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Perioperative patient care involved with robotic-assisted bariatric surgery

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ABSTRACT Background: The use of robotic-assisted bariatric surgery has recently gained an increased amount of positive reception. In this paper we share our experiences with robotic-assisted bariatric surgery in hopes of increasing the surgical team members’ (such as surgical residents, circulators, scrub technicians and surgical assistants) abilities to understand the setup of the room, the positioning of patients, and intraoperative planning & duties concerning patient’s care and the surgical procedure itself. Methods: From 2009 to 2015, there were 409 patients who underwent robotic-assisted bariatric surgery by a single bariatric surgeon and his team. Of the 409 procedures, 288 were Roux-en-Y gastric bypass and 121 were vertical sleeve gastrectomy. Of the patients involved their average age was 47.4 and BMI was 53.9 kg/m2. Results: The average operating room times (includes 60-80 mins of anesthesia time and patient positioning time) were 247.7 minutes on Roux-en-Y gastric bypass and 142.6 minutes on sleeve gastrectomy. There have not been any complications concerning the patients. Only 4 patients were converted to open. On average the post-op hospital stay was 3.7 days. Conclusion: The robotic-assisted bariatric surgery is safe and feasible as opposed to an open approach despite it requiring a greater operative timespan. After understanding the procedures, room setup, intra-op patient’s care and teamwork, the robotic approach should be an ability all bariatric surgeons should possess.
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Introduction
Obesity has become one of many serious public health
problems in the United States as obesity rates are seen
to be increasing every year (1). It is a well-known fact
that obesity contributes to various complications such
as non-insulin-dependent diabetes, hypertension, and
hypercholesterolemia (2).
Roux-en-Y gastric bypass (RYGB) and vertical sleeve
gastrectomy (VSG) are the two most commonly practiced
bariatric procedures. In the 1990s, the first laparoscopic
RYGB was performed by Wittgrove and Clark (3) and the
laparoscopic sleeve gastrectomy was initially performed in
2000 (having been reported by Ren et al.) (4).
Within the last 20 years, the arrival of robotic surgery
systems has enabled many complex minimally invasive
procedures to be performed in several surgical specialties,
including bariatric surgery (5). In September of 2000,
Original Article
Perioperative patient care involved with robotic-assisted bariatric
surgery
Jessica W. Levine1, Zuliang Feng1, David P. Feng2, Willie V. Melvin3
1Department of Perioperative Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, USA; 2Department of
Biology, Belmont University, Nashville, TN, USA; 3General Surgery, Stonecrest Clinic, Smyrna, TN 37167, USA
Contributions: (I) Conception and design: All authors; (II) Administrative support: None; (III) Provision of study materials or patients: All authors;
(IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final
approval of manuscript: All authors.
Correspondence to: Zuliang Feng. Department of Perioperative Services, Vanderbilt University Medical Center, Nashville, TN, USA.
Email: zuliang.feng@vanderbilt.edu.
Background: The use of robotic-assisted bariatric surgery has recently gained an increased amount of
positive reception. In this paper, we share our experiences with robotic-assisted bariatric surgery in hopes of
increasing the surgical team members’ (such as surgical residents, circulators, scrub technicians and surgical
assistants) abilities to understand the setup of the room, the positioning of patients, and intraoperative
planning & duties concerning patient’s care and the surgical procedure itself.
Methods: From 2009 to 2015, there were 409 patients who underwent robotic-assisted bariatric surgery by
a single bariatric surgeon and his team. Of the 409 procedures, 288 were Roux-en-Y gastric bypass (RYGB)
and 121 were vertical sleeve gastrectomy (VSG). Of the patients involved their average age was 47.4 and
BMI was 53.9 kg/m2.
Results: The average operating room times (includes 60–80 mins of anesthesia time and patient positioning
time) were 247.7 minutes on RYGB and 142.6 minutes on sleeve gastrectomy. There have not been any
complications concerning the patients. Only four patients were converted to open. On average, the post-op
hospital stay was 3.7 days.
Conclusions: The robotic-assisted bariatric surgery is safe and feasible as opposed to an open approach
despite it requiring a greater operative timespan. After understanding the procedures, room setup, intra-op
patient’s care and teamwork, the robotic approach should be an ability all bariatric surgeons should possess.
Keywords: da Vinci robotic surgery; obesity; bariatric surgery; Roux-en-Y gastric bypass (RYGB); vertical sleeve
gastrectomy (VSG)
Received: 05 July 2017; Accepted: 17 July 2017; Published: 26 August 2017.
doi: 10.21037/ales.2017.07.13
View this article at: http://dx.doi.org/10.21037/ales.2017.07.13
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Horgan and his colleagues performed the first robot-
assisted gastric bypass (6). Since, the robotic-assisted
bariatric surgery has gained wider acceptance due to the
advantages of using the robot for the bariatric procedure
including 3-D vision, freedom of movement of Endowrist
instruments, and surgical precision. In the interest of safer
care for the patient(s) involved, the operating room requires
surgical staff with special robotics training to set up the
operative suite and maintain the surgical robotic equipment.
Perioperative staff must demonstrate expert execution
during setup which includes proficiency connections,
positioning, & operations involved in the robotic
components.
The purpose of this article is to inform nursing staff
of the sequence of events as well as to have special
considerations for specific robotic bariatric surgery. It
also aims to outline the role of the surgical team members
within this particular setting.
Patients and results
From 2009 to 2015, there were 409 patients who underwent
robotic-assisted bariatric surgery by a single bariatric
surgeon and his team. Of the 409 procedures, 288 were
RYGB and 121 were VSG. Of the patients involved their
average age was 47.4 and BMI was 53.9 kg/m2. The average
operating room times (includes 60–80 mins of anesthesia
time and patient positioning time) were 247.7 minutes on
RYGB and 142.6 minutes on sleeve gastrectomy. There
have not been any complications concerning the patients.
Only four patients were converted to open. On average, the
post-op hospital stay was 3.7 days.
Methods and procedures
Room setup and patient positioning
The da Vinci Surgical System has three parts which
includes surgeon’s console, robotic arms, and video tower.
The surgeon controls movement of the robotic arms when
seated at the surgeon’s console, both of which are attached
to the video tower. One arm holds the camera and scope;
the other two—or three if necessary—arms control the
robotic instruments. With a thorough understanding of
how the robotic system works, surgical staff can provide
the most valuable assistance to the surgeon during the
procedures and be key players in this cutting edge of robotic
surgical care (7).
The room organization for both robotic bariatric
surgeries are the same, giving special attention to arrange for
the sterile eld to eventually be positioned on the patient’s
left after rotating the operating table about 180 degrees.
Prior to transporting the patient to the OR, the nursing
staff should conrm that the operating room bed will both
accommodate the weight of the obese patient and enter
reverse Trendelenburg to the surgeon’s satisfaction. After
intubation, the surgical team will move the patient to the
edge of the right side of the operating table. This is a crucial
step because a exible retraction instrument will be xated
to the operating table and must be close enough to extend
up the patient’s side and reach the liver retractor to suspend
the liver in the abdominal cavity. If the patient has excess
axillary fat, the circulator will need to remember to pad that
area when the instrument is attached to the operating table.
The circulator or bed-side assistant will secure a footboard
under the patient’s feet, verifying that their feet are at and
legs in a neutral position.
The draw sheet on the bed should be long on the
patient’s left side where the patient’s arm will be liberally
padded and then tucked. The right arm is left extended on
the arm board to allow space for the liver retractor system
(Figure 1). The patient will be supine with mild reverse
Trendelenburg. Since the robot will be docked above the
patient’s head, an arm cradle is used to surround the top
and sides of the head. The cradle is secured with a chin
strap fashioned out of 3-inch silk tape (Figure 2).
Anesthesia provisions
The surgeon’s assistant should advise the anesthesia
provider that the endotracheal tube should be taped to the
left side of the patient’s mouth to later accommodate the 34
Figure 1 Positioning with right arm on arm board.
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French bougie dilator (for sleeve gastrectomy) or 34 French
gastric lavage tube (for RYGB only). The assistant should
also clarify that—in docking the robot over the patient’s
head—the patient’s face may not be readily to them during
the course of the procedure and to plan accordingly. In
urgent circumstances where the anesthesia provider needs
access to the patient’s head, the robot may be undocked
to better accommodate the necessary interventions. The
anesthesia provider should also be aware that the procedure
requires rotating the operating table almost 180 degrees,
and they will therefore need several IV extensions. After
rotating the bed, airway tubing, IV lines, pulse oximeter,
and any other monitoring cords will be taped along the
patient’s right side down to the feet. After the head wrap is
applied, the bougie or gastric lavage tube should be inserted
up to about 50 to 55 centimeters from the front teeth.
Operative sequence for robotic RYGB and VSG
After prepping the skin, draping the patient, and performing
the timeout, the surgeon will mark anatomical landmarks
and the incision sites for trocars. Figure 3 shows trocar
placement for robotic RYGB (left) and robotic VSG (right).
We use all four robotic arms for the robotic RGB and only
use three arms for the robotic VSG. After all the trocars
are placed, the circulator will drive the robot, positioning
it over the patient’s head (Figure 4). During this step, the
sterile team members and the circulator must be aware of
the sterile robotic arms in relation to unsterile equipment.
Also, all staff must monitor the robot when it nears the
patient’s head, though the head wrap will offer a margin
between skull and robot as another element of protection.
Once the robot is positioned, robotic arms will be secured
to the robotic trocars and instruments will be inserted.
The robotic fenestrated bipolar forceps, Maryland bipolar
forceps, Cadiere forceps, Cautery scissors, Cautery hook
and double fenestrated forceps were used in robotic RYGB.
And only fenestrated bipolar forceps, Cautery hook and
double fenestrated forceps were used in robotic VSG.
The standard procedure of both robotic RYGB and
VSG have been described in many studies (8-11).
Figure 5 shows anatomy pictures of gastric bypass (left)
and sleeve gastrectomy (right) after they were done. After
the procedures, the intralumen anastomosis is insufflated
using a gastroscope (under extralumen irrigation) to verify
the absence of leakage. All the robotic instruments were
Figure 2 Head padding and chin strap.
Figure 3 Trocar placement.
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removed and robot was moved away from patients. Then
all the ports are removed and the skin incisions are sutured
closed.
Discussion
The operative cares for robotic procedures are the same
as for traditional laparoscopic procedures, and patient
education is a key component to recovery for both styles.
For intra-operative patient care, the robotic surgery
requires more staff than most other surgical procedures,
and, in hopes of keeping a safe and orderly work place, the
operating room requires highly trained staff to prepare
the surgical robot and ensure its appropriate maintenance
(12,13). In many institutions, specialized teams work
with robotic surgeons on a regular basis (13) and many
hospitals are requiring that the nurse coordinator of any
given robotics program become as specialized as the
doctors doing the actual surgery (13). The expertise of a
seasoned coordinating nurse, circulating nurses, surgical
technologists, and surgical assistants puts the surgeon more
at ease and provides for better, consistent results for the
patients we serve.
The robot would generally be prepared before the
patient arrives to the operating room. The bedside staff
should understand how to install instruments and remove
them from the robotic arm ports. Perioperative nurses
must be proficient in positioning the robot components
in relation to the patient and all other equipment in the
room. The nurse sustains vigilance regarding all aspects
of the procedure. Prior to admitting the patient into the
operating room suite, the nurse should make sure that the
staff has any necessary information about the patient. The
nurse should also watch the surgeon at the console, the
display monitor showing the surgeon’s activities inside the
abdomen, and the sterile team members and equipment
that they must utilize. This is to insure that all aspects of
the surgery are progressing smoothly and to anticipate
needs for the remainder of the procedure, retrieving any
items that may be required by other team members. The
nurse also communicates with the anesthesiologist to
assure that the vital signs are satisfactory, that the patient
is achieving adequate respiratory excursion (14) and that
Figure 4 Robot in place over head of patient.
Figure 5 Picture of Roux-en-Y gastric bypass and sleeve gastrectomy.
Pouch
Esophagus
Small intestine
Stomach
Gastric sleeve
Sleeve gastrictomyRoux-en-Y gastric bypass
Resected
stomach
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intravenous lines are running well; this is a task that begins
during the positioning stage until the patient leaves the
operating room.
Most importantly, though, the nurse will keep careful
watch over the patient which includes: (I) padding pressure
points at the beginning of the case and rechecking those
areas during the procedure; (II) observation of the robotic
arms throughout the procedure to make sure the patient
will not be struck with the arm movements; (III) observing
the patient’s position throughout the case to insure that
nothing would cause the patient to shift on the table.
Conclusions
The robotic-assisted bariatric surgery is safe and feasible
over open approach even more time in the operating.
After understanding the procedures, room setup, intra-
op patient’s care and teamwork, the robotic approach of
bariatric surgery should be in the surgeon’s skillset.
Acknowledgements
None.
Footnote
Conicts of Interest: The authors have no conicts of interest
to declare.
Ethical Statement: This study did not require any approval
by institutional ethical committee or informed consent.
References
1. Ogden CL, Carroll MD, Kit BK, et al. Prevalence of
obesity and trends in body mass index among US children
and adolescents, 1999-2010. JAMA 2012;307:483-90.
2. Crawford AG, Cote C, Couto J, et al. Prevalence of
obesity, type II diabetes mellitus, hyperlipidemia, and
hypertension in the United States: ndings from the GE
Centricity Electronic Medical Record database. Popul
Health Manag 2010;13:151-61.
3. Wittgrove AC, Clark GW. Laparoscopic gastric bypass: a
ve-year prospective study of 500 patients followed from
3–60 months. Obes Surg 1999;9:123-44.
4. Ren CJ, Patterson E, Gagner M. Early results of
laparoscopic biliopancreatic diversion with duodenal
switch: a case series of 40 consecutive patients. Obes Surg
2000;10:514-23.
5. Deng JY, Lourié DJ. 100 100 robotic-assisted laparoscopic
gastric bypasses at a community hospital. Am Surg
2008;74:1022-5.
6. Horgan S, Vanuno D. Robots in laparoscopic surgery. J
Laparoendosc Adv Surg Tech A 2001;11:415-9.
7. Tabor W. On the cutting edge of robotic surgery. Nursing
2007;37:48-50.
8. Ayloo SM, Addeo P, Buchs NC, et al. Robot-assisted
versus laparoscopic Roux-en-Y gastric bypass: is there a
difference in outcomes? World J Surg 2011;35:637-42.
9. Jacobsen G, Berger R, Horgan S. The role of robotic
surgery in morbid obesity. J Laparoendosc Adv Surg Tech
A 2003;13:279-83.
10. Ijah RF, Bhatia P, Kaltan S, et al. Sleeve Gastrectomy for
Morbid Obesity: Robotic vs Standard Laparoscopic Sleeve
Gastrectomy Methods. World J Lap Surg 2014;7:1-6.
11. Ayloo S, Buchs NC, Addeo P, et al. Robot-assisted
sleeve gastrectomy for super-morbidly obese patients. J
Laparoendosc Adv Surg Tech A 2011;21:295-9.
12. Mohr CJ, Nadzam GS, Alami RS, et al. Totally robotic
laparoscopic Roux-en-Y Gastric bypass: results from 75
patients. Obes Surg 2006;16:690-6.
13. Francis P. Evolution of robotics in surgery and
implementing a perioperative robotics nurse specialist role.
AORN J 2006;83:630-42, 644-6, 649-50 passim.
14. Neil JA. Perioperative nursing care of the patient
undergoing bariatric revision surgery. AORN J
2013;97:210-26.
doi: 10.21037/ales.2017.07.13
Cite this article as: Levine JW, Feng Z, Feng DP, Melvin
WV. Perioperative patient care involved with robotic-assisted
bariatric surgery. Ann Laparosc Endosc Surg 2017;2:136.
... 16 Laparoscopy sleeve gastrectomy (LSG) is the most commonly performed bariatric surgery in the United States and consists of the creation of a tubular stomach by removing the majority of the greater curvature of the stomach, including the fundus 16 (Fig. 2, right). 17 The remaining stomach has decreased capacity with resistance to expansion, making LSG a restrictive procedure. In addition, postoperatively LSG has been shown to uniquely decrease fasting and postprandial ghrelin levels, leading to appetite suppression. ...
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