IJGII Inernational Journal of Gastrointestinal Intervention

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Review Article

Int J Gastrointest Interv 2022; 11(2): 70-71

Published online April 30, 2022 https://doi.org/10.18528/ijgii220015

Copyright © International Journal of Gastrointestinal Intervention.

Current status of bariatric surgery

Young Suk Park1,2,*

1Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
2Department of Surgery, Seoul National University College of Medicine, Seoul, Korea

Correspondence to:*Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea.
E-mail address: youngsukmd@gmail.com (Y.S. Park).

Received: March 31, 2022; Revised: April 21, 2022; Accepted: April 21, 2022

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The prevalence of obesity has increased steadily both in Korea and throughout the world, and bariatric surgery is the most powerful treatment modality for morbid obesity. Robotic digital platforms provide potential benefits such as three-dimensional visualization, wristed instruments that lead to enhanced dexterity, and blocked torque transmission to ports. These advantages are remarkable when robotic systems are employed for bariatric surgery. If robotic bariatric surgery can be demonstrated to be clinically safer than other approaches, it could become the standard procedure.

Keywords: Bariatric surgery, Obesity, Robotic surgical procedure

Obesity is a growing global health issue, and obesity-related diseases have recently emerged as the focus of increasing attention in Asian countries, including Korea. In 2019, the Korean Ministry of Health and Welfare declared that the national health insurance system would reimburse the costs of bariatric surgery, a decision that reflects the importance of surgical intervention in morbidly obese patients. Bariatric surgery in patients with morbid obesity is associated with significant weight loss and decreased mortality. Currently, laparoscopic sleeve gastrectomy is the most frequently performed primary procedure for bariatric surgery worldwide.1 However, the robotic approach to bariatric surgery has attracted interest as an option because it offers several advantages, including an ergonomically comfortable position, increased precision (the surgeon’s movements are downscaled, enabling fine tissue dissection), blocked torque transmission to ports (a major advantage in morbidly obese patients with very thick abdominal walls), three-dimensional vision with a stable camera that surgeons handle themselves, articulated wrists of instruments (yielding three additional degrees of freedom), and the availability of an accessory arm allowing a surgeon to operate without any assistants.2 However, the high costs of robotic systems have been a persistent concern. The gap in medical costs borne by the patient between laparoscopic and robotic bariatric surgery has widened significantly since 2019, when the Korean national health insurance system started to cover laparoscopic bariatric surgery. Before 2019, laparoscopic bariatric surgery was as expensive for patients as robotic bariatric surgery, but since 2019, patients’ expenses for laparoscopic surgery have dropped significantly. Therefore, the expansion of national health insurance coverage to include laparoscopic bariatric surgery has increased the number of bariatric surgery cases in Korea, but decreased the number of robotic bariatric surgery cases.

Sleeve gastrectomy is technically simple because it does not include gastrointestinal anastomosis. Hence, the merits of robotic systems are difficult to highlight in sleeve gastrectomy. Although some surgeons have suggested that robotic sleeve gastrectomy facilitates the visualization and mobilization of the fundus and enables safe and precise dissection near the gastroesophageal junction and left crus, insufficient evidence has been adduced to prove their arguments. Specifically, three studies have compared laparoscopic and robotic sleeve gastrectomy.35 All three of these studies similarly reported no statistically significant difference in postoperative complication rates, such as leakage, stricture, and bleeding, despite a longer operating time for robotic sleeve gastrectomy.

Initially, a robotic system was used for anastomosis procedures during Roux-en-Y gastric bypass, while other procedures such as gastric pouch formation were performed laparoscopically. This kind of surgery is referred to as “robot-assisted gastric bypass.” Subsequently, totally robotic gastric bypass has become more popular. However, as history demonstrates, a robotic system can offer advantages to surgeons when performing hand-sewn gastrojejunostomy. Buchs et al6 also revealed favorable results for robotic gastric bypass, which showed significantly lower rates of anastomosis leakage (robotic = 0.3% vs laparoscopic = 3.6%; P < 0.001) and early reoperation (robotic = 1% vs laparoscopic = 3.3%; P = 0.05) than laparoscopic gastric bypass.

Surgeons can produce the best results when using familiar instruments; thus, it is difficult to conclude which technique is superior until a multicenter prospective randomized controlled trial comparing laparoscopic and robotic gastric bypass is performed. Nevertheless, it is obvious that a robotic platform can offer favorable conditions, such as three-dimensional vision and wristed instruments, for hand-sewn anastomosis to all surgeons.

Reoperations pose significant technical difficulties and challenges for bariatric surgeons. The risk of complications is higher due to the complexity of revisional cases, which include adhesions from the primary procedure, inflammation, and anatomical changes. The risk of complications in revisional bariatric surgery depends on which procedure was performed in the primary surgery and which will be performed in the revisional procedure. This choice can be affected by the causes of reoperation, which include the patient’s dissatisfaction, weight regain, or complications of the first operation.

Snyder et al7 reviewed 99 cases of robotic revisional surgery. The reasons for revisional surgery varied from abdominal pain, dysphagia, and insufficient weight loss or weight regain to complications such as hiatal hernia or a malfunctioning band. The overall complication rate was 17%, and the 90-day readmission rate was 24%. However, there were no cases of leakage, hemorrhage, or mortality.

The frequency of bariatric and metabolic surgery in Korea has increased since 2019. However, many doctors (including surgeons) and patients still misunderstand bariatric surgery as a form of plastic surgery. Instead, bariatric and metabolic surgery is a therapeutic operation that can improve survival and reduce cardiovascular disease through the treatment of severe obesity and metabolic syndrome.

A robotic platform is a method for the surgical approach. Therefore, it would be unreasonable to expect differences in efficacy outcomes, such as body weight loss or improvement of metabolic syndrome, between the robotic and laparoscopic approaches because these outcomes are determined by postoperative anatomical changes such as the length of the bypassed small bowel.8 However, safety outcomes such as postoperative morbidity or mortality can differ between approach methods. Since bariatric and metabolic surgery is performed for a benign disease, safety is prioritized to a greater extent than for other kinds of surgery for malignancy. However, studies have not yet proven the superior safety of robotic surgery.8,9 Nonetheless, if robotic bariatric surgery shows safer results than laparoscopic surgery, it could become the standard procedure for bariatric surgery in the future.

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