biliary pancreatic diversion with duodenal switch Performance of the robotic-assisted biliary pancreatic diversion with duodenal switch has been reported in abstract form by several centers [5]. Most reports describe performing the duodenal-jejunal anastomosis with robotic assistance. No comparative data have been reported to our

6 F. Moser and S. Horgan / The American Journal of Surgery 188 (Suppl to October 2004) 38S 44S 43S Fig. 5. Robot-assisted adjustable gastric banding wrap suturing. knowledge. However, the stated advantages are the system s ability to complete an otherwise difficult and advanced laparoscopic maneuver with greater ease and more precision, with no untoward effects to date. Discussion Performing the gastrojejunal anastomosis is among the most technically challenging steps in laparoscopic gastric bypass. We perform a robot-assisted hand-sewn gastrojejunostomy for completion of the laparoscopic Roux-en-Y gastric bypass procedure because we believe that it offers the best opportunity to decrease the risks of leak (1% to 3%) and/or stricture (9% to 31%) reported with other circular stapler anastomotic techniques [8,9]. The microprecision of the articulating instruments and 3-dimensional view facilitate completion of the hand-sewn anastamosis. This is most notable in patients with a high BMI ( 60, or superobese) and/or those who have an enlarged left hepatic lobe, which greatly decreases the working area beneath the liver. We and other groups are currently collecting prospective data on patient outcomes and the clinical utility of robot-assisted surgery. Due to the average reported leak rate of 1% to 3%, several hundred cases will be required for comparison to give statistical significance to the trial [10]. Published data reveal 107 cases of robot-assisted Roux-en-Y gastric bypasses by 7 surgeons in the United States in 2003 [5]. The greatest advantages reported by these surgeons include articulating wrists, 3-dimensional view, motion scaling for precise hand movement, and mechanical forces to counteract the abdominal wall torque. Surgeons with experience in 20 cases reported that set-up times and operative times were inversely proportional to the number of operative cases performed. Preparation for the robot can be decreased to as few as 6 minutes and robotic work time can also diminish by 50%, decreasing from 70.7 minutes to 33.9 minutes as shown by the group at New York Medical College (New York, NY) [5]. The ability to perform a hand-sewn anastamosis under direct visualization is the most obvious advantage of the robotics system. Performing hand-sewn anastamosis also eliminates the requirement of

7 44S F. Moser and S. Horgan / The American Journal of Surgery 188 (Suppl to October 2004) 38S 44S passing a stapler anvil down the esophagus, adding the risk of esophageal injury, or adding an additional stapler line after passing the anvil transgastrically. There have also been several recent reports of higher anastamotic stricture rates after use of circular staplers or linear cutting staplers [8,9,11]. A hand-sewn anastamosis may be tailored to each patient, based on surgeon preference. Moreover, use of a circular stapler was associated with higher wound infection rates and higher costs compared with a hand-sewn anastomosis [11]. In addition, the New York Medical College group showed that greater BMI did not adversely affect the operative time required for performing the gastric bypass; times were similar regardless of whether the BMI was 60 or 60 [5]. Early patient outcomes were also within accepted standards and were actually better than some. Notably, there was only 1 patient with a stricture requiring dilation. This study and other anecdotal reports in the literature show the Roux-en-Y gastric bypass can be performed with robotic assistance in a safe and reliable manner. Larger studies conducted in a prospective randomized fashion directly comparing robotically assisted hand-sewn gastrojejunostomies with stapled or laparoscopic hand-sewn anastamosis are still needed. Comparisons of clinical outcomes and complications still need to be performed to verify currently perceived clinical advantages. Regarding robot-assisted adjustable gastric banding, no differences in outcomes were found when compared with conventional laparoscopic surgery, but there was a longer operative time. We found the greatest benefit of using robotics is manipulation of the articulating instruments in small working areas. Also, there was greater ease of operation despite increased torque pressures from thicker abdominal walls in patients with a BMI 60. The articulating instruments are appreciated most commonly during posterior dissection of the gastric wall during the pars flaccida technique and for placing gastrogastric sutures. Robotic instruments are notably thicker and provide more force while operating in patients with thick abdominal walls. The mechanical power provided by the robotics system provides relief to the operating surgeon, who does not have to struggle to maintain instrument position or counter the torque from rotating instruments around the fixed pivot point. We have successfully performed placement of adjustable gastric banding in several patients with BMI 60; our largest patient had a BMI of 82. As of this writing, we only use the robotic system if the patient has a BMI 65. Summary The demand for an effective long-term cure for the epidemic of morbid obesity will continue to drive the search for surgery that provides the ideal combination of acceptably low morbidity and mortality with sustained long-term excessive weight loss and a significant reduction of medical comorbidities. Robotically assisted bariatric surgery will allow more surgeons to offer patients the same safety and successful outcomes currently available through open surgical techniques but without the significant morbidities of large surgical wounds. We conclude from this early experience that the implementation of robotic surgical technology for assistance in performing the complex task of a hand-sewn gastrojejunostomy is safe and practical and results in outcomes comparable to other current techniques. Our 0% leak rate has shown that robotically assisted gastrojejunostomy is the optimal technique for reducing the leak rate in these already sick patients. We also conclude that robot-assisted adjustable gastric banding provides the surgeon with advantages when dealing with superobese patients. Further prospective randomized studies are needed to continue to assess the advantages of robotically assisted bariatric surgery. References [1] Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, JAMA 2002;288: [2] Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, JAMA 2004;291: [3] Giusti V, Suter M, Heraief E, Gaillard RC, Burckhardt P. Effects of laparoscopic gastric banding on body composition, metabolic profile and nutritional status of obese women: 12-months follow-up. Obes Surg 2004;14: [4] Dixon JB, O Brien PE. Changes in comorbidities and improvements in quality of life after LAP-BAND placement. Am J Surg 2002; 184(Suppl 6B):51S 4S. [5] Jacobsen G, Berger R, Horgan S. The role of robotic surgery in morbid obesity. 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