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

Behind The Knife: The Surgery Podcast

Science, Medicine, Health & Fitness, Education

4.8 • 1.4K Ratings

🗓️ 14 July 2025

⏱️ 44 minutes

🔗️ Recording | iTunes | RSS

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Summary

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

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Transcript

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0:00.0	Behind the Knife, the Surgery Podcast.
0:09.1	Relevant and engaging content designed to help you dominate the day.
0:23.9	Thanks for listening to Behind the Knife.
0:27.2	This is Patrick Georgoff, and I want to share an important message.
0:30.3	Our oral board review kicks ass.
0:34.8	We have over 100 scenarios with top-notch commentary to get you prepared for the exam,
0:37.7	or maybe even just prepare for your next rotation.
0:42.7	We're also adding over 30 new scenarios this fall and a brand new interactive video feature so that you can practice for the real thing.
0:44.7	Get quick and easy access via our app for on-the-go use.
0:47.9	It's still the best and it is still significantly less expensive than anything else out there.
0:52.4	Group discounts are available.
0:53.9	Now, enjoy the episode and dominate the day.
0:57.0	Hi, everyone.
0:58.0	Welcome back to the bariatric surgery team on the behind-the-knife specialty series.
1:02.2	I am Katie Speroni.
1:03.4	I am a general surgery resident at the University of Southern California,
1:06.6	and I am joined by our team of bariatric surgeons.
1:09.6	Dr. Martin.
1:11.0	Hi, I'm Matt Martin. I'm a team of bariatric surgeons. Dr. Martin. Hi, Matt Martin.
1:12.4	I'm a trauma and bariatric surgeon at University of Southern California.
1:17.7	And Dr. Dan.
1:19.5	Yeah, Adrian Dan, I'm the program director for the Advanced GIMIS Bariatric and Foregud Fellowship
	...

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