THE INTERNATIONAL JOURNAL OF MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY ORIGINAL Int J Med Robotics Comput Assist Surg 2015; 11: 284–289. Published online 10 October 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/rcs.1622
ARTICLE
Robotic revisional bariatric surgery: single-surgeon case series
Subhashini M. Ayloo* Nabajit Choudhury Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois Hospital and Health Sciences, Chicago, IL, USA * Correspondence to: S. M. Ayloo, Division of General, Minimally Invasive and Robotic Surgery, 840 South Wood Street, Mail Code 958, Suite 435E, Chicago, IL 60612, USA. E-mail: [email protected]
Abstract Background Bariatric surgery is the only effective treatment for the long-term maintenance of significant weight loss. Minimally invasive revisional procedures are on the rise. Data is lacking in terms of safety, feasibility and outcomes with robotic revisional procedures. Methods Robotic revisional bariatric procedures (RRBPs) of gastric band to Roux-en-Y gastric bypass and sleeve gastrectomy, revision of gastro–jejunal anastomosis and stricturoplasty performed during 2009–2013 were retrospectively reviewed. Results RRBPs were performed on 14 patients with mean age, pre-operative body mass index (BMI) and weight of 45.2 ± 11.4 years, 40.1 ± 8.7 kg/m2 and 109.4 ± 26 kg, respectively. The mean operative time, estimated blood loss and length of hospital stay were 220.6 ± 64.3) min, 31 ± 22.7 ml and 3.3 ± 1.5 days, respectively. There were no conversions, blood transfusions, gastrointestinal leaks, intraoperative complications or mortalities. Conclusion RRBP can be performed safely without increased morbidity and with the added benefit of a minimally invasive approach. Copyright © 2014 John Wiley & Sons, Ltd. Keywords revisional bariatric surgery; Roux-en-Y gastric bypass; robotic surgery; marginal ulcer; sleeve gastrectomy; gastric banding
Introduction
Accepted: 11 September 2014
Copyright © 2014 John Wiley & Sons, Ltd.
In 2008 there were 220 000 bariatric procedures performed in the USA, a number that continues to increase annually (1). Unfortunately, the long-term followup results for procedures such as adjustable gastric banding (AGB) and vertical banded gastroplasty (VBG) have been mostly poor. Revisional rates for these procedures have been reported to be 8–58% for AGB and 30–79% for VBG (2). Conversion to the Roux-en-Y gastric bypass (RYGB) has commonly served as the preferred alternative, although recently sleeve gastrectomy (SG) has been on the rise. An open approach to the revisional procedures remains the mainstay for these complex procedures; however, use of the laparoscopic platform is continuing to increase. Here we present our experience in a small series of revisional bariatric surgery procedures using the robotic platform.
285
Robotic revisional bariatric surgery
Revisional Roux-en-Y gastric bypass and sleeve gastrectomy
Materials and methods All cases of revisional bariatric procedures performed at a tertiary academic centre during 2009–2013 were maintained prospectively in a dedicated database and reviewed retrospectively. Revisional bariatric procedures included removal of the AGB and its components, with concurrent or delayed RYGB or SG. Other procedures included revision of gastrojejunostomy for marginal ulceration and gastro-gastric fistula, and stricturoplasty for gastric stricture from a VBG procedure. All the anastomoses for the revisional procedures were performed by a double-layered, hand-sewn technique. Simpler cases were excluded from the series (Table 1), which included removal of AGB or cracked tubing in the AGB, addressed by replacing the connecting tubing and subcutaneous port. All patients were reviewed for mean age, gender, ASA classification, original, pre-operative and postoperative weight and BMI, pre-operative and postoperative comorbidities, operative time, intraoperative complications, conversion to laparoscopic or open approach, estimated blood loss, blood transfusions, postoperative morbidity and mortality.
The major difference in the revisional RYGB and SG procedures versus the primary procedures are the adhesions of the stomach to the omentum and other organs, including
Surgical technique Patients were positioned in the reverse Trendlenburg supine or lithotomy position with arms tucked to the side, and the da Vinci robot was docked cranially. The trocars were set up similarly to a foregut operation, with the camera port at the umbilicus. The first and second arms of the robot were on either side of the camera port at the left mid-axillary line and the right lateral axillary line. The third robotic arm was placed in the left lateral axillary line and an assistant port placed in the right mid-axillary line. A Nathanson retractor was placed at the xiphoid to retract the left lateral segment, as in Figure 1.
Figure 1. Port positioning for revisional bariatric procedures: 1, first arm of the robot/right arm of the surgeon; 2, second arm of the robot/left arm of the surgeon; 3, third arm of the robot; NR, Nathanson liver retractor; SUL, spino-umbilical line; MCL, midclavicular line
Table 1. List of excluded patients Year of primary procedure
Type of primary procedure
Year of secondary procedure
1 2
2003 2009
AGB AGB
2009 2009
Intolerance Early stoma occlusion
3 4 5
2005 2007 2007
AGB AGB AGB
2008 2007 2012
Intolerance Intolerance Breakage of connecting tubing
6
2007
AGB
2012
7 8
2010 2009
AGB AGB
2011 2011
Recurrent pneumonia secondary to aspiration Intolerance Breakage of connecting tubing
Patient
Indication for secondary procedure
Type of secondary procedure Band removal Replacement with larger size AGB Band removal Band removal Replacement of the connecting tube/port Band removal Band removal Replacement of the connecting tube/port
AGB, adjustable gastric banding. Copyright © 2014 John Wiley & Sons, Ltd.
Int J Med Robotics Comput Assist Surg 2015; 11: 284–289. DOI: 10.1002/rcs
286
the liver, spleen, retroperitoneum and mesocolon. These adhesions need to be carefully taken down in order to avoid any inadvertent injury. We find leaving the band and its tubing in place until the creation of the pouch to be useful, as the tubing can be used to retract the stomach for dissection of the angle of His and to guide the bougie along the lesser curvature for creation of the pouch. The rest of the components of the procedure are similar to the primary procedures. Intraoperative endoscopy was performed to check the integrity of the anastomoses and the staple line.
Revision of gastro-jejunostomy for marginal ulceration For this procedure, en bloc resection of the gastro–jejunal anastomosis was performed, followed by recreation of the anastomosis between the pouch and the jejunum. In the other case of marginal ulceration, there was a fistula identified from the gastro–jejunal anastomosis to the remnant stomach. As a result, en bloc resection of the anastomosis and portion of the remnant stomach where the fistula was identified was removed. The remnant stomach gastrotomy was closed using absorbable sutures and the gastrojejunostomy was recreated. In both cases, the entire gastric pouch was dissected in order to rule out any other fistulas on any other part of the stomach.
Revision of VBG for obstruction For this procedure adhesiolysis was performed, with identification and removal of the silastic ring, and stricturoplasty of the stenotic area on the vertical banded gastroplasty was performed using a hand-sewn technique.
Results A total of 14 cases of revisional bariatric procedures were performed using the robotic platform. The primary procedures included 11 (78.5%) AGBs, two (14.2%) RYGBs and one VBG (7.1%). The revisional procedures performed included five (35.7%) conversions from AGB to robotic RYGB, six (42.8%) conversions from AGB to robotic SG, two (14.2%) cases of robotic revision of gastrojejunostomy anastomosis for marginal ulcer and gastrogastric fistula, and one (7.1%) case of revision of a VBG for gastric stricture. Associated procedures involved adhesiolysis (n = 12), band and component removal (n = 6), esophagogastroduodenoscopy (n = 8) and removal of a gastric ring (n = 1). Of the 14 cases, there were 13 women and 1 man; the mean age was 45.2 ± 11.4 years, Copyright © 2014 John Wiley & Sons, Ltd.
S. M. Ayloo and N. Choudhury
the mean pre-operative weight and BMI were 109.4 ± 26 kg and 40.1 ± 8.7) kg/m2, respectively. Using the American Society of Anesthesiologists (ASA) classification of patients, there were seven patients in class II and seven in class III. The mean operative time was 220.6 ± 64.3 min and the mean length of hospital stay was 3.3 ± 1.4 days. The estimated blood loss was 31 ± 22.7 ml and there were no intraoperative complications or conversions to open surgery or requirement for blood transfusions. Postoperative complications included one bowel obstruction, due to a pre-existing ventral hernia, which required diagnostic laparoscopy with reduction of incarcerated bowel and hernia repair on postoperative day 5. Two other patients were re-admitted for pain management and another two patients were treated on an outpatient basis for pain control. There were no gastrointestinal leaks or deaths in this series. Table 2 demonstrates the changes in BMI and weight from original to primary bariatric surgery (pre-operative) and ≤ 6 months after the secondary procedure (postoperative). The mean postoperative BMI and weight within 6 months follow-up in all patients were 35 kg/m2 and 95.3 kg, respectively. The mean postoperative BMI and weight beyond 6 months follow-up in seven patients were 30 kg/m2 and 82.5 kg, respectively. The changes in comorbidities that were accounted were type II diabetes, hypertension, dyslipidemia, osteoarthritis, obstructive sleep apnea, asthma and acid reflux.
Discussion The failure rate associated with AGB has been significant. Likewise, VBG, the once popular weight-loss procedure, has been abandoned as the procedure of choice for longterm maintenance of successful weight loss. In fact, approximately 25–54% of VBG patients eventually required a revisional procedure (3). Similarly, while RYGB has become the procedure of choice, reports have identified a 15–25% long-term failure rate (4). Moreover, RYGB is associated with long-term complications, including pouch enlargement, dilatation of the gastro–jejunal anastomosis, marginal ulceration and fistulas, all of which can contribute to the need for revisional surgeries (5–7). Thus, revisional bariatric procedures are unintended consequence of index bariatric procedures for failure to maintain lost weight or to address complications from the primary procedure. Revisional procedures are not benign and are associated with significant morbidity. In the Hallowell et al. (8) series, the authors found a nine-fold increase in gastrointestinal leaks and a 2.5-fold increase in ICU stay, along with a 1.5-fold increase in hospital stay; this was attributed to the complexity of the revisional cases, which Int J Med Robotics Comput Assist Surg 2015; 11: 284–289. DOI: 10.1002/rcs
Copyright © 2014 John Wiley & Sons, Ltd.
2010 2010
2007 2009
2006
47 46
49 33
54
RYGB RYGB VBG
AGB AGB
AGB AGB placed and removed AGB
AGB placed and removed AGB AGB
AGB placed and removed
AGB
AGB
Type of primary procedure
II III III
III II
III
II III
II II
II
III
II
II
ASA
Associated procedures
RRYGB AGB removal, adhesiolysis, EGD RRYGB AGB removal, adhesiolysis, EGD RRYGB Adhesiolysis, EGD
Type of revisional procedure
RSG RSG
Gastro-gastric fistula RGJ Marginal ulcer RGJ PSC inability to RG access biliary tree
Insufficient Wt loss Insufficient Wt loss
AGB removal, EGD AGB removal, adhesiolysis Adhesiolysis, EGD Adhesiolysis Adhesiolysis, prosthetic ring removal
Intolerance to RRYGB Adhesiolysis band, weight regain Insufficient Wt loss RRYGB Adhesiolysis Insufficient Wt loss RSG AGB removal, adhesiolysis, EGD Insufficient Wt loss RSG Band removal, EGD Intolerance to RSG Adhesiolysis, EGD band, weight regain Insufficient Wt loss RSG Adhesiolysis, EGD
Intolerance to band, weight regain
Insufficient Wt loss
Insufficient Wt loss
Indication for revisional procedure BMI
55.8
NA
52.7
NA 59.14
40.3
128.34 47.09 NA NA NA NA
NA 156
102
125.73 48 145 44
106.23 38 100.22 36.77
129
NA
122
125.64 42.1
Wt
Original
DM, HTN DM, HTN HTN, OA, GERD
DM, HTN, DL, OA, asthma GERD None
DM, GERD, HTN, DL, OSA, HT DM, HTN, OA HTN, DL DM, HTN, DL, KP, TX DL, GERD OSA, OA
OA
DM, GERD
Comorbiditities
BMI
36.12
BMI
WT
NA
NA
NA
BMI
NA NA
31.08 71.66 30.9 80.84 30.09 NA 87.2 31.9 NA
71.8
43.59
97.51 37.31 87
35.3
74.82 27.45 76.73 29.04 93.42 31.32
68 24.9 65.5 24.8 89.79 30.1
72.57 26.6 69.39 26.3 98.86 33.14
127.43 45 119.29 41 93.62 32.33 161 59.14 150.6 55.32 NA NA
110.2
DM, HTN DM, HTN NA
NA None
DM, HTN
DM OA
NA DM
HTN
DM, HTN
NA
DM
Co-morbidities improved/ resolved
> 6 months
76.79 29.96 69.38 27.1
119.74 49
114.73 39.62 NA
Wt
< 6 months
Postoperative (after secondary procedure)
102.04 38.61 89.7 34 88.45 33.5 149.34 44.65 103.85 31.05 91.62 27.4
100.45 36.29 100.1 37
83.9
96.23 38
128.11 52.5
128.34 43
Wt
Pre-operative (after primary procedure)
AGB, adjustable gastric banding; RRYGB, robotic Roux-en-Y gastric bypass; RSG, robotic sleeve gastrectomy; RGJ, robotic revision of gastrojejunostomy; RG, robotic gastroplasty; EGD, oesophagogastroduodenoscopy; Wt, weight (kg); BMI, body mass index; GERD, gastro-oesophageal reflux disease; KP-TX, kidney–pancreas transplant; DM, type II diabetes mellitus; OSA, obstructive sleep apnoea; OA, osteoarthritis; DL, dyslipidaemia; VBG, vertical banded gastroplastyl PSC, primary sclerosing cholangitis; HT, hypertriglyceridaemia; HTN, hypertension; NA, not available.
2009 2011 1982
2004
61
43 43 63
2007
55
2006 2010
2006
25
44 45
2006
26
Year of primary Age procedure
Table 2. Original, pre- and postoperative changes in weight, BMI and co-morbidities
Robotic revisional bariatric surgery
287
Int J Med Robotics Comput Assist Surg 2015; 11: 284–289. DOI: 10.1002/rcs
288
included adhesions from the primary procedure, inflammation, tissue changes and metabolic derangements. Thus, significant higher morbidity must be balanced with the resulting weight loss and improvement in comorbidities. Although there is an increase in the number of these procedures performed laparoscopically, the complexity of the procedure must dictate the approach. Victorzon (9) published, in a series of 34 patients with laparoscopic revisional bariatric procedures, an early morbidity rate of 26.5%; the author concluded that the laparoscopic approach required expertise and was technically challenging; however, the procedure could still be performed safely in majority of cases. Mognol et al. (10) presented a series of 24 patients who had conversion from VBG to RYGB with acceptable morbidity. Likewise, Mor et al. (11) presented a case-matched analysis of 160 revisional versus primary laparoscopic RYGBs and concluded that the revisional group experienced a longer length of stay, a higher conversion rate to open surgery and a higher 30 day morbidity rate. Although revisional procedures are laparoscopically feasible, they carry substantial morbidity. This is due to working in a previously operated abdomen with significant adhesions, loss of tissue planes, tissues that are scarred, compromised, fragile or inflamed, and in patients who have subclinical metabolic derangements along with challenging psychological issues. As a result, working in an environment such as this requires expertise with laparoscopy, a higher learning curve and a potentially lower threshold for conversion. Victorzon confirmed this in his series, emphasizing the need for such operations to be performed by expert surgeons or to have these types of cases centralized. The complexity of the cases depended on the primary procedure, indication for the secondary procedure and the number of previous surgeries. Removal of AGB and conversion to RYGB or SG might be less challenging in comparison to revision of gastro–jejunal anastomosis for gastro-gastric fistula with a marginal ulcer, because of the inflammatory process associated with such cases. Similar experience has been published by Stefanidis et al. (12) who, analysing their experience in 102 patients who underwent laparoscopic revisional procedures, concluded that the complexity of the revisional procedure and the number of prior surgeries predicted the perioperative morbidity. Conversely, the robotic platform offers superior ergonomics, which has the potential to make a difference in the outcomes of these complex procedures. Advantages include three-dimensional (3D) visualization, 7 + 1 degrees of freedom (DoFs), a stable platform to provide precise and reproducible moments, and an additional arm for tissue retraction and exposure. The robotic platform enables a more fluid work environment, with instruments that provide higher DoFs than laparoscopic instruments with two DoFs. Additionally, 3D magnification and a stable platform allow for a less strenuous operation for the surgeon, while Copyright © 2014 John Wiley & Sons, Ltd.
S. M. Ayloo and N. Choudhury
another robotic arm results in less dependence on the first assistant. Finally, in cases that require the creation of an anastomosis, this can be achieved easily using a hand-sewn, double-layered technique, thereby eliminating the need for staplers in an environment where the thickness of the tissues can be variable or the length of the pouch might be a limiting factor. If necessary, oversewing of the staple line for hemostasis can be accomplished effortlessly. In our experience, all the anastomoses were hand-sewn, without any gastrointestinal leak. There was one re-operation on a patient with pre-existing ventral hernia causing immediate postoperative bowel obstruction. Although, there is limited literature about the utility of the robotic platform in revisional bariatric procedures, Kim et al. (13) published their experience on 71 revisional procedures; they found that the robotic platform allows for safe operation and minimizes conversion to an open procedure. Buchs et al. (14) published their experience with revisional bariatric procedures with open, laparoscopic and robotic platforms. Their study noted significantly prolonged operative times with the robotic platform in comparison to the open or laparoscopic approaches.
Conclusion In summary, we find that the robotic platform can play a significant role in improving ergonomics, improving the quality of the dissection, thus potentially decreasing the morbidity associated with revisional procedures, and increasing the threshold for conversion to the open approach. The robotic platform can be used safely to perform these complex procedures with good outcomes. Still larger series are needed to weigh the potential benefits and avoidance of complications against the cost of using such a system for revisional cases.
Conflict of interest The authors declare no conflicts of interest.
Funding No specific funding.
References 1. American Society for Metabolic and Bariatric Surgery. Fact Sheet: metabolic and bariatric surgery. http://www.asmbs.org/ Int J Med Robotics Comput Assist Surg 2015; 11: 284–289. DOI: 10.1002/rcs
Robotic revisional bariatric surgery
2.
3. 4. 5. 6.
7.
Newsite07/media/ASMBS_Metabolic_Bariatric_Surgery_Overview_ FINAL_09.pdf. Accessed Feb 2013. Apers JA, Wens C, van Vlodrop V, et al. Perioperative outcomes of revisional laparoscopic gastric bypass after failed adjustable gastric banding and after vertical banded gastroplasty: experience with 107 cases and subgroup analysis. Surg Endosc 2013; 27: 558–564. Tevis S, Garren MJ, Gould JC. Revisional surgery for failed vertical-banded gastroplasty. Obes Surg 2011; 21: 1220–1224. Khoursheed MA, Al-Bader IA, Al-Asfar FS, et al. Revision of failed bariatric procedures to Roux-en-Y gastric bypass (RYGB). Obes Surg 2011; 21: 1157–1160. Schwartz RW, Strodel WE, Simpson WS, et al. Gastric bypass revision: lessons learned from 920 cases. Surgery 1988; 104: 806–812. Carrodeguas L, Szomstein S, Soto F, et al. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1292 consecutive patients and review of literature. Surg Obes Relat Dis 2005; 1: 467–474. Neff K, Olbers T, le Roux CW. Bariatric surgery: the challenges with candidate selection, individualizing treatment and clinical outcomes. BMC Med 2013; 11: 8.
Copyright © 2014 John Wiley & Sons, Ltd.
289 8. Hallowell PT, Stellato TA, Yao DA, et al. Should bariatric revisional surgery be avoided secondary to increased morbidity and mortality? Am J Surg 2009; 197: 391–396. 9. Victorzon M. Revisional bariatric surgery by conversion to gastric bypass or sleeve – good short-term outcomes at higher risks. Obes Surg 2012; 22: 29–33. 10. Mognol P, Chosidow D, Marmuse JP. Roux-en-Y gastric bypass after failed vertical banded gastroplasty. Obes Surg 2007; 17: 1431–1434. 11. Mor A, Keenan E, Portenier D, et al. Case-matched analysis comparing outcomes of revisional versus primary laparoscopic Roux-en-Y gastric bypass. Surg Endosc 2013; 27: 548–552. 12. Stefanidis D, Malireddy K, Kuwada T, et al. Revisional bariatric surgery: perioperative morbidity is determined by type of procedure. Surg Endosc 2013; 27: 4504–4510. 13. Kim K, Hagen ME, Buffington C. Robotics in advanced gastrointestinal surgery: the bariatric experience. Cancer J 2013; 19: 177–182. 14. Buchs NC, Pugin F, Azagury DE, et al. Robotic revisional bariatric surgery: a comparative study with laparoscopic and open surgery. Int J Med Robot 2014; 10: 213–217.
Int J Med Robotics Comput Assist Surg 2015; 11: 284–289. DOI: 10.1002/rcs
ARTICLE
Robotic revisional bariatric surgery: single-surgeon case series
Subhashini M. Ayloo* Nabajit Choudhury Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois Hospital and Health Sciences, Chicago, IL, USA * Correspondence to: S. M. Ayloo, Division of General, Minimally Invasive and Robotic Surgery, 840 South Wood Street, Mail Code 958, Suite 435E, Chicago, IL 60612, USA. E-mail: [email protected]
Abstract Background Bariatric surgery is the only effective treatment for the long-term maintenance of significant weight loss. Minimally invasive revisional procedures are on the rise. Data is lacking in terms of safety, feasibility and outcomes with robotic revisional procedures. Methods Robotic revisional bariatric procedures (RRBPs) of gastric band to Roux-en-Y gastric bypass and sleeve gastrectomy, revision of gastro–jejunal anastomosis and stricturoplasty performed during 2009–2013 were retrospectively reviewed. Results RRBPs were performed on 14 patients with mean age, pre-operative body mass index (BMI) and weight of 45.2 ± 11.4 years, 40.1 ± 8.7 kg/m2 and 109.4 ± 26 kg, respectively. The mean operative time, estimated blood loss and length of hospital stay were 220.6 ± 64.3) min, 31 ± 22.7 ml and 3.3 ± 1.5 days, respectively. There were no conversions, blood transfusions, gastrointestinal leaks, intraoperative complications or mortalities. Conclusion RRBP can be performed safely without increased morbidity and with the added benefit of a minimally invasive approach. Copyright © 2014 John Wiley & Sons, Ltd. Keywords revisional bariatric surgery; Roux-en-Y gastric bypass; robotic surgery; marginal ulcer; sleeve gastrectomy; gastric banding
Introduction
Accepted: 11 September 2014
Copyright © 2014 John Wiley & Sons, Ltd.
In 2008 there were 220 000 bariatric procedures performed in the USA, a number that continues to increase annually (1). Unfortunately, the long-term followup results for procedures such as adjustable gastric banding (AGB) and vertical banded gastroplasty (VBG) have been mostly poor. Revisional rates for these procedures have been reported to be 8–58% for AGB and 30–79% for VBG (2). Conversion to the Roux-en-Y gastric bypass (RYGB) has commonly served as the preferred alternative, although recently sleeve gastrectomy (SG) has been on the rise. An open approach to the revisional procedures remains the mainstay for these complex procedures; however, use of the laparoscopic platform is continuing to increase. Here we present our experience in a small series of revisional bariatric surgery procedures using the robotic platform.
285
Robotic revisional bariatric surgery
Revisional Roux-en-Y gastric bypass and sleeve gastrectomy
Materials and methods All cases of revisional bariatric procedures performed at a tertiary academic centre during 2009–2013 were maintained prospectively in a dedicated database and reviewed retrospectively. Revisional bariatric procedures included removal of the AGB and its components, with concurrent or delayed RYGB or SG. Other procedures included revision of gastrojejunostomy for marginal ulceration and gastro-gastric fistula, and stricturoplasty for gastric stricture from a VBG procedure. All the anastomoses for the revisional procedures were performed by a double-layered, hand-sewn technique. Simpler cases were excluded from the series (Table 1), which included removal of AGB or cracked tubing in the AGB, addressed by replacing the connecting tubing and subcutaneous port. All patients were reviewed for mean age, gender, ASA classification, original, pre-operative and postoperative weight and BMI, pre-operative and postoperative comorbidities, operative time, intraoperative complications, conversion to laparoscopic or open approach, estimated blood loss, blood transfusions, postoperative morbidity and mortality.
The major difference in the revisional RYGB and SG procedures versus the primary procedures are the adhesions of the stomach to the omentum and other organs, including
Surgical technique Patients were positioned in the reverse Trendlenburg supine or lithotomy position with arms tucked to the side, and the da Vinci robot was docked cranially. The trocars were set up similarly to a foregut operation, with the camera port at the umbilicus. The first and second arms of the robot were on either side of the camera port at the left mid-axillary line and the right lateral axillary line. The third robotic arm was placed in the left lateral axillary line and an assistant port placed in the right mid-axillary line. A Nathanson retractor was placed at the xiphoid to retract the left lateral segment, as in Figure 1.
Figure 1. Port positioning for revisional bariatric procedures: 1, first arm of the robot/right arm of the surgeon; 2, second arm of the robot/left arm of the surgeon; 3, third arm of the robot; NR, Nathanson liver retractor; SUL, spino-umbilical line; MCL, midclavicular line
Table 1. List of excluded patients Year of primary procedure
Type of primary procedure
Year of secondary procedure
1 2
2003 2009
AGB AGB
2009 2009
Intolerance Early stoma occlusion
3 4 5
2005 2007 2007
AGB AGB AGB
2008 2007 2012
Intolerance Intolerance Breakage of connecting tubing
6
2007
AGB
2012
7 8
2010 2009
AGB AGB
2011 2011
Recurrent pneumonia secondary to aspiration Intolerance Breakage of connecting tubing
Patient
Indication for secondary procedure
Type of secondary procedure Band removal Replacement with larger size AGB Band removal Band removal Replacement of the connecting tube/port Band removal Band removal Replacement of the connecting tube/port
AGB, adjustable gastric banding. Copyright © 2014 John Wiley & Sons, Ltd.
Int J Med Robotics Comput Assist Surg 2015; 11: 284–289. DOI: 10.1002/rcs
286
the liver, spleen, retroperitoneum and mesocolon. These adhesions need to be carefully taken down in order to avoid any inadvertent injury. We find leaving the band and its tubing in place until the creation of the pouch to be useful, as the tubing can be used to retract the stomach for dissection of the angle of His and to guide the bougie along the lesser curvature for creation of the pouch. The rest of the components of the procedure are similar to the primary procedures. Intraoperative endoscopy was performed to check the integrity of the anastomoses and the staple line.
Revision of gastro-jejunostomy for marginal ulceration For this procedure, en bloc resection of the gastro–jejunal anastomosis was performed, followed by recreation of the anastomosis between the pouch and the jejunum. In the other case of marginal ulceration, there was a fistula identified from the gastro–jejunal anastomosis to the remnant stomach. As a result, en bloc resection of the anastomosis and portion of the remnant stomach where the fistula was identified was removed. The remnant stomach gastrotomy was closed using absorbable sutures and the gastrojejunostomy was recreated. In both cases, the entire gastric pouch was dissected in order to rule out any other fistulas on any other part of the stomach.
Revision of VBG for obstruction For this procedure adhesiolysis was performed, with identification and removal of the silastic ring, and stricturoplasty of the stenotic area on the vertical banded gastroplasty was performed using a hand-sewn technique.
Results A total of 14 cases of revisional bariatric procedures were performed using the robotic platform. The primary procedures included 11 (78.5%) AGBs, two (14.2%) RYGBs and one VBG (7.1%). The revisional procedures performed included five (35.7%) conversions from AGB to robotic RYGB, six (42.8%) conversions from AGB to robotic SG, two (14.2%) cases of robotic revision of gastrojejunostomy anastomosis for marginal ulcer and gastrogastric fistula, and one (7.1%) case of revision of a VBG for gastric stricture. Associated procedures involved adhesiolysis (n = 12), band and component removal (n = 6), esophagogastroduodenoscopy (n = 8) and removal of a gastric ring (n = 1). Of the 14 cases, there were 13 women and 1 man; the mean age was 45.2 ± 11.4 years, Copyright © 2014 John Wiley & Sons, Ltd.
S. M. Ayloo and N. Choudhury
the mean pre-operative weight and BMI were 109.4 ± 26 kg and 40.1 ± 8.7) kg/m2, respectively. Using the American Society of Anesthesiologists (ASA) classification of patients, there were seven patients in class II and seven in class III. The mean operative time was 220.6 ± 64.3 min and the mean length of hospital stay was 3.3 ± 1.4 days. The estimated blood loss was 31 ± 22.7 ml and there were no intraoperative complications or conversions to open surgery or requirement for blood transfusions. Postoperative complications included one bowel obstruction, due to a pre-existing ventral hernia, which required diagnostic laparoscopy with reduction of incarcerated bowel and hernia repair on postoperative day 5. Two other patients were re-admitted for pain management and another two patients were treated on an outpatient basis for pain control. There were no gastrointestinal leaks or deaths in this series. Table 2 demonstrates the changes in BMI and weight from original to primary bariatric surgery (pre-operative) and ≤ 6 months after the secondary procedure (postoperative). The mean postoperative BMI and weight within 6 months follow-up in all patients were 35 kg/m2 and 95.3 kg, respectively. The mean postoperative BMI and weight beyond 6 months follow-up in seven patients were 30 kg/m2 and 82.5 kg, respectively. The changes in comorbidities that were accounted were type II diabetes, hypertension, dyslipidemia, osteoarthritis, obstructive sleep apnea, asthma and acid reflux.
Discussion The failure rate associated with AGB has been significant. Likewise, VBG, the once popular weight-loss procedure, has been abandoned as the procedure of choice for longterm maintenance of successful weight loss. In fact, approximately 25–54% of VBG patients eventually required a revisional procedure (3). Similarly, while RYGB has become the procedure of choice, reports have identified a 15–25% long-term failure rate (4). Moreover, RYGB is associated with long-term complications, including pouch enlargement, dilatation of the gastro–jejunal anastomosis, marginal ulceration and fistulas, all of which can contribute to the need for revisional surgeries (5–7). Thus, revisional bariatric procedures are unintended consequence of index bariatric procedures for failure to maintain lost weight or to address complications from the primary procedure. Revisional procedures are not benign and are associated with significant morbidity. In the Hallowell et al. (8) series, the authors found a nine-fold increase in gastrointestinal leaks and a 2.5-fold increase in ICU stay, along with a 1.5-fold increase in hospital stay; this was attributed to the complexity of the revisional cases, which Int J Med Robotics Comput Assist Surg 2015; 11: 284–289. DOI: 10.1002/rcs
Copyright © 2014 John Wiley & Sons, Ltd.
2010 2010
2007 2009
2006
47 46
49 33
54
RYGB RYGB VBG
AGB AGB
AGB AGB placed and removed AGB
AGB placed and removed AGB AGB
AGB placed and removed
AGB
AGB
Type of primary procedure
II III III
III II
III
II III
II II
II
III
II
II
ASA
Associated procedures
RRYGB AGB removal, adhesiolysis, EGD RRYGB AGB removal, adhesiolysis, EGD RRYGB Adhesiolysis, EGD
Type of revisional procedure
RSG RSG
Gastro-gastric fistula RGJ Marginal ulcer RGJ PSC inability to RG access biliary tree
Insufficient Wt loss Insufficient Wt loss
AGB removal, EGD AGB removal, adhesiolysis Adhesiolysis, EGD Adhesiolysis Adhesiolysis, prosthetic ring removal
Intolerance to RRYGB Adhesiolysis band, weight regain Insufficient Wt loss RRYGB Adhesiolysis Insufficient Wt loss RSG AGB removal, adhesiolysis, EGD Insufficient Wt loss RSG Band removal, EGD Intolerance to RSG Adhesiolysis, EGD band, weight regain Insufficient Wt loss RSG Adhesiolysis, EGD
Intolerance to band, weight regain
Insufficient Wt loss
Insufficient Wt loss
Indication for revisional procedure BMI
55.8
NA
52.7
NA 59.14
40.3
128.34 47.09 NA NA NA NA
NA 156
102
125.73 48 145 44
106.23 38 100.22 36.77
129
NA
122
125.64 42.1
Wt
Original
DM, HTN DM, HTN HTN, OA, GERD
DM, HTN, DL, OA, asthma GERD None
DM, GERD, HTN, DL, OSA, HT DM, HTN, OA HTN, DL DM, HTN, DL, KP, TX DL, GERD OSA, OA
OA
DM, GERD
Comorbiditities
BMI
36.12
BMI
WT
NA
NA
NA
BMI
NA NA
31.08 71.66 30.9 80.84 30.09 NA 87.2 31.9 NA
71.8
43.59
97.51 37.31 87
35.3
74.82 27.45 76.73 29.04 93.42 31.32
68 24.9 65.5 24.8 89.79 30.1
72.57 26.6 69.39 26.3 98.86 33.14
127.43 45 119.29 41 93.62 32.33 161 59.14 150.6 55.32 NA NA
110.2
DM, HTN DM, HTN NA
NA None
DM, HTN
DM OA
NA DM
HTN
DM, HTN
NA
DM
Co-morbidities improved/ resolved
> 6 months
76.79 29.96 69.38 27.1
119.74 49
114.73 39.62 NA
Wt
< 6 months
Postoperative (after secondary procedure)
102.04 38.61 89.7 34 88.45 33.5 149.34 44.65 103.85 31.05 91.62 27.4
100.45 36.29 100.1 37
83.9
96.23 38
128.11 52.5
128.34 43
Wt
Pre-operative (after primary procedure)
AGB, adjustable gastric banding; RRYGB, robotic Roux-en-Y gastric bypass; RSG, robotic sleeve gastrectomy; RGJ, robotic revision of gastrojejunostomy; RG, robotic gastroplasty; EGD, oesophagogastroduodenoscopy; Wt, weight (kg); BMI, body mass index; GERD, gastro-oesophageal reflux disease; KP-TX, kidney–pancreas transplant; DM, type II diabetes mellitus; OSA, obstructive sleep apnoea; OA, osteoarthritis; DL, dyslipidaemia; VBG, vertical banded gastroplastyl PSC, primary sclerosing cholangitis; HT, hypertriglyceridaemia; HTN, hypertension; NA, not available.
2009 2011 1982
2004
61
43 43 63
2007
55
2006 2010
2006
25
44 45
2006
26
Year of primary Age procedure
Table 2. Original, pre- and postoperative changes in weight, BMI and co-morbidities
Robotic revisional bariatric surgery
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included adhesions from the primary procedure, inflammation, tissue changes and metabolic derangements. Thus, significant higher morbidity must be balanced with the resulting weight loss and improvement in comorbidities. Although there is an increase in the number of these procedures performed laparoscopically, the complexity of the procedure must dictate the approach. Victorzon (9) published, in a series of 34 patients with laparoscopic revisional bariatric procedures, an early morbidity rate of 26.5%; the author concluded that the laparoscopic approach required expertise and was technically challenging; however, the procedure could still be performed safely in majority of cases. Mognol et al. (10) presented a series of 24 patients who had conversion from VBG to RYGB with acceptable morbidity. Likewise, Mor et al. (11) presented a case-matched analysis of 160 revisional versus primary laparoscopic RYGBs and concluded that the revisional group experienced a longer length of stay, a higher conversion rate to open surgery and a higher 30 day morbidity rate. Although revisional procedures are laparoscopically feasible, they carry substantial morbidity. This is due to working in a previously operated abdomen with significant adhesions, loss of tissue planes, tissues that are scarred, compromised, fragile or inflamed, and in patients who have subclinical metabolic derangements along with challenging psychological issues. As a result, working in an environment such as this requires expertise with laparoscopy, a higher learning curve and a potentially lower threshold for conversion. Victorzon confirmed this in his series, emphasizing the need for such operations to be performed by expert surgeons or to have these types of cases centralized. The complexity of the cases depended on the primary procedure, indication for the secondary procedure and the number of previous surgeries. Removal of AGB and conversion to RYGB or SG might be less challenging in comparison to revision of gastro–jejunal anastomosis for gastro-gastric fistula with a marginal ulcer, because of the inflammatory process associated with such cases. Similar experience has been published by Stefanidis et al. (12) who, analysing their experience in 102 patients who underwent laparoscopic revisional procedures, concluded that the complexity of the revisional procedure and the number of prior surgeries predicted the perioperative morbidity. Conversely, the robotic platform offers superior ergonomics, which has the potential to make a difference in the outcomes of these complex procedures. Advantages include three-dimensional (3D) visualization, 7 + 1 degrees of freedom (DoFs), a stable platform to provide precise and reproducible moments, and an additional arm for tissue retraction and exposure. The robotic platform enables a more fluid work environment, with instruments that provide higher DoFs than laparoscopic instruments with two DoFs. Additionally, 3D magnification and a stable platform allow for a less strenuous operation for the surgeon, while Copyright © 2014 John Wiley & Sons, Ltd.
S. M. Ayloo and N. Choudhury
another robotic arm results in less dependence on the first assistant. Finally, in cases that require the creation of an anastomosis, this can be achieved easily using a hand-sewn, double-layered technique, thereby eliminating the need for staplers in an environment where the thickness of the tissues can be variable or the length of the pouch might be a limiting factor. If necessary, oversewing of the staple line for hemostasis can be accomplished effortlessly. In our experience, all the anastomoses were hand-sewn, without any gastrointestinal leak. There was one re-operation on a patient with pre-existing ventral hernia causing immediate postoperative bowel obstruction. Although, there is limited literature about the utility of the robotic platform in revisional bariatric procedures, Kim et al. (13) published their experience on 71 revisional procedures; they found that the robotic platform allows for safe operation and minimizes conversion to an open procedure. Buchs et al. (14) published their experience with revisional bariatric procedures with open, laparoscopic and robotic platforms. Their study noted significantly prolonged operative times with the robotic platform in comparison to the open or laparoscopic approaches.
Conclusion In summary, we find that the robotic platform can play a significant role in improving ergonomics, improving the quality of the dissection, thus potentially decreasing the morbidity associated with revisional procedures, and increasing the threshold for conversion to the open approach. The robotic platform can be used safely to perform these complex procedures with good outcomes. Still larger series are needed to weigh the potential benefits and avoidance of complications against the cost of using such a system for revisional cases.
Conflict of interest The authors declare no conflicts of interest.
Funding No specific funding.
References 1. American Society for Metabolic and Bariatric Surgery. Fact Sheet: metabolic and bariatric surgery. http://www.asmbs.org/ Int J Med Robotics Comput Assist Surg 2015; 11: 284–289. DOI: 10.1002/rcs
Robotic revisional bariatric surgery
2.
3. 4. 5. 6.
7.
Newsite07/media/ASMBS_Metabolic_Bariatric_Surgery_Overview_ FINAL_09.pdf. Accessed Feb 2013. Apers JA, Wens C, van Vlodrop V, et al. Perioperative outcomes of revisional laparoscopic gastric bypass after failed adjustable gastric banding and after vertical banded gastroplasty: experience with 107 cases and subgroup analysis. Surg Endosc 2013; 27: 558–564. Tevis S, Garren MJ, Gould JC. Revisional surgery for failed vertical-banded gastroplasty. Obes Surg 2011; 21: 1220–1224. Khoursheed MA, Al-Bader IA, Al-Asfar FS, et al. Revision of failed bariatric procedures to Roux-en-Y gastric bypass (RYGB). Obes Surg 2011; 21: 1157–1160. Schwartz RW, Strodel WE, Simpson WS, et al. Gastric bypass revision: lessons learned from 920 cases. Surgery 1988; 104: 806–812. Carrodeguas L, Szomstein S, Soto F, et al. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1292 consecutive patients and review of literature. Surg Obes Relat Dis 2005; 1: 467–474. Neff K, Olbers T, le Roux CW. Bariatric surgery: the challenges with candidate selection, individualizing treatment and clinical outcomes. BMC Med 2013; 11: 8.
Copyright © 2014 John Wiley & Sons, Ltd.
289 8. Hallowell PT, Stellato TA, Yao DA, et al. Should bariatric revisional surgery be avoided secondary to increased morbidity and mortality? Am J Surg 2009; 197: 391–396. 9. Victorzon M. Revisional bariatric surgery by conversion to gastric bypass or sleeve – good short-term outcomes at higher risks. Obes Surg 2012; 22: 29–33. 10. Mognol P, Chosidow D, Marmuse JP. Roux-en-Y gastric bypass after failed vertical banded gastroplasty. Obes Surg 2007; 17: 1431–1434. 11. Mor A, Keenan E, Portenier D, et al. Case-matched analysis comparing outcomes of revisional versus primary laparoscopic Roux-en-Y gastric bypass. Surg Endosc 2013; 27: 548–552. 12. Stefanidis D, Malireddy K, Kuwada T, et al. Revisional bariatric surgery: perioperative morbidity is determined by type of procedure. Surg Endosc 2013; 27: 4504–4510. 13. Kim K, Hagen ME, Buffington C. Robotics in advanced gastrointestinal surgery: the bariatric experience. Cancer J 2013; 19: 177–182. 14. Buchs NC, Pugin F, Azagury DE, et al. Robotic revisional bariatric surgery: a comparative study with laparoscopic and open surgery. Int J Med Robot 2014; 10: 213–217.
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