Robotic Bariatric Surgery. Richdeep S. Gill, MD Research Fellow Center for the Advancement of Minimally Invasive Surgery (CAMIS)

Transcription

1 Robotic Bariatric Surgery Richdeep S. Gill, MD Research Fellow Center for the Advancement of Minimally Invasive Surgery (CAMIS)

2 Background Over 500 million obese individuals worldwide Bariatric surgery is an evidence based strategy shown to produce marked weight loss Number of bariatric surgical procedures

3 Roux en Y Gastric Bypass

4 Minimally Invasive Surgery Gradual progression from Open Bariatric Surgery to Minimally Invasive Surgery

5 Robotics Is it the next evolution of minimally invasive surgery?

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7 Germain et al, J Visc Surg 2011

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13 Advantages 3 D visualization Seven degrees of freedom improved dexterity and agility Three robotic arms No physiologic tremor

14 Disadvantage Cost! Lack of tactile feedback Specialized OR team

15 Questions Is robotic assisted bariatric surgery safe and feasible? Is it worth it?

16 Objective Our objective was to systematically review the literature on robotic bariatric surgery (RYGB)

17 Methods Types of studies Human Case Series, non randomized controlled trials, randomized controlled trials, prospective cohort series Types of participants The target population consists of obese adult (>18 years old) male or female patients undergoing robotic assisted bariatric surgery. Patients considered clinically obese with a BMI greater than 35 were included. Types of interventions The intervention under study was robotic assisted bariatric surgery. This includes robotic assisted gastroplasty, LAGB, RYGB and BPDDS.

18 Outcomes Primary outcomes The primary outcomes are complications and mortality rate for robotic assisted bariatric surgery. Secondary outcomes The secondary outcome includes intra operative procedure time, conversion rate, length of hospital stay post operatively and cost of procedure.

19 Search Methods Electronic searches Unpublished and/or non English language manuscripts were considered for review inclusion. A comprehensive search of electronic databases (e.g., MEDLINE, EMBASE, SCOPUS, DARE, BIOSIS Previews, Cochrane Library, EBM, Scopus, Dare, Clinical evidence, TRIP and HTA database) using broad search terms was completed (see appendix for the search terms). All human studies reported from 2003 to April 2010 were included. Search Terms: robot; robotic; computer assisted; bariatric; obesity; gastric bypass; gastric band

20 Study Selection Selection of studies Studies of any design involving robotic assisted bariatric surgery for adult obese patients from 2003 to 2010 were included. A trained librarian conducted the electronic searches One author conducted a pre screen to identify the articles clearly irrelevant by title and keywords of publication. Two independent reviewers then assessed the studies for relevance, inclusion, and methodological quality. Articles were classified as either: 1. Relevant (meeting all specified inclusion criteria); 2. Possibly relevant (meeting some but not all inclusion criteria); 3. Rejected (not relevant to the review). Two reviewers independently reviewed full text versions of all studies classified as relevant or possibly relevant. Disagreements were resolved by re extraction.

21 Treatment Effect Complication rates were calculated based on total number of complications for total of surgical procedures. Mortality rate was calculated in a similar fashion. Operative time and length of hospital stay were averaged as a mean ± SD.

22 Risk of Bias All included trials were assessed independently by two reviewers for methodological quality using the Cochrane (concealment of allocation) and Risk of Bias (RoB) tools.

23 Statistical Analysis Descriptive statistics (simple counts and means) were used to report study, patients and treatment level data. The number of patients enrolled was used in the calculation of study and patient demographics. Efficacy outcomes of interest were synthesized by pooling data of all robotic assisted bariatric surgery. Due to the high heterogeneity among the studies and only one randomized controlled trial, a meta analysis was not deemed appropriate.

24 Results

25 Table 1. Description of studies (bypass procedures) included in systematic review Gill et al, IJMRCAS 2011

26 Table 2. Robotic-assisted bypass surgery outcomes

27 Mortality & Morbidity No mortalities reported Anastomotic leak rate = 2.4% Bleeding rate = 2% Stricture/stenosis rate = 3%

28 Conclusion Although the concept of robotic assisted general surgery, including bariatric surgery, is still in its infancy, this systematic review demonstrates that robotic assisted bariatric surgery is both a safe and feasible option for severely obese patients. However, more studies are needed to compare the short and long term outcomes of patients undergoing laparoscopic and robotic assisted bariatric surgeries in order to define a clear patient benefit that justifies the increased costs and operational impact. Gill et al, Int. J. Med. Robotics Comput. Assist. Surg 2010

29 Markar SR, Int. J. Med. Robotics Comput. Assist. Surg 2011

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35 Comparative Studies Single surgeon, consecutive cases, non-randomized Ayloo et al, World J Surg 2011

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37 Non-randomized, consecutive patient over a 3 year period Scozzari et al, Surg Endosc 2011

38 Cost Scozzari et al, Surg Endosc 2011

39 Synder et al, Obes Surg 2010

40 Is it worth the cost?

41 Acknowledgements Daniel W. Birch Shahzeer Karmali Xinzhe Shi CAMIS

42 Questions