Sleeve gastrectomy and the Roux-en-Y gastric bypass (RYGB) are the two principal bariatric surgeries worldwide [1]. RYGB yields better outcomes in terms of weight loss and diabetic complications [2]. RYGB is considered necessary for even Asians who need more proper metabolic benefits. The first robotic RYGB was performed by Santiago Horgan and Daniel Vanuno in 2001 [3]. Robotic surgeries allow surgeons to achieve better wrist articulation, greater ergonomics, and better visualization [4]. Robotic bariatric surgeries with hand-sewn anastomoses exhibit lower levels of gastrojejunostomy anastomosis leakage, compared with laparoscopic surgeries [5]. Moreover, robotic RYGB is reportedly associated with fewer complications [6]. Despite these advantages, robotic bariatric surgeries are rarely performed in South Korea, largely because of insurance issues. In Korea, patients with body mass index (BMI) of ≥35 kg/m², or ≥30 kg/m² with comorbidities can undergo nonrobotic sleeve gastrectomy or RYGB, procedures that are covered by the National Healthcare Insurance system [7]. However, robotic bariatric surgery is not covered. Here, we describe a morbidly obese patient with type II diabetes mellitus (DM) who underwent totally robotic RYGB, which was covered by private insurance. This video article presents a totally robotic Roux-en-Y gastric bypass in a morbidly obese patient (Supplementary Video 1).

Patient

A 57-year-old obese woman visited our metabolic and bariatric surgery center. Her height was 155.7 cm and her weight was 80.9 kg; thus, her BMI was 33.4 kg/m². She had bulimia, which was attributed to a stressful family. Even though she had undergone psychiatric treatment, she could not stop eating midnight snacks. She stated that she could only manage the stressful situation by satisfying her appetite. Thus, despite an effort to exercise, she was unable to lose weight. She had several underlying diseases; type II DM, hypertension, dyslipidemia, fatty liver, obstructive sleep apnea, major depressive disorder, and arthritis. She was taking more than three oral agents to treat DM and had been treated with insulin since 2010. Her ABCD and DiaRem scores were 3 and 17, respectively. Computed tomography revealed that the ratio of mesenteric fat and subcutaneous fat area was more than 0.4, fulfilling a diagnostic criterion for central obesity. Esophagogastroduodenoscopy yielded no specific finding. The CLO test result was negative. Brain magnetic resonance imaging revealed no lesion that could cause obesity.

Surgical procedures

The patient underwent totally robotic RYGB. She was positioned in the reverse Trendelenburg position with a 30° Fowler and open arms and legs, which were wrapped in pneumatic leg sleeves upon the induction of general anesthesia following intubation. An arterial line was inserted for arterial pulse monitoring, and a urinary catheter was used to monitor urinary output. Five trocars were placed: three trocars of 12 mm and two trocars of 8 mm. The trocar for the camera was inserted in the infraumbilical region. The other four trocars were inserted at least 8 cm apart from each other. A pneumoperitoneum was created with CO₂ insufflation. A peak pressure of 15 mmHg was maintained to ensure an appropriate surgical field. The two-time-docking manner of the da Vinci Xi system (Intuitive Surgical) was used throughout the procedure. After dissection of tissues around the angle of His, dissection along the lesser omentum proceeded by the creation of a retrogastric window with ligation of the second branch of the left gastric artery. After assessment of the posterior side of the stomach, a gastric pouch (25 mL) was created using four robotic staplers (SureForm; Intuitive Surgical). A reinforced barbed suture was carried out along the stapling line by barbed suture (V-Loc; Covidien). A 2 cm-long posterior row of gastrojejunostomy was created using a robotic stapler. Hand-sewn barbed and reinforced sutures were used to close the anterior row of the gastrojejunostomy entry hole. Next, the equipment was de-docked and the patient’s position was changed to supine from reverse Trendelenburg. After re-docking, jejunojejunostomy proceeded at 150 cm from the gastrojejunostomy site using 45-mm and 60-mm robotic staplers. The indocyanine green (ICG) leak test was performed by flushing the Levin tube with ICG solution; there was no leakage from the stapling line. Thus, the mesenteric and Petersen defects were closed using barbed sutures (V-Loc). Bleeding control was conducted, followed by the application of hemostatic particles (Arista AH 5 g; BD). A Jackson-Pratt drain (200 mL) was inserted around the stapling line of the gastric pouch through the right lower quadrant port site. The operative site was closed in a layer-by-layer manner.

After the operation, the patient was transferred to the intensive care unit for close observation. On the postoperative day 1, she underwent an upper gastrointestinal tract series, which revealed no evidence of leakage. The patient was allowed to consume a liquid diet on the following day, and she was discharged without any complications. After a month, the patient weighed 71.7 kg (BMI, 29.8 kg/m²) with an excess weight loss of 38%. She exhibited no malnutrition or vitamin deficiency.

Laparoscopic bariatric surgeries have been considered difficult because of torque on surgeons’ hands and intracorporeal sutures. On the other hand, robotic surgeries eliminate these issues. The instruments can be comfortably manipulated, and the operative field is clear and close. Unfortunately, robotic bariatric surgery is not yet the first choice for morbidly obese patients in Korea. Because it is not covered by the National Healthcare Insurance system. However, our patient had private insurance.

Totally robotic RYGB took longer operative time than laparoscopic approach. The operative time of this case was 240 minutes, which was longer than laparoscopic cases. The increase in the operative time for the robotic RYGB is most likely due to preparation for docking and undocking. Although we have performed many robotic surgeries, this was our first totally robotic RYGB. We should soon have sufficient additional experience to decrease the operative time. Kim and Buffington [8] reported that the mean operative time for their first 10 cases was 183 minutes whereas the mean operative time for the last 10 cases was 95 minutes.

The postoperative outcomes of robotic RYGB are comparable with the outcomes of laparoscopy. In 2014, Buchs et al. [9] compared totally robotic and laparoscopic RYGB. In terms of intraoperative complications, length of stay (LOS), and postoperative complications, the clinical outcomes of the robotic approach and laparoscopy were similar. We encountered no intraoperative or postoperative complications.

The cost-benefit ratio of robotic RYGB remains unclear. Because National Healthcare Insurance system does not support robotic RYGB, the high cost is a burden for patients who must undergo bariatric surgery. However, the large torques and forces induced by laparoscopic instruments can cause postoperative wound pain. Such patients require more expensive analgesics. Additionally, the LOS is prolonged by greater postoperative pain. Thus, the increased LOS associated with a laparoscopic approach leads to higher costs. Park et al. [10] described that an analysis of total hospital charges between robotic and laparoscopic RYGB billed for surgical admission had similar total hospital charges. Although the robotic instrument itself is expensive, the cost of postoperative management may be lower than the cost after laparoscopic surgery due to less pain and shorter hospital stay. Therefore, total hospital costs of robotic RYGB are comparable to that of laparoscopic RYGB.

In conclusion, totally robotic RYGB required a longer operative time than laparoscopy and was expensive; however, its technical feasibility, safety, and efficacy were comparable with laparoscopic surgery.

Ethical statements

This study was approved by the Institutional Review Board of The Catholic University of Korea, St. Vincent’s Hospital (No. VC22ZASI0316) with a waiver of informed consent.

Authors’ contributions

Conceptualization: KHJ

Formal analysis: JWS

Methodology: JWS, KHJ

Writing–original draft: JWS

Writing–review & editing: KHJ

Conflicts of interest

All authors have no conflicts of interest to declare.

Funding/support

None.