Fig. 4: Left crural dissection Fig 5: First staple firing Fig 6: Completed sleeve

Fig. 1: Operating theatre schematic

INTRODUCING THE dA VINCI ROBOT TO A BARIATRIC SURGICAL PRACTICE UTILIZING THE SLEEVE GASTRECTOMY – THE FIRST 10 CASES

DR CANDICE SILVERMANGENERAL & LAPAROSCOPIC SURGEON

Kirra Hill Specialist Medical Suites 3/3 Mclean Street, Coolangatta QLD 4225 t. 07 5536 8855 e. info@drcandicesilverman.com.au www.drcandicesilverman.com.au

Candice Silverman1 MBBS(hons), FRACS; Michael Ghusn1 MBBS, FRACS1John Flynn Private Hospital, Tugun, Australia

Table 1: Demographics

Table 2: Patient operative details and length of stay

Demographic descriptive statistics for surgery patients (N = 10).

Variables Mean Median Standard Deviation

Range

Age (yrs) 53.9 56 9.3 34 - 64Height (cm) 171.0 169 8.1 159 - 185Weight (kgs) 141.6 132 41.0 102 - 218BMI 47.8 46 9.9 35.3 – 67.3

Number Sex Age (years)

BMI kg/m2

Revisional Hiatal repair

Robotic arms

Additional procedures performed Docking time (minutes)

Total operation time (minutes)

Length of Stay (days)

1 Male 28 62 No No 3 15 110 32 Female 40 43 No Yes 3 20 105 33 Female 54 46 Yes No 3 laparoscopic and robotic division of adhesions 43 115 34 Female 56 46 No No 3 15 105 35 Female 58 35 No Yes 3 37 125 36 Female 44 43 No No 3 robotic cholecystectomy 15 168 37 Female 57 48 Yes No 3 laparoscopic and robotic division of adhesions 17 130 38 Male 48 50 No No 3 Gastroscopy 10 135 39 Male 54 67 No No 4 30 165 210 Female 45 38 No Yes 3 20 120 2

References1. Wilson EB, Sudan R. The evolution of robotic bariatric surgery. World Journal of Surgery.37(12):2756-60.2. Rosenthal RJ, International Sleeve Gastrectomy Expert P, Diaz AA, Arvidsson D, Baker RS, Basso N, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience

of >12,000 cases. Surgery for Obesity & Related Diseases.8(1):8-19.3. Tieu K, Allison N, Snyder B, Wilson T, Toder M, Wilson E. Robotic-assisted Roux-en-Y gastric bypass: update from 2 high-volume centers. Surgery for Obesity & Related Diseases.9(2):284-8.4. Romero RJ, Kosanovic R, Rabaza JR, Seetharamaiah R, Donkor C, Gallas M, et al. Robotic sleeve gastrectomy: experience of 134 cases and comparison with a systematic review of the laparoscopic approach. Obesity

Surgery.23(11):1743-52.5. Vilallonga R, Fort JM, Caubet E, Gonzalez O, Armengol M. Robotic sleeve gastrectomy versus laparoscopic sleeve gastrectomy: a comparative study with 200 patients. Obesity Surgery.23(10):1501-7.6. Diamantis T, Alexandrou A, Nikiteas N, Giannopoulos A, Papalambros E. Initial experience with robotic sleeve gastrectomy for morbid obesity. Obesity Surgery.21(8):1172-9.7. Ayloo S, Buchs NC, Addeo P, Bianco FM, Giulianotti PC. Robot-assisted sleeve gastrectomy for super-morbidly obese patients. Journal of Laparoendoscopic & Advanced Surgical Techniques Part A.21(4):295-9.8. Elli EG-H, R.; Sarvepalli S.; Masrur, M. Laparoscopic and Robotic Sleeve Gastrectomy: Short and Long-Term Results. Obesity Surgery. 2015;25:967-74.

Fig. 2: Operating theatre set up photoFig. 3: Position of ports and liver retractor

Patient cart

Anesthesiacart

Endoscopycart

Anesthe-siologist

R3

Patient side

surgeon

Patient table

Scrubnurse

Consolesurgeon

Da Vinci console

INTUITIVEmonitor, surgical

devices, and harmonic scalpel

2nd assistant

Scrubtable

Electrocautery

R1

MC

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Midline

A1Camera port

N

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Patient cart

Anesthesiacart

Endoscopycart

Anesthe-siologist

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Patient side

surgeon

Patient table

Scrubnurse

Consolesurgeon

Da Vinci console

INTUITIVEmonitor, surgical

devices, and harmonic scalpel

2nd assistant

Scrubtable

Electrocautery

R1

MC

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R2

CARTBackgroundThe difficulties experienced by surgeons in operating on obese patients are dealing with thick abdominal walls and the limited space to maneuver instruments secondary to fatty livers and increased intra-abdominal adiposity. The da Vinci robot (Intuitive Surgical®) as an extension of the minimally invasive surgeon’s armamentarium would seem to be ideally suited for use on these patients(1). When performing anastomotic procedures in the obese for example roux en y gastric bypass, surgeons can be limited by the use of straight instruments to suture and fatigue due to poor ergonomics. Revisional Surgery after failed gastric bands take longer then primary operations which can exacerbate fatigue, and the correct planes may be easier to identify with the use of three dimensional visualization achieved with the da Vinci robot. The ability of the surgeons to control their own camera and assistant instrument is also an advantage seen with the use of the da Vinci robot compared with standard laparoscopy.

When introducing new technology it is important to set one self up for success, i.e. become comfortable with the technology before utilizing it for more complex procedures. It is these more complex cases where the da Vinci robot’s benefit over traditional laparoscopy may be easier to demonstrate. The sleeve gastrectomy in this regard could be considered an ideal training procedure for introducing the robot into a bariatric surgical practice. It is now an established and commonly performed stand-alone bariatric surgical procedure(2). The theatre set up can be utilized for other upper gastro-intestinal surgical procedures with liver retraction and access to the head for gastroscopy if required. It is a single quadrant procedure; it can allow the surgeon to become accustomed to the robotic platform and the tissue handling of various robotic instruments that lack haptic feed back. Suturing when performed for hiatal laxity is done without the angst of an anastamosis. Additional procedures when required such as division of adhesions and cholecystectomy can add to the surgeon’s robotic operative experience.

MethodsThe da Vinci Surgical System (da Vinici Si Surgical System, Intuitive Surgical®) was effectively installed in our hospital in 2013. This is a retrospective review of a prospectively maintained database of the first 10 and consecutive Robotic Sleeve Gastrectomies performed at a single institution from the 13th of April 2014 to the 13th of February 2015. Descriptive Statistics were achieved using SPSS software, version 19.0 (IBM, Armonk, New York). Values are expressed as mean ± standard deviation. Variables examined include patient demographics (age, sex, height, weight and Body Mass Index (BMI)) and whether these were primary bariatric procedures or performed after removal of gastric bands. Revisional sleeve gastrectomy procedures were performed at a minimum of three months after band removal.

Both authors are general and minimally invasive trained surgeons who are members of the institutions upper gastro-intestinal surgery department. Both authors had undergone the necessary simulation training, “dry docking” experience, case observation and the da Vinci Surgery training pathway with online and laboratory-based training provided by Intuitive Surgical. The Hospital’s Medical Advisory committee had credentialed both surgeons to undergo their initial robotic surgical experience, an international proctor was present for the first three patients operated on with the robot. The primary author was the consol surgeon with the final author being the bed-side surgeon for these robotic cases.

Hiatal defect repair and additional procedures performed were recorded. Operating times being time from first surgical incision to having the robot docked was recorded as was the total operative time. Blood loss > 200mLs was noted. Length of stay details was recorded. The patients were reviewed daily in hospital and at one month, three months and six months post procedure where they were weighed and any complications noted.

ResultsEvolution of the TechniqueThe operating room set up is as illustrated in Fig. 1 and photographed in Fig. 2. The anaesthetist administers a general anaesthetic, places a 38 french bougie into the patients oesophagus, gives 2gm of IV cephazolin and 5000units of subcutaneous heparin. Compression devices are placed on the legs. The patient is placed in the reverse trendelenburg position (beach chair position) with the left arm extended by the patient’s side and the right arm is out on an arm-board. Initial entry into the abdomen is in the left rectus position 16cm inferior to the xiphoid in the midline and then 5cm lateral and left of this point using the 8mm da Vinci zero degree camera through a 12mm optical entry port, which is subsequently changed to the 10mm 30 degree da Vinci camera. CO2 Insufflation is via the video consol. Ports and the StrongArmTM Nathanson® Hook Liver Retractor (Mediflex Surgical Products) are placed as illustrated (Fig. 3). The robot is docked.

The devascularisation of the greater curve of the stomach is with the da Vinci’s vessel sealer with dissection to 2cm from the pylorus distally and then proximally to expose well the left crus (Fig. 4). Hiatal laxity if present is repaired with 0-novafil sutures. The anaethetists passes the bougie to the pylorus with the guidance of the robotic instruments. Stapling is achieved via the assistant port with the Echelon FlexTM 60mm with a green cartridge and staple line reinforcers (Gore Seamguard; WL Gore & Associates, Inc) for all firings. 30 seconds of compression time is achieved prior to firing the stapler. Only some of the antrum is included in the specimen with the first firing aiming to be “wide” at the incisura angularus (Fig. 5). All firings are “loose” on the bougie with the final firing aiming at the left crus ensuring all posterior fundus is excised (Fig. 6). Fibrin glue is used for haemostasis and the specimen is extracted via the assistant’s port.

The first three cases were completed using three of the robotic arms, with the robot docking in from the left shoulder and were performed as hybrid procedures i.e. the dissection was performed robotically, once the stomach was adequately devascularised and mobilised the robot was undocked and the stapling was completed laparoscopically. Subsequent cases were all performed “totally” robotically with the bedside surgeon firing the stapler. Four robotic arms were utilised for the super morbidly obese after lessons learnt from the eight patient where there was difficulty visualising the short gastric vessels and left crura due to visceral adiposity. For this patient the vessel sealer divided fundus which was adherent to the spleen, a check gastroscopy was performed and the gastrostomy was included in the resection specimen. From then for patients over a BMI of 50kg/m2 we elect to use the fourth robotic arm, this gives the consol surgeon an extra instrument for retraction. When using four robotic arms the robot needs to be docked directly overhead of the patient and we found this position to have less external clashes of the robotic arms so we now routinely dock the robot directly overhead for all cases.

Following the procedure the patients are placed on a liquid diet as tolerated and discharged home when they can tolerate this and are adequately mobile. They receive 5000 units of subcutaneous unfractionated heparin three times

a day till discharge and daily pantoprazol 40mg intitially intravenously then orally as tolerated and this is continued for a minimum of one month post-operatively. They are on a fluid only diet for the first two weeks postoperatively and then they proceed to a pureed diet for a further two weeks. They commence a normal textured diet at four weeks post procedure.

Patient’s Demographics are shown in Table 1. There was no significant intra-operative bleeding (> 200mL) or peri-operative complications. Table 2 displays the BMIs, sex and operative times for the patients in order of their date of surgery. Additional procedures performed are as listed. The mean time for the total procedure was 128± 23 minutes and mean time to robot docking was 22± 11 minutes. The quickest time achieved for docking was 10 minutes. Patient number nine who had a BMI of 67kg/m2 and extensive body wall psoriasis was treated with oral antibiotics for a superficial wound infection from the assistant port site and this had resolved by the clinical review at one month post procedure. The length of stay ranged from 2 to 3 days. The 6 month Excess Weight Loss Percentage was 50.1± 16.5 with an absolute weight loss of 27.5± 10kg and a BMI decrease of 9.4± 3.1 kg/m2.

ConclusionThe Sleeve Gastrectomy can be performed safely robotically prior to using the robot for more complex bariatric procedures such as the roux en y gastric bypass where the advantage of using the robot over standard laparoscopy may be more evident(3). The mean operative time for these first 10 consecutive robotic sleeve gastrectomy procedures of 128 minutes is reasonable when compared with other published series(4-8) with mean operative times ranging from 95 to 135 minutes. The learning process for robotic surgery involves the whole theatre team where good team work and communication are essential. Having a skilled bed-side surgeon for one’s initial robotic experience is felt to be very useful. Consistency in achieving an incision to robot docking time of under 10 minutes is a reasonable goal for non revisional robotic bariatric procedures. We describe one method of safely introducing the robot to a bariatric surgical practice.

Acknowledgements• Thank you to the 10 patients for allowing me to operate on them.• Thank you to Dr Erik Wilson for allowing me to observe the use of the robot

at Herman Memorial Hospital and for proctoring the first three cases.• Thank you to Tony Hurd for the statistical analysis.

ABSTRACTBackgroundThe Sleeve Gastrectomy is an ideal training procedure for introducing the robot into a bariatric surgical practice. This is a review of the first 10 and consecutive Robotic Sleeve Gastrectomy procedures performed at a single institution describing the evolution of technique and initial outcomes.

MethodsRobotic Sleeve Gastrectomy was performed as primary and revisional procedures (at least 3 months after removal of gastric bands). Patient demographics, operative time (incision to robot docking time and total operation time), additional operative procedures performed and weight loss achieved at 6 months was retrospectively reviewed from a prospectively maintained database. The evolution of the technique and theatre set up is described. Operative complications and post-operative complications were recorded with patients reviewed daily in hospital, then at one month, three months and six months post procedure.

Results10 Robotic Sleeve Gastrectomies were performed without any significant operative complications. One patient was treated as an outpatient with oral antibiotics for a superficial wound infection. The mean total operative time was 128 minutes with a mean docking time of 22 minutes. The length of stay in hospital was 2 to 3 days. Mean weight loss achieved at 6 months was 27.5kg with an excess weight loss percentage of 50.1.

ConclusionThis study describes a method of safely introducing the da Vinci robot into a bariatric surgical practice.

Patient Cart

PatientTable

Endoscopycart

Anesthe-siologist

Scrubnurse

SurgeonConsole

INTUITIVEmonitor, surgical

devices, and harmonic scalpel

Assistant

Nurse

Nurse Table

Visual Cart

Slave Monitor

Electrocautery

MCL = Mid Clavicular Line