Robotic Roux-en-Y gastric bypass: surgical technique and short-term experience from 329 cases

Abstract

Objective: minimally invasive bariatric surgery is clearly superior over open procedures including better early outcomes. Different surgical approaches are used to treat the severely obese, having Roux-en-Y gastric bypass (RYGB) being a highly frequent procedure. Robotic surgery overcomes some laparoscopic limitations adding ergonomics, articulating instruments and a three-dimensional high definition camera. Based on our vast robotic experience, we present our referred group case series and a standardized Robotic Roux-en-Y gastric bypass (rRYGB) technique as well as its outcomes.

Methods: a review of a prospective maintained database was conducted in patients submitted to robotic Roux en Y bariatric surgery between April 2015 and July 2019. Surgical technique is described and illustrated. We also reported patients demographics, outcomes and its follow-up.

Results: a Retrospective analysis identified 329 patients submitted to Robotic Roux-en-Y gastric bypass. Both da Vinci Si and Xi platforms were used. Mean age was 34.4 years, with median BMI of 44.2 kg/m2. Mean console time was 102 min and there was no conversion. No surgical hospital readmission rates were seen in the first 30 days.

Conclusion: this study represents our initial experience of robotic Roux-en-Y gastric bypass (rRYGB), its short outcomes and a standardized surgical technique. Our results encourage that rRYGB is technically feasible and safe, and might offer some advantages showing good outcomes and minimal complications.

Figure 1. A: Da vinci Si port placement for a rRYGB. B: Da vinci Xi port placement for a rRYGB. C: Hiss angle dissection and visualization of the left crux. D: Lesser omentum opening to achieve the lesser sac and visualization of the posterior wall of the stomach.

Figure 2. A: A 45mm linear stapler clamped and fired transversely assuring an equal anterior and posterior stomach wall division. B: Clearing posterior stomach wall of any possible adherences. C: Pouch creation with subsequent 45mm linear staplers, calibrated by an oral bougie. D: Identification of Treitz angle and first jejunal branch.

Figure 3. A: Jejunum bowel measured assuring the proximal segments to be laterally in the abdomen. B: A 45mm linear stapler inserted in the jejunum for a gastrojejunal anastomosis. C: A side-to-side gastrojejunostomy fashioned and calibrated having an equal positioning of both tissues. D: Anastomosis single stitch in the medial aspect of the gastrojejunal orifice.

Figure 4. A: First layer of closure in an inverted T extramucosal continuous technique with forehand bites in the jejunum. B: First layer of closure in an inverted T extramucosal continuous technique with backhand bites in the stomach. C/D: A second layer of suture is done in an unidirectional continuous seromuscular technique.

Figure 5. A: A side-to-side jejunojejunostomy created using the 45mm linear stapler. B/C: single extramucosal running suture technique. D: Mesenteric defects closure with a running suture.

Figure 6. A: Transection of the bowel loop created for the gastrojejunostomy using a 45mm linear stapler, assuring a Roux-en-Y anatomy. B: Gastrojejunal anastomosis methylene blue test. C: Using a Robotic Sureform with SmartfireT stapler for a total robotic RYGB. D: Gastrojejunal anastomosis vascular assessment using ICG with Firefly technologyT.