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 .
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.
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.
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