July 14, 2025

Clinical Challenges in Robotic Bariatric Surgery: The Robot is Here to Stay!

43 minutes

Join us as we dissect the use of robotics in bariatric surgery – where precision meets programming, and the scalpel gets a software upgrade.

Video Clip Link: https://app.behindtheknife.org/video/clinical-challenges-in-robotic-bariatric-surgery-the-robot-is-here-to-stay

This videos includes:

- Robotic RYGB

- Robotic Sleeve Gastrectomy

- SADI: Single Anastomosis Duodenoileostomy

Hosts:

- Matthew Martin, trauma and bariatric surgeon at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California)

- Adrian Dan, bariatric and MIS surgeon, program director for the advanced MIS bariatric and foregut fellowship at Summa Health System (Akron, Ohio)

- Crystal Johnson Mann, bariatric and foregut surgeon at the University of Florida (Gainesville, Florida)

- Katherine Cironi, general surgery resident at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California)

Learning objectives:

Strengths of the robot:

Surgical robots are at the forefront of technology and continue to improve with detailed, precision cameras and the ability to remove baseline tremors

Allows for smooth movements, fine dissection, and precise tissue handling

Ergonomics are more advantageous to the surgeon when compared to laparoscopy

Weaknesses of the robot:

The loss of haptic feedback can be challenging for surgeons early in their learning curve

Emphasis on surgical robots means some trainees may be losing exposure to laparoscopic techniques

Longer operative time when working robotically, and more time under anesthesia for the patient

Increased cost for robotic surgery

Outcomes data:

Mixed data from the MBSA QIP database (metabolic and bariatric surgery accreditation and quality improvement program)

The most recent study looked at 824,000 patients from 2015-2022 who had a sleeve gastrectomy or RNY gastric bypass, either laparoscopically (lap sleeve 61%, lap RYGB 24%) or robotically (robo sleeve 11%, robo RYGB 4%).

Robotic sleeves were reported to have higher complication rates compared to laparoscopy, seen as higher overall morbidity and an increased rate of leaks

While the robotic RYGBs have lower overall complications, including decreased morbidity and bleeding. Robotic RYGB can be especially advantageous with revisional surgeries when compared to lap.

Setting up for success

Train your eyes to determine tension on tissue, since there is no haptic feedback

Learn how to assist yourself (manipulating the camera and effectively utilizing the fourth arm)

Understand how techniques of the surgery change when doing it robotically, as compared to laparoscopy

Experienced operating room team

When learning, recommend putting all cases feasible on the robot (including easier cases), to master the straightforward cases before moving to technically challenging revision cases.

Don’t hesitate to add an additional trocar or assistant port when needed

Education in Robotic learning

Learning by observation/mirroring – ex: robotic bilateral inguinal hernia (mirroring the attending/instructor)

Easy for the attending/instructor in the case to switch instruments seamlessly, then give them back intermittently at the appropriate time

Helpful when the attending annotates the screen to depict where to go

Data-driven teaching tools on the Davinci system

Tips for robotic sleeve gastrectomy:

Of the robotic bariatric surgeries, sleeve gastrectomy is most similar to its laparoscopic procedure

30-40 degrees of reverse Trendelenburg

Liver hammock stitch instead of a liver retractor (one less trocar), which makes a total of 4 trocars needed for the case

Green staple load for the first firing, then the rest are typically blue loads

Mixed opinions on reinforced staple loads versus non-reinforced staple loads and oversewing the staple line (discussed cost-benefit)

Tips for robotic gastric bypass:

Watch videos from colleagues to learn what they do

Gastric bypass is a multi-quadrant surgery; thus, you must set yourself up for success so that your arms are not fighting when moving through different quadrants

A size 12 trocar on the left can make the formation of the gastric pouch easier

GJ and JJ anastomosis formed with a linear fire, then a two-layer closure with absorbable barb suture

Don’t forget to close the mesenteric defect (non-absorbable braided suture)

Tips for robotic DS and SADI:

If doing a duodenal anastomosis hand-sewn, then recommend planning the exact number of sutures and locations of each for ease

Hand-sewn anastomosis can have less bleeding and fewer strictures for patients, and is completed in a much more seamless fashion with the robot

Future of Robotics

Haptic feedback

Integrated visual overlays to identify anatomical structures/serve as an intraoperative map

Artificial intelligence integration

Telesurgery – ex, small surgical robot deployed to space

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

...more

View all episodes

By Behind The Knife: The Surgery Podcast

4.8

12861,286 ratings