Discussion
The concept of robotic surgery appeared in the 90's with the main objective of rendering possible distant procedures in battle fields, launching the principles of "telesurgery" [28-29]. Since its military applicability did not develop as initially expected, robotic surgery technology was modified towards the development of equipment which could align the excellent quality of high definition 3D-image, the intuitive movements of the open surgery and the precision, refinement and minimally invasive aspects of laparoscopic surgery. This combination seems to be very useful and beneficial in advanced and complex gastrointestinal surgeries, such as bariatric surgery [30-33].
Full mobilization of the greater gastric curvature can sometimes be quite tricky, especially as dissection approaches the uppermost part of the gastro-splenic ligament, and can become even more difficult when a sliding hernia is present. Failure to mobilize the herniated part of the stomach from the left crus results in retention of part of the gastric fundus, which in turn is considered one of the main reasons for poor postoperative excess weight loss. Additionally, an unclear view of this area during the application of the stapler can lead to a partial esophageal resection, predisposing in this way to a high leak from the staple line. All these technical difficulties can be even more pronounced when operating on super obese patients. The application of the robotic surgical system to lSG can help the surgeon overcome all these potential problems [34].
This literature review identified 14 articles [35-38] describing lSG and RSG as two alternative bariatric procedures, measuring the patients' outcomes and published between 2011 and 2016 (tabl. 1, 2). The articles included in this study bring us closer to linking the implementation of either method with improved standards of safety, efficiency and cost-effectiveness. The present study demonstrates that RSG and lSG are well-tolerated, feasible and effective surgical approaches.
Table 1. Characteristics of the studies that were finally included in the review for RSG (robotic sleeve gastrectomy) and LSG (laparoscopic sleeve gastrectomy)
Note. N/A not available, R retrospective, P prospective, LSG laparoscopic sleeve gastrectomy, RSG robotic sleeve gastrectomy, OT operative time, LOS length of stay
Table 2. Comparison of reported series of the intraoperative parameters and outcomes of every study for RSG (robotic sleeve gastrectomy) and LSG (laparoscopic sleeve gastrectomy)
Note. N/A not available, R retrospective, P prospective, LSG laparoscopic sleeve gastrectomy, RSG robotic sleeve gastrectomy, OT operative time, LOS length of stay.
We have compared mean age, mean preoperative BMI (kg/m2), bougie diameter (Fr), length of hospital stay (days), mean operative time (min), conversion rate (%), EWL 1 month (%), EWL 6 months (%).
According to previous studies [49-50], robot-assisted procedures are associated with greater mean operative time, due to the increased setup time. This is in accordance with our outcomes. In fact, in our study, mean operative time was greater in the RSG group. Mean length of hospital stay was significantly greater in the RSG group in these studies, instead in our experience was the same for both group. Moreover, both techniques are associated with small and comparable rates of complications and conversions, being significantly safe. Since stapling phase, in both groups, is not robotic, it would be interesting to examine the technique of oversewing or buttressing. However, the available data were not sufficient to address this technical aspect. leaks and hemorrhage are the main risks of bariatric procedures, due to the long stapled lines and gastrointestinal anastomosis. According to our findings, the incidence of complications were comparable between the two groups. No significant differences were reported for % EWL at 1 month and 6 month was comparable between the 2 methods.
Conclusions
The key advantage of the currently available robotic technology for minimally invasive bariatric surgery is the technical ease of complex laparoscopic maneuvers. In our study there aren't significant differences between the robotic and laparoscopic groups in terms of length of stay, EWL and complications, except for the mean operative time that is slightly higher in the robotic group and this difference is statistically significant. RSG proved to be a safe and efficient procedure, with satisfactory results comparable to LSG. longer and larger studies are needed for a better comparative evaluation.
References
1. Ng M., Fleming T., Robinson M., Thomson B., Graetz N., Margono C., et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014; 384 (9945): 766-81.
2. Buchwald H. The evolution of metabolic/bariatric surgery. Obes Surg. 2014; 24: 1126-35.
3. Harrison G.G. Height-weight tables. Ann Intern Med. 1985; 103 (6 Pt 2): 989-94.
4. Bray G.A., Greenway F.L., Molitch M.E., Dahms W.T., Atkinson R.L., Hamilton K. Use of anthropometric measures to assess weight loss. Am J Clin Nutr. 1978; 31 (5): 769-73.
5. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000; 894: i-xii, 1-253.
6. Jensen M.D., Ryan D.H., Apovian C.M., Ard J.D., Comuzzie A.G., Donato K.A., et al.; American College of Cardiology/American Heart Association Task Force onPractice Guidelines Obesity Society. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2014; 129 (25 suppl 2): S102-38.
7. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary. Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults. Am J Clin Nutr. 1998; 68 (4): 899-917.
8. Buchwald H., Avidor Y., Braunwald E., Jensen M.D., Pories W., Fahrbach K., et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004; 292 (14): 1724-37.
9. Christou N.V., Sampalis J.S., liberman M., look D., Auger S., Mclean A.P., et al. Surgery decreases longterm mortality, morbidity, and health care use in morbidly obese patients. Ann Surg. 2004; 240 (3): 416-24.
10. Sjostrom l., Narbro K., Sjostrom C.D., Karason K., larsson B., Wedel H., et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007; 357 (8): 741-52.
11. Cianci P., Tartaglia N., Altamura A., Di Lascia A., Fersini A., Neri V., et al. Cervical esophagotomy for foreign body extraction: a case report and extensive literature review of the last 20 years. Am J Case Rep. 2018; 19: 400-5. e-ISSN 1941-5923. DOI: https://doi.org/10.12659/AJCR.908373
12. Hess D.S., Hess D.W. Biliopancreatic diversion with a duodenal switch. Obes Surg. 1998; 8: 267-82.
13. Lagace M., Marceau P., Marceau S., Hould F.S., Potvin M., Bourque R.A., et al. Biliopancreatic diversion with a new type of gastrectomy: some previous conclusions revisited. Obes Surg. 1995; 5: 411-8.
14. Marceau P., Hould F.S., Simard S., Lebel S., Bourque R.A., Potvin M., et al. Biliopancreatic diversion with duodenal switch. World J Surg. 1998; 22: 947-54.
15. Scopinaro N., Gianetta E.,Adami G.F., Friedman D., Traverso E., Marinari G.M., et al. Biliopancreatic diversion for obesity at eighteen years. Surgery. 1996; 119: 261-8.
16. Cianci P., Fersini A., Tartaglia N., Altamura A., Lizzi V., Stoppino L.P., et al. Spleen assessment after laparoscopic transperitoneal left adrenalectomy: preliminary results. Surg Endosc. 2015; 30: 1503-7. ISSN: 0930-2794. DOI: https://doi.org/10.1007/S00464-015-4363-Y
17. Neri V., Ambrosi A., Fersini A., Tartaglia N., Cianci P., Lapolla F., et al. laparoscopic cholecystectomy: evaluation of liver function tests. Ann Ital Chir. 2014; 85 (5): 431-7. ISSN: 0003-469X.
18. Schauer P.R., Ikramuddin S., Gourash W., et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000; 232 (4): 515-29. PubMed PMID: 10998650. Pubmed Central PMCID: 1421184.
19. Cianci P., Tartaglia N., Altamura A., Fersini A., Sanguedolce F., Ambrosi A., et al. Hemoperitoneum due to breaking uterine adenosarcoma located in the omentum. Report of a case. Ann Ital Chir. 2016; 5. ISSN: 2239-253X.
20. Lee S., Carmody B., Wolfe L., et al. Effect of location and speed of diagnosis on anastomotic leak outcomes in 3828 gastric bypass cases. J Gastrointest Surg. 2007; 11 (6): 708-13. PubMed PMID: 17562118.
21. DeMaria E.J., Sugerman H.J., Kellum J.M., et al. Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Ann Surg. 2002; 235 (5): 640-7. PubMed PMID: 11981209. Pubmed Central PMCID: 1422489.
22. Tartaglia N., Cianci P., Di Lascia A., Fersini A., Ambrosi A., Neri V. Laparoscopic antegrade cholecystectomy: a standard procedure? Open Med. 2016; 11. P. 429-32. ISSN: 2391-5463. DOI: https://doi.org/10.1515/med-2016-0078
23. Trastulli S., Farinella E., Cirocchi R., et al. Robotic resection compared with laparoscopic rectal resection for cancer: systematic review and meta-analysis of shortterm outcome. Colorectal Dis. 2012; 14 (4): e134-56. PubMed PMID: 22151033.
24. Buchs N.C., Morel P., Azagury D.E., et al. laparoscopic versus robotic Roux-en-Y gastric bypass: lessons and long-term follow-up learned from a large prospective monocentric study. Obes Surg. 2014; 24 (12): 2031-9. PubMed PMID: 24962109.
25. Tartaglia N., di Lascia A., Lizzi V., Cianci P., Fersini A., Ambrosi A., et al. Haemostasis in thyroid surgery: collagen-fibrinogen-thrombin patch versus cellulose gauze - our experience. Surg Res Pract. 2016; 2016: 3058754. ISSN: 2356-6124. DOI: http://doi.org/10.1155/2016/3058754
26. Cianci P., Fersini A., Tartaglia N., Ambrosi A., Neri V. Are there differences between the right and left laparoscopic adrenalectomy? Our experience. Ann Ital Chir. 2015; 87: 242-6. ISSN: 0003-469X.
27. Tartaglia N., Di Lascia A., Cianci P., Fersini A., Sanguedolce F., Iadarola R., et al. One stage surgery for synchronous liver metastasis from a neuroendocrine tumor of the colon. A case report. Ann Ital Chir. 2017; Nov 20; 6. ISSN: 0003-469X.
28. Sanguedolce F., Landriscina M., Ambrosi A., Tartaglia N., Cianci P., Di Millo M., et al. Bladder metastases from breast cancer: managing the unexpected. A systematic review. Urol. Int. 2018; 101 (2): 125-31. ISSN: 00421138. DOI: http://doi.org/10.1159/000481576
29. Kim K., Hagen M.E., Buffington C. Robotics in advanced gastrointestinal surgery. The bariatric experience. Cancer J. 2013; 19: 177-82.
30. Wilson E.B., Sudan R. The evolution of robotic bariatric surgery. World J Surg. 2013; 37 (12): 2756-60.
31. Tartaglia N., Cianci P., Iadarola R., Di Lascia A., Fersini A., Ambrosi A., et al. Acute suppurative thyroiditis after fine needle aspiration. Case report and literature review. Chirurgia. 2017; 30: 89-94. ISSN: 1827-1782. DOI: http://doi.org/10.23736/S0394-9508.16.04613-1
32. Cianci P., Giaracuni G., Tartaglia N., Fersini A., Ambrosi A., Neri V. T-tube biliary drainage during reconstruction after pancreaticoduodenectomy. A single-center experience. Ann Ital Chir. 2017; 88: 330-5. ISSN: 2239-253X.
33. Diamantis T., Alexandrou A., Nikiteas N., et al. Initial experience with robotic sleeve gastrectomy for morbid obesity. Obes Surg. 2011; 21: 1172-9. DOI: http://doi.org/10.1007/s11695-010-0242-8
34. Alexandrou A., Athanasiou A., Michalinos A., et al. laparoscopic sleeve gastrectomy for morbid obesity: 5-year results. Am J Surg. 2015; 209 (2): 230-4.
35. Altieri M.S., Yang J., Telem D.A., et al. Robotic approaches may offer benefit in colorectal procedures, more controversial in other areas: a review of 168,248 cases. Surg Endosc. 2016; 30: 925-33. DOI: http://doi.org/10.1007/s00464-015-4327-2
36. Ayloo S., Buchs N.C., Addeo P., et al. Robot-assisted sleeve gastrectomy for super-morbidly obese patients. J laparoendosc Adv Surg Tech A. 2011; 21 (4): 295-9. DOI: http://doi.org/10.1089/lap.2010.0398
37. Bhatia P., Bindal V., Singh R., et al. Robot-assisted sleeve gastrectomy in morbidly obese versus super obese patients. J Soc Laparoendosc Surg. 2014; 18 (3). DOI: http://doi.org/10.4293/JSlS.2014.00099
38. Ecker B.L., Maduka R., Ramdon A., et al. Resident education in robotic-assisted vertical sleeve gastrectomy: outcomes and costanalysis of 411 consecutive cases. Surg Obes Relat Dis. 2016; 12 (2): 313-20. DOI: http://doi.org/10.1016/j.soard.2015.05.011
39. Elli E., Gonzalez-Heredia R., Sarvepalli S., et al. laparoscopic and robotic sleeve gastrectomy: short- and long-term results. Obes Surg. 2015; 25: 96 7 - 74. DOI: http://doi.org/10.1007/s11695-014-1499-0
40. Kannan U., Ecker B.L., Choudhury R., et al. laparoscopic hand assisted versus robotic-assisted laparoscopic sleeve gastrectomy: experience of 103 consecutive cases. Surg Obes Relat Dis. 2016; 12: 94-9. DOI: http://doi.org/10.1016/j.soard.2015.07.011
41. Moon R.C., Stephenson D., Royal N.A., et al. Robot-assisted versus laparoscopic sleeve gastrectomy: learning curve, perioperative, and short-term outcomes. Obes Surg. 2016; 26 (10): 2463-8. DOI: http://doi.org/10.1007/s11695-016-2131-2
42. Romero R.J., Radomir K., Rabaza J.R., et al. Robotic sleeve gastrectomy: experience of 134 cases and comparison with a systematic review of the laparoscopic approach. Obes Surg. 2013; 23: 1743 - 52. DOI: http://doi.org/10.1007/s11695-013-1004-1
43. Schraibman V., Macedo A.l.V., Epstein M.G., et al. Comparison of the morbidity, weight loss, and relative costs between robotic and laparoscopic sleeve gastrectomy for the treatment of obesity in Brazil. Obes Surg. 2014; 24: 1420-4. DOI: http://doi.org/10.1007/s11695-014-1239-5
44. Vilallonga R., Fort J.M., Caubet E., et al. Robotic sleeve gastrectomy versus laparoscopic sleeve gastrectomy: a comparative study with 200 patients. Obes Surg. 2013; 23: 1501-7. DOI: http://doi.org/10.1007/s11695- 013-1039-3
45. Villamere J., Gebhart A., Vu S., et al. Utilization and outcome of laparoscopic versus robotic general and bariatric surgical procedures at Academic Medical Centers. Surg Endosc. 2015; 29: 1729-36. DOI: http://doi.org/10.1007/s00464-014-3886-y
46. Zacharoulis D., Sioka E., Papamargaritis D., et al. Influence of the learning curve on safety and efficiency of laparoscopic sleeve gastrectomy. Obes Surg. 2012; 22: 411-5. DOI: http://doi.org/10.1007/s11695-011-0436-8
47. Magouliotis D.E., Tasiopoulou V.S., Sioka E., Zacharoulis D. Robotic versus laparoscopic sleeve gastrectomy for morbid obesity: a systematic review and meta-analysis. Obes Surg. 22017; 7: 245-53.
48. Di Lascia A., Tartaglia N., Fersini A., Petruzzelli F., Ambrosi A. Endoscopy for treating minor postcholecystectomy biliary fistula. A review of the literature. Ann Ital Chir. 2018; 89: 270-7. ISSN 2239-253X.
49. Tartaglia N., Iadarola R., Di Lascia A., Cianci P., Fersini A., Ambrosi A. What is the treatment of tracheal lesions associated with traditional thyroidectomy? Case report and systematic review. World J. Emerg. Surg. 2018; 13: 1-6. ISSN: 1749-7 9 2 2. DOI: http://doi.org/10.1186/s13017-018-0175-4
50. Neri V., Ambrosi A., Fersini A., Tartaglia N., la-polla F. Common bile duct lithiasis: therapeutic approach. Ann Ital Chir. 2013; 84 (4): 405-10. ISSN: 0003-469X