with the rise in the prevalence of obesity , the field of bariatric surgery is witnessing an ever increasing demand .
along with that , comes the challenge of operating on patients with high body mass index ( bmi ) , revisional bariatric procedures ( rbp ) , managing complications and reoperative abdomens . performing bariatric surgery can be technically demanding in many situations because of large patients , large livers , thick abdominal walls and substantial visceral fat making exposure , dissection , and reconstruction difficult .
the super obese ( so ) patients with a bmi 50 kg / m is a difficult to manage population because of limited working space , excessive torque on instruments due to thick abdominal wall , co - morbidities and high - risk anaesthesia .
the management of patients with super - super obesity ( bmi > 60 kg / m ) also remains a challenge .
moreover , the surgeons encounter very difficult ergonomic positions , which can potentially be career shortening for them .
the surgeons have been looking for methods to improve the patient outcomes , surgical technique and decrease complications on one hand , and reducing the number and size of incisions on the other hand .
robotic surgery has provided the surgeons with the advantage of three - dimensional vision , increased dexterity and precision by downscaling surgeon 's movements enabling a fine tissue dissection and filtering out physiological tremor .
it overcomes the restraint of torque on ports from thick abdominal wall , and minimises port site trauma by remote centre technology .
the main limitation with robotic surgery is the perceived higher cost and set - up time compared with laparoscopy . but
with increased experience , it is seen that set - up times reduce , and costs may also come down as material prices reduce .
the mainstream bariatric procedures are adjustable gastric banding ( agb ) , sleeve gastrectomy ( sg ) , roux - en - y gastric bypass ( rygb ) and biliopancreatic diversion with duodenal switch . using pubmed
, we reviewed the published evidence of using robotics for these procedures as well as performing rbp .
the search terms included bariatric surgery , robotic bariatric surgery , robotic gastric banding , robotic sg , robotic roux - en - y gastric bypass ( rrygb ) , robotic biliopancreatic diversion and robotic revisional bariatric surgery .
the inclusion criteria were english language , original research , bariatric surgical procedures using robotics and human studies .
the use of agb has decreased tremendously all over the world because of low efficacy and high revision / complication rate associated with it .
there have been few studies published in the literature looking at outcomes of robotic assistance in agb , and showed little benefit for using the robot .
edelson et al . reported the largest study with 287 patients of robotic agb compared with 120 patients who underwent laparoscopic agb .
no significant differences were found in the operating room ( or ) times , hospital stay , complication rates , or excess weight loss .
they did find a shorter operative time by 12 min in the robotic arm when compared for so patients . as of now , robot is used mostly for managing complications and revising gastric band to another weight loss procedure , and this is dealt with in the section on rbp .
sleeve gastrectomy is increasingly becoming popular because of its low morbidity , excellent outcome and perceived technical simplicity .
it is especially so in indian sub - continent because of high prevalence of a vegetarian population , who tend to choose a restrictive procedure rather than a malabsorptive one .
there are certain peculiarities in sg like it has a long staple line with the potential to leak , and a precise and safe dissection is required in the area of the left crus and hiatus entirely to mobilize the fundus .
compared to laparoscopic surgery , robotic surgery offers the possibility for endowrist , and this action facilitates the hiatal dissection and over sewing of the staple line .
five studies have been published , which focus on robotic sleeve gastrectomy ( rsg ) .
compared 30 robotic with 39 laparoscopic sg procedures and found no difference in length of hospital stay , complication rates or excess body weight loss at 1-year .
they found a significantly longer or time for rsg ( 135 vs. 114 min ) , due to the fact that they had oversewn the staple line in the robotic arm and not in the laparoscopic arm .
he also published a large comparative series on sg including 100 patients each in robotic and laparoscopic arms .
they found that or time was significantly longer in a robotic group by 12 min .
they did found that leaks occurred only in those patients in whom they did not oversew the staple line , but used a buttress material .
they concluded that rsg is a good stepping stone to robotic gastric bypass and rbp .
published their experience of 134 rsg cases and compared it with descriptive results of a systematic review of laparoscopic sg ( n = 3148 ) .
the or time was significantly higher by 12 min ( p = 0.006 ) , whereas the length of stay was lower by 1.1 days in a robotic group ( p  0.005 ) .
leaks were found in 0 rsg versus 1.97% laparoscopic sg ( p = 0.101 ) ; strictures in 0 versus 0.43% ( p = 0.447 ) ; bleeding in 0.7 versus 1.21% ( p = 0.594 ) ; and mortality in 0 versus 0.1% ( p = 0.714 ) , respectively .
we performed a comparative study of rsg in morbidly obese ( mo ) versus so patients at our centre .
11 so patients were compared with 24 mo patients who underwent robotic sg with oversewing of the staple line in all the cases .
there was no significant difference in or time , length of hospital stay or complications in between the two groups .
thus , presumably , using a robotic system overcomes many difficulties in the so patients and enables the surgeon perform the similar procedure as in mo patients with equal precision , similar time and little or no extra effort .
roux - en - y gastric bypass is considered as the gold standard surgical procedure for morbid obesity by many specialists .
as rygb involves two anastomoses ( gastrojejunostomy [ gj ] and jejunojejunostomy ) , robotic surgery is currently considered as an attractive technology that could help perform rygb , given its well - described advantages .
there have been nine significant published series comparing outcomes of rrygb versus laparoscopic rygb ( lrygb ) .
these studies represent the entire literature on rrygb and its outcomes . for each study , we report the number of patients , mean age , mean preoperative bmi , mean or time , type of gj ( sutured or stapled ) , length of hospital stay , overall complication rate , leak rate , gj stricture rate and mortality . these results are compiled in tables 1 and 2 .
robotic vs. laparoscopic rygb : preoperative data robotic vs. laparoscopic rygb : peri - operative data there was a total of 3337 patients in these 9 studies with 1381 in a robotic arm and 1956 in the laparoscopic arm . the mean age in rrygb and lrygb group was 43.3 years and 42.4 years , respectively .
average bmi was 45.8 in rrygb patients and 46.7 in lrygb patients . the mean or time was 211.9 min in robotic arm versus 185.1 min in the laparoscopic arm .
three studies report a significantly shorter operative time in a robotic group , while four studies report a significantly longer operative time in a robotic arm .
this may be compounded by the fact that in all the studies , a sutured gj was done in the robotic arm , while a stapled gj was done in the laparoscopic arm in six out of nine studies .
the average length of stay was 5 days in robotic group versus 7.1 days in the laparoscopic group .
three studies found a statistically significant shorter hospital stay in the robotic arm , while one study found a significantly longer stay in the robotic arm .
found a significantly lower incidence of complication in a robotic group ( 11.6% vs. 16.1% ) .
the average leak rate across studies was 0.9% in rrygb versus 1.6% in lrygb , while the gj stricture rate was 3.1% in a robotic arm and 3.2% in the laparoscopic arm .
of all the published studies , there is only one prospectively randomized trial by sanchez et al .
the other studies are either comparative studies , case series , retrospective or prospective analyses .
there is a surgeon skill bias at play in the majority of these studies as it is very difficult to find a surgeon equally skilled in both robotic and laparoscopic techniques .
most of the surgeons and their teams become proficient in either of the two techniques . but
learning curve for lrygb has been reported to be 75 - 100 cases in order to normalize complications .
analysed the learning curve for rrygb and found it to be 14 cases in order to achieve mastery for a surgeon well versed in laparoscopic surgery but not in bariatric procedures .
studied complications in first 100 cases of rrygb , and found no leaks and one reoperation .
the published literature seems to suggest that the learning curve for robot assisted rygb is shorter than laparoscopic technique .
reported the outcomes , learning curve and technique of robotic biliopancreatic diversion with duodenal switch ( rbpdds ) .
they published experience of 47 patients who underwent this procedure with a mean bmi of 45 kg / m and the mean age of 38 years . the median or time was 514 min , which decreased to 379 min in last 10 patients .
the learning for rbpdds was found to be around 50 cases after which the complications and or time normalised .
revisional bariatric procedures are difficult and complex situations in which use of robotics hold a great potential .
with increasing numbers of bariatric procedures , more and more patients require revisional procedures for inadequate weight loss or complications arising out of previous surgery .
the anatomy in these situations is distorted which along with adhesions present a challenge to the surgeons .
complication rates of laparoscopy in these situations have been high with leak rates of 13.2% and mortality of 2% .
there is a couple of studies available on rbp that show better outcomes with robot assistance in these challenging cases .
however , there was no leak , haemorrhage or mortality in the series , which is promising considering the high incidence of these complications in these situations .
compared the outcomes of rbp performed by robotic ( n = 11 ) , laparoscopic ( n = 21 ) and open ( n = 28 ) method .
they found that the robotic arm had fewer complications ( 0 vs. 14.3% for laparoscopy , vs. 10.7% for open ) , but took longer to perform ( 352 vs. 270 vs. 250 min , respectively ) .
there were fewer conversions in robotic group ( 0 vs. 14.3% for laparoscopy ) and a significantly shorter hospital stay ( 6 vs. 8 vs. 9 days , respectively ) .
the use of agb has decreased tremendously all over the world because of low efficacy and high revision / complication rate associated with it .
there have been few studies published in the literature looking at outcomes of robotic assistance in agb , and showed little benefit for using the robot .
edelson et al . reported the largest study with 287 patients of robotic agb compared with 120 patients who underwent laparoscopic agb .
no significant differences were found in the operating room ( or ) times , hospital stay , complication rates , or excess weight loss .
they did find a shorter operative time by 12 min in the robotic arm when compared for so patients .
as of now , robot is used mostly for managing complications and revising gastric band to another weight loss procedure , and this is dealt with in the section on rbp .
sleeve gastrectomy is increasingly becoming popular because of its low morbidity , excellent outcome and perceived technical simplicity .
it is especially so in indian sub - continent because of high prevalence of a vegetarian population , who tend to choose a restrictive procedure rather than a malabsorptive one .
there are certain peculiarities in sg like it has a long staple line with the potential to leak , and a precise and safe dissection is required in the area of the left crus and hiatus entirely to mobilize the fundus .
compared to laparoscopic surgery , robotic surgery offers the possibility for endowrist , and this action facilitates the hiatal dissection and over sewing of the staple line .
five studies have been published , which focus on robotic sleeve gastrectomy ( rsg ) .
compared 30 robotic with 39 laparoscopic sg procedures and found no difference in length of hospital stay , complication rates or excess body weight loss at 1-year .
they found a significantly longer or time for rsg ( 135 vs. 114 min ) , due to the fact that they had oversewn the staple line in the robotic arm and not in the laparoscopic arm .
he also published a large comparative series on sg including 100 patients each in robotic and laparoscopic arms .
they found that or time was significantly longer in a robotic group by 12 min .
they did found that leaks occurred only in those patients in whom they did not oversew the staple line , but used a buttress material .
they concluded that rsg is a good stepping stone to robotic gastric bypass and rbp .
published their experience of 134 rsg cases and compared it with descriptive results of a systematic review of laparoscopic sg ( n = 3148 ) .
the or time was significantly higher by 12 min ( p = 0.006 ) , whereas the length of stay was lower by 1.1 days in a robotic group ( p  0.005 ) .
leaks were found in 0 rsg versus 1.97% laparoscopic sg ( p = 0.101 ) ; strictures in 0 versus 0.43% ( p = 0.447 ) ; bleeding in 0.7 versus 1.21% ( p = 0.594 ) ; and mortality in 0 versus 0.1% ( p = 0.714 ) , respectively .
we performed a comparative study of rsg in morbidly obese ( mo ) versus so patients at our centre .
11 so patients were compared with 24 mo patients who underwent robotic sg with oversewing of the staple line in all the cases .
there was no significant difference in or time , length of hospital stay or complications in between the two groups .
thus , presumably , using a robotic system overcomes many difficulties in the so patients and enables the surgeon perform the similar procedure as in mo patients with equal precision , similar time and little or no extra effort .
roux - en - y gastric bypass is considered as the gold standard surgical procedure for morbid obesity by many specialists .
as rygb involves two anastomoses ( gastrojejunostomy [ gj ] and jejunojejunostomy ) , robotic surgery is currently considered as an attractive technology that could help perform rygb , given its well - described advantages .
there have been nine significant published series comparing outcomes of rrygb versus laparoscopic rygb ( lrygb ) .
, we report the number of patients , mean age , mean preoperative bmi , mean or time , type of gj ( sutured or stapled ) , length of hospital stay , overall complication rate , leak rate , gj stricture rate and mortality . these results are compiled in tables 1 and 2 .
robotic vs. laparoscopic rygb : preoperative data robotic vs. laparoscopic rygb : peri - operative data there was a total of 3337 patients in these 9 studies with 1381 in a robotic arm and 1956 in the laparoscopic arm .
the mean age in rrygb and lrygb group was 43.3 years and 42.4 years , respectively .
the mean or time was 211.9 min in robotic arm versus 185.1 min in the laparoscopic arm .
three studies report a significantly shorter operative time in a robotic group , while four studies report a significantly longer operative time in a robotic arm .
this may be compounded by the fact that in all the studies , a sutured gj was done in the robotic arm , while a stapled gj was done in the laparoscopic arm in six out of nine studies .
the average length of stay was 5 days in robotic group versus 7.1 days in the laparoscopic group .
three studies found a statistically significant shorter hospital stay in the robotic arm , while one study found a significantly longer stay in the robotic arm .
found a significantly lower incidence of complication in a robotic group ( 11.6% vs. 16.1% ) .
the average leak rate across studies was 0.9% in rrygb versus 1.6% in lrygb , while the gj stricture rate was 3.1% in a robotic arm and 3.2% in the laparoscopic arm .
of all the published studies , there is only one prospectively randomized trial by sanchez et al .
the other studies are either comparative studies , case series , retrospective or prospective analyses .
there is a surgeon skill bias at play in the majority of these studies as it is very difficult to find a surgeon equally skilled in both robotic and laparoscopic techniques .
most of the surgeons and their teams become proficient in either of the two techniques . but large comparative studies and systematic reviews do offer some tendencies for robotic bariatric surgery .
learning curve for lrygb has been reported to be 75 - 100 cases in order to normalize complications .
buchs et al . analysed the learning curve for rrygb and found it to be 14 cases in order to achieve mastery for a surgeon well versed in laparoscopic surgery but not in bariatric procedures .
yu et al . studied complications in first 100 cases of rrygb , and found no leaks and one reoperation .
the published literature seems to suggest that the learning curve for robot assisted rygb is shorter than laparoscopic technique .
sudan et al . reported the outcomes , learning curve and technique of robotic biliopancreatic diversion with duodenal switch ( rbpdds ) .
they published experience of 47 patients who underwent this procedure with a mean bmi of 45 kg / m and the mean age of 38 years . the median or time was 514 min , which decreased to 379 min in last 10 patients .
the learning for rbpdds was found to be around 50 cases after which the complications and or time normalised .
revisional bariatric procedures are difficult and complex situations in which use of robotics hold a great potential .
with increasing numbers of bariatric procedures , more and more patients require revisional procedures for inadequate weight loss or complications arising out of previous surgery .
the anatomy in these situations is distorted which along with adhesions present a challenge to the surgeons .
complication rates of laparoscopy in these situations have been high with leak rates of 13.2% and mortality of 2% .
there is a couple of studies available on rbp that show better outcomes with robot assistance in these challenging cases .
the overall complication rate was 17% with a 90 days readmission rate of 24% . however , there was no leak , haemorrhage or mortality in the series , which is promising considering the high incidence of these complications in these situations .
compared the outcomes of rbp performed by robotic ( n = 11 ) , laparoscopic ( n = 21 ) and open ( n = 28 ) method .
they found that the robotic arm had fewer complications ( 0 vs. 14.3% for laparoscopy , vs. 10.7% for open ) , but took longer to perform ( 352 vs. 270 vs. 250 min , respectively ) .
there were fewer conversions in robotic group ( 0 vs. 14.3% for laparoscopy ) and a significantly shorter hospital stay ( 6 vs. 8 vs. 9 days , respectively ) .
this review of published literature reveals that the routine use of robotics in bariatric surgery is a safe and feasible option .
several studies have shown a lower complication rate with the robotic platform including leaks , haemorrhage and stricture .
the advantage of robotics is perceived much more in challenging situations like rbp . however , in order to graduate to these advanced procedures , one has to move a step by step , starting with rsg and moving on to rrygb and rbp .
the learning curve of rrygb has also been shown to be shorter as compared to lrygb .
the entire team learns with the surgeon and develops experience about patient safety precautions , or set - up , and type of instruments needed , thus leading to better or times with better patient outcomes .
robotic surgery is a team effort , and more so in bariatric surgery , where the role of an experienced bedside surgeon can not be understated , as he is responsible for stapling ( if robotic staplers are not used ) . as the main surgeon is separated from the patient ,
while performing robotic surgery , the assistant surgeon has to be trained enough to help him perform difficult tasks and also to take care of any emergency situation arising during the procedure .
the role of a trained scrub nurse and or technician is also very important in streamlining the conduct of the procedure and prevent any wastage of time and resources .
another advantage , which comes with the use of the robotic system , is improved ergonomics and lesser operator fatigue .
ergonomics in laparoscopic surgery can be very challenging with big patients and uncomfortable postures , which lead to surgeon fatigue and work related musculoskeletal symptoms .
robotics provides the advantage of more degrees of freedom , which is advantageous in performing difficult dissection and sutured anastomosis
. there has been a concern about cost every time use of the robotic system is considered as the direct costs are generally higher for the robotic approach in bariatric procedures like rygb
. however , hagen et al . took into consideration the total costs including the complications and readmissions .
they found that the cost of rrygb was lower as compared to lrygb when all the factors were counted for .
there is also a saving due to decrease in number of laparoscopic staplers used in robotic procedures , by doing a handsewn anastomosis . at the end of the day
, the big question to be answered is whether the use of robotics is going to stay or will it perish with time like many fancy technologies .
looking at the basic concept of computer - assisted navigational surgery , robotics provides an enabling platform in between surgeon and the patient .
it provides augmented and higher quality inputs from the patient to the surgeon , and his output is refined to a superior quality before reaching back to the target . according to us ,
this should not be analysed in terms of features of the present machine that is available for use , but in terms of the potential in the concept of using a digital interface to interact with patients and enhance the performance of the surgeon . with the advent of newer technologies in robotics like fluorescence , integration of images , virtual and augmented reality , telesurgery , single site platforms , natural orifice surgery and haptic feedback
, we believe that it will provide an empowering tool to the surgeons , which can potentially change the way surgery is practiced today .
 with the rise in a number of bariatric procedures , surgeons are facing more complex and technically demanding surgical situations . 
 robotic digital platforms potentially provide a solution to better address these challenges . 
 this review examines the published literature on the outcomes and complications of bariatric surgery using a robotic platform . 
 use of robotics to perform adjustable gastric banding , sleeve gastrectomy , roux - en - y gastric bypass ( rygb ) , biliopancreatic diversion with duodenal switch and revisional bariatric procedures ( rbp ) is assessed . 
 a search on pubmed was performed for the most relevant articles in robotic bariatric surgery . 
 a total of 23 articles was selected and reviewed in this article . 
 the review showed that the use of robotics led to similar or lower complication rate in bariatric surgery when compared with laparoscopy . 
 two studies found a significantly lower leak rate for robotic gastric bypass when compared to laparoscopic method . 
 the learning curve for rygb seems to be shorter for robotic technique . 
 three studies revealed a significantly shorter operative time , while four studies found a longer operative time for robotic technique of gastric bypass . 
 as for the outcomes of rbp , one study found a lower complication rate in robotic arm versus laparoscopic and open arms . 
 most authors stated that the use of robotics provides superior visualisation , more degrees of freedom and better ergonomics . 
 the application of robotics in bariatric surgery seems to be a safe and feasible option . 
 use of robotics may provide specific advantages in some situations , and overcome limitations of laparoscopic surgery . 
 large and well - designed randomised clinical trials with long follow - up are needed to further define the role of digital platforms in bariatric surgery . 
INTRODUCTION
METHODS
Robotic Adjustable Gastric Banding
Robotic Sleeve Gastrectomy
Robotic Roux-en-Y Gastric Bypass
Robotic Biliopancreatic Diversion with Duodenal Switch
Robotic Revisional Bariatric Procedures
DISCUSSION