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Surgical Technique for Robotic-Assisted Laparoscopic Vertical Clip Gastroplasty (LVCG)

Authors:
Claudio Arcudi at Policlinico Tor Vergata
Claudio Arcudi
Bruno Sensi at University of Rome Tor Vergata
Bruno Sensi
Federica Alicata
Federica Alicata
Federica Alicata
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Leandro Siragusa at Istituto Clinico Humanitas IRCCS
Leandro Siragusa
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Vol:.(1234567890)
Obesity Surgery (2023) 33:1314–1316
https://doi.org/10.1007/s11695-023-06507-4
1 3
MULTIMEDIA ARTICLE
Surgical Technique forRobotic‑Assisted Laparoscopic Vertical Clip
Gastroplasty (LVCG)
ClaudioArcudi1· BrunoSensi2· FedericaAlicata1,2 · LeandroSiragusa2· ChiaraProcaccini1,2· DavidPavoncello1,2·
LorenzaBeomonteZobel1,2· EmanuelaBianciardi3· PaoloGentileschi1,2
Received: 26 October 2022 / Revised: 4 February 2023 / Accepted: 7 February 2023 / Published online: 24 February 2023
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023
Keywords Bariatric surgery· BariClip· Robotic surgery
Introduction
Laparoscopic sleeve gastrectomy (LSG) is the most per-
formed bariatric surgical procedure [1].
Unfortunately, LSG may lead, although rarely, to life-
threatening complications including gastric leakage and
bleeding. Specifically, gastric leakage remains a difficult-to-
treat complication, requiring further surgery or endoscopic
treatment, with a non-negligible risk of management failure
and risk of mortality [2].
To overcome LSG’s limitations, a promising bariatric
procedure has been proposed: laparoscopic vertical clip
gastroplasty (LVCG) using the BariClip device, which fol-
lows principles of LSG, but may have fewer associated risks
and improved long-term results. The procedure, character-
ised by a completely reversible mechanism, consists of a
nonadjustable clip that is vertically placed parallel to the
lesser curvature of the stomach, separating the stomach in a
medial restricted alimentary segment and a lateral excluded
segment, effectively mimicking LSG, without requiring sta-
pling, resection, or change in anatomy [3–5].
Despite having some similarities with the LAGB (e.g., the
usage of a foreign body and reversibility of the procedure),
LVCG differs from the former because it applies a restric-
tive mechanism rather than an obstructive one, which makes
LAGB particularly fallible.
As of today, LVCG is still an investigational procedure; how-
ever, its diffusion is predicted to increase in the next decade.
Robotic surgery (RS) has been slowly on the rise in the
past decade, and utilisation in BS has followed a similar
trend [6, 7]. LVCG may be technically challenging, and
therefore, RS may aid in making LVCG easier and more
precise [8–13].
This report elucidates, for the first time, the technique for
robotic-assisted LVCG (RLVCG).
Methods
This was a stage 1 study according to the IDEAL framework
(SCARE checklist in TableS1).
Following a pre-operative work-up and protocol (includ-
ing 20days of ketogenic diet), indication for restrictive BS
was given to a 62-year-old lady affected with obesity (BMI
37.7kg/m2) and complaining of a low-quality of life due to
her obesity-related comorbidities, including hypertension.
RLVCG was proposed to patient instead of LSG, inform-
ing her thoroughly about the procedure by explaining its
advantages in terms of reversibility and warning her about
Claudio Arcudi and Bruno Sensi contributed equally to this
manuscript and share first authorship.
Key Points
• Vertical clip gastroplasty (VCG) is a new restrictive bariatric
surgery procedure.
• Laparoscopic vertical clip gastroplasty (LVCG) is technically
challenging.
• Robotic-assisted laparoscopic vertical gastroplasty (RLVCG)
may overcome several technical difficulties and potentially reduce
complication rate.
• Robotic-assisted laparoscopic vertical gastroplasty (RLVCG) is
reported here for the first time.
* Federica Alicata
fedealicata@gmail.com
1 Bariatric andMetabolic Sugery, San Caro di Nancy
Hospital, Via Aurelia, 275-00165Rome, Italy
2 Department ofSurgery, Università Degli Studi Roma “Tor
Vergata”, Via Montpellier, 1–00133Rome, Italy
3 Department ofSystems Medicine, Psychiatric Chair,
University ofRome Tor Vergata, 00133, Via Montpellier, 1,
81-0133Rome, Italy
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Direct medical costs of robotic sleeve gastrectomy compared to laparoscopic approach in a single academic center
Article
Full-text available
  • Mar 2022
Background: The use of the robotic platform in bariatric surgery remains controversial because of lack of level I evidence to support its superiority compared to the laparoscopic approach and because of cost concerns. Recently, an extended use program (EUP) for robotic instruments was also introduced at our institution to help reduce the associated direct medical costs of robotic surgery. Objectives: To evaluate the direct medical costs of a robotic sleeve gastrectomy (R-SG) and compare it to a standard laparoscopic approach (L-SG). Setting: Academic, tertiary care center. Methods: The analysis included the last 50 R-SG performed at our institution between June 1st 2019 and October 31st 2020. Those cases were compared to the L-SG cases (29 cases) performed in the same time period. All revisions or conversions were then excluded which resulted in a total of 74 primary SG (R-SG = 45 and L-SG = 29). Direct medical costs included operating room cost, instrument cost, miscellaneous cost, and cost of hospital stay. Direct cost data was generated using the StrataJazz reporting module, which is fed daily from EPIC, our electronic health record system. Patients who underwent a primary SG or a primary SG with a concomitant Paraesophageal Hernia Repair (PEH) were analyzed separately using Mann-Whitney rank sum tests and Student's t tests. An additional analysis and subanalysis of the groups was also performed after applying the potential savings of the Extended Use Program (EUP). Results: Overall, the direct medical cost of R-SG was comparable to L-SG (6330.77vs6330.77 vs 6804.12 respectively, p = 0.07). The direct medical cost of patients undergoing SG alone without PEH was significantly lower in the R-group compared to the L-group (5927.08vs5927.08 vs 6508.01, respectively, p = 0.04). When applying the EUP savings to our data, the predicted direct medical cost of R-SG becomes significantly lower than L-SG (6145.77vs6145.77 vs 6804.12 respectively, p = 0.01). Conclusion: At our academic medical center, we found no difference in direct medical costs between R-SG and L-SG. With the application of the EUP, direct medical costs of R-SG can be significantly lowered compared to L-SG. It is important to consider that cost data are largely dependent upon the academic medical center of interest, and surgeons need to collect their own cost data to evaluate whether robotic surgery is feasible at their institution.
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Is staple line oversewing in patients on chronic anticoagulation during laparoscopic sleeve gastrectomy necessary? Propensity score matching analysis using the 2015–2018 MBSAQIP
Article
Full-text available
  • Feb 2022
  • SURG ENDOSC
Background There is an increased incidence of post-operative bleeding in patients on chronic anticoagulation (CAC). This incited some surgeons to oversew the sleeve staple line as a potentially preventive measure for post-operative bleeding. However, there is no clear evidence to assess the effectiveness of staple line oversewing during laparoscopic sleeve gastrectomy (LSG) in patients with CAC. Methods Using the 2015–2018 metabolic and bariatric surgery accreditation and quality improvement program database, patients between ages 18 and 65 who underwent LSG were included. To investigate the role of CAC, we performed 1:1 propensity score matching (PSM) between the CAC and non-CAC patients. Then, to explore the impact of oversewing, we focused on the CAC patients and divided them into 2 subgroups: oversewing versus non-oversewing. PSM was also performed to compare both subgroups. To avoid confounders, both PSM analyses were performed using 22 preoperative characteristics. 30-day postoperative outcomes including bleeding and blood transfusion requirement were assessed. Results 402,826 patients underwent LSG. 9148 patients (2.3%) were on CAC. In the CAC cohort (8843 matched cases), the anticoagulated patients showed significant increase in postoperative bleeding (1.2% vs. 0.5%; P < 0.001), blood transfusion requirements (1.7% vs. 0.7%; P < 0.001), unplanned ICU admissions (2.0% vs. 1.3%; P = 0.001), interventions (2.0% vs. 1.5%; P = 0.015), and readmissions (6.2% vs. 4.7%; P < 0.001). 1939 (21.2%) patients on CAC underwent oversewing during the LSG. The operative time was significantly longer in these patients (87.11 ± 40 vs. 76.19 ± 37; P < 0.001). Patients who underwent oversewing showed similar results in 30-day outcomes as those who did not, with no statistical difference, including postoperative bleeding (1.0% vs. 0.9%; P = 0.8) and blood transfusion requirements (1.4% vs. 1.8%; P = 0.9). Conclusion Incidences of post-operative bleeding and blood transfusion requirements are higher in patients on CAC during the LSG. Oversewing the sleeve staple line leads to longer operative times without additional benefit in 30-day outcomes.
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Five Year Trends in the Utilization of Robotic Bariatric Surgery Procedures, United States 2015-2019
Article
Full-text available
  • May 2022
  • OBES SURG
Purpose Robotic approaches have been steadily replacing laparoscopic approaches in metabolic and bariatric surgeries (MBS); however, their superiority has not been rigorously evaluated. The main goal of the study was to evaluate the 5-year utilization trends of robotic MBS and to compare to laparoscopic outcomes. Methods Retrospective analysis of 2015–2019 MBSAQIP data. Kruskal-Wallis test/Wilcoxon and Fisher’s exact/chi-square were used to compare continuous and categorical variables, respectively. Generalized linear models were used to compare surgery outcomes. Results The use of robotic MBS increased from 6.2% in 2015 to 13.5% in 2019 (N= 775,258). Robotic MBS patients had significantly higher age, BMI, and likelihood of 12 diseases compared to laparoscopic patients. After adjustment, robotic MBS patients showed higher 30-day interventions and 30-day readmissions alongside longer surgery time (26–38 min). Conclusion Robotic MBS shows higher intervention and readmission even after controlling for cofounding variables. Graphical Abstract
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Robot-assisted versus laparoscopic approach to concurrent bariatric surgery and hiatal hernia repair: propensity score matching analysis using the 2015–2018 MBSAQIP
Article
Full-text available
  • Sep 2022
  • SURG ENDOSC
Background Up to 37% of class three obesity patients have a Hiatal Hernia (HH). Most of the existent HHs get repaired at the time of bariatric surgery. Although the robotic platform might offer potential technical advantages over traditional laparoscopy, the clinical outcomes of the concurrent bariatric surgery and HH repair comparing robotic vs laparoscopic approaches have not been reported. Methods Using the 2015–2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, patients between 18 and 65 year old who underwent Sleeve gastrectomy (SG) or Roux en-Y Gastric Bypass (RYGB) with concurrent HH repair were identified. Demographic, operative, and 30-day postoperative outcomes data were compared between laparoscopic and robotic groups. To adjust for potential confounders, 1:1 propensity score matching was performed using 22 preoperative characteristics. Results 75,034 patients underwent SG (n = 61,458) or RYGB (n = 13,576) with concurrent HH repair. The operative time was significantly longer in the Robotic-assisted compared to the laparoscopic approach both for SG (102.31 ± 44 vs. 75.27 ± 37; P < 0.001) and for RYGB (163.48 ± 65 vs. 132.87 ± 57; P < 0.001). In the SG cohort (4639 matched cases), the robotic approach showed similar results in 30 day outcomes as in the laparoscopic approach, with no statistical difference. Conversely, for the RYGB cohort (1502 matched cases), the robotic approach showed significantly fewer requirements for blood transfusions (0.3% vs. 1.7%; P = 0.001), fewer anastomotic leaks (0.2% vs. 0.8%; P = 0.035), and less postoperative bleeding (0.4% vs. 1.1%; P = 0.049). Conclusion Robotic concurrent bariatric surgery and HH repair leads to similar overall clinical outcomes as the laparoscopic approach despite longer operative times. Furthermore, the robotic approach is associated with reduced blood transfusion and anastomotic leak incidence in the RYGB group.
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Robotic bariatric surgery for the obesity: a systematic review and meta-analysis
Article
Full-text available
  • Apr 2021
  • SURG ENDOSC
Objective The aim of this meta-analysis is to evaluate the safety and efficacy of bariatric surgery (BS) in patients with obesity by robotic bariatric surgery (RBS) compared with laparoscopic bariatric surgery (LBS).Methods The study was performed through searching in Pubmed, Web of Science, Embase database and Cochrane Library until March 31, 2020 comparing RBS with LBS. Data were calculated on the following endpoints: operative time, length of hospital stay, reoperation within 30 days, overall complications, leak, stricture, pulmonary embolisms, estimated blood loss and mortality. Data as relative risks (OR), or weighted mean difference (WMD) were summarized with 95% confidence interval (CI). Risk of publication bias was assessed through standard methods.ResultsThirty eligible trials including 7,239 robotic and 203,181 laparoscopic surgery cases showed that RBS was referred to attain longer operative time [WMD = 27.61 min; 95%CI (16.27–38.96); P < 0.01] and lower mortality [OR 2.40; 95% CI (1.24–4.64); P = 0.009] than LBS. Length of hospital stay [WMD = − 0.02; 95% CI (− 0.19–0.15); P = 0.819], reoperation within 30 days [OR 1.36; 95% CI (0.65–2.82); P = 0.411], overall complications [OR 0.88; 95% CI (0.68–1.15); P = 0.362], leak [OR 1.04; 95% CI (0.43–2.51); P = 0.933], stricture [OR 1.05; 95% CI (0.52–2.12); P = 0.895], pulmonary embolisms [OR 1.97; 95% CI (0.93–4.17); P = 0.075], estimated blood loss[WMD = − 1.93; 95% CI (− 4.61–0.75); P = 0.158] were almost similar in both RBS group and LBS group. Three was no statistically significant difference between RRYGB and LRYGB in EWL%, no statistical significance between RSG and LSG after 1 year, 2 years and 3 years.ConclusionRBS presented lower mortality within 90 days and longer operative time in this meta-analysis with similar safety and efficacy for the obesity compared with LBS in other outcomes. Additionally, RBS might be beneficial in the future if it would be evaluated in comprehensive and long-term endpoints.
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Robotic-Assisted Surgery Results in a Shorter Hospital Stay Following Revisional Bariatric Surgery
Article
Full-text available
  • Feb 2021
  • OBES SURG
Background Revisional surgery is rapidly growing within the field of bariatric surgery. The use of robotic assisted surgery, considered controversial by many, may offer advantages in revisional bariatric surgery (RBS). There are few studies comparing laparoscopic and robotic-assisted RBS. The aim of this study is to compare the safety and outcome of laparoscopic and robotic RBS in a single accredited center.MethodsA retrospective analysis of data collected prospectively on patients undergoing either laparoscopic (L-RBS) or robotic (R-RBS) RBS between January 1, 2017 and December 31, 2019 was performed. The primary outcomes included length of stay (LOS), 30-day major and minor complication rates, readmission rates, and mortality rates.ResultsA total of 167 patients were included in our analysis. Fifty-two patients underwent R-RBS (31%), and 115 underwent L-RBS (69%). Thirty-day major and minor complication rates for R-RBS and L-RBS were 1.9% and 5.8% vs 5.2% and 5.2%, respectively (p > .05). There was no difference in readmission rates (3.8% vs 8.7%, p > 0.05) or intraoperative blood loss (35.5 mL vs 37.4 mL, p > .05) between R-RBS and L-RBS. R-RBS resulted in a shorter length of stay when compared with L-RBS (40.2 h vs 62.6 h, p < .05).ConclusionsR-RBS has a decreased, albeit non-significant, rate of 30-day major complications with no difference in minor complications, readmission rates, or intraoperative blood loss when compared with L-RBS. R-RBS resulted in a decreased length of stay when compared with L-RBS. Randomized clinical trials are needed to better elucidate our findings.
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Laparoscopic Clip Gastroplasty with the BariClip
Article
Full-text available
  • Dec 2020
  • OBES SURG
Having the advantages of the reversibility by clipping and not cutting the stomach, the BariClip procedure reproduces the effect of the SG [1, 2] without adding the risk of leaks, and minimizes the occurrence of postoperative GERD by decreasing the intragastric pressure [3]. We present an edited video on the placement of a BariClip with the main steps of the procedure for a female patient with a BMI 41 kg/sqm. A 36 F bougie is placed to calibrate the size of the pouch. Using a laparoscopic approach, the BariClip is placed into the peritoneal cavity through a 12 mm trocar. The BariClip is then closed around the stomach parallel to the lesser curvature, creating a small medial pouch and an excluded large lateral segment. To prevent slippage (rate is approximately 3%), the BariClip is sutured to the gastric wall both anteriorly and posteriorly at various levels of the stomach, as shown in the video. Despite the possibility to suture on either side of the BariClip, the left indentations are preferred in order to avoid vessels of the lesser curvature which are closer to the right indentations. The recovery was uneventful, and 4 h after the surgery, the patient was tolerating liquids. She was discharged the following day with a prescription of PPI (pantoprazole 40 mg) for 30 days and of clexane 0.4 IM for 5 days. As with most bariatric procedures, she was started on 2 weeks of liquids, followed by 2 weeks of soft diet, before experiencing solid food. At 1 month after surgery, the patient had lost 10% of her TBW, and at 1-year follow-up, she had lost 31% of her TBW. She had no reflux, pain, or any other complaints and was very happy. The closing of the BariClip has been designed to be a low-pressure system, and in addition, it has a wide inferior outlet (2.5 cm), which does not create high intraluminal pressure. Both of these factors result in a low risk of erosion and of GERD. The rate of erosion in the original series was 1.3% with up to a 7-year history of implantation. The most common complication encountered at the beginning of our experience has been a slippage of the BariClip, and with the learning curve, this rate dropped to 3%. The QOL has been studied on a first series of patients and showed good results comparable with those given with the LSG and the RYGB [4]. In conclusion, the BariClip accomplishes almost similar weight loss as a SG, without a gastrectomy, without risks of leaks, and without causing reflux, and at the same ,time the BariClip is reversible [5].
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Trends in the utilization and perioperative outcomes of primary robotic bariatric surgery from 2015 to 2018: a study of 46,764 patients from the MBSAQIP data registry
Article
Full-text available
  • Jul 2021
  • SURG ENDOSC
Background Utilization of robotic surgery has increased over time. Outcomes in bariatric surgery have been variable. This study used the Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program (MBSAQIP) dataset to compare nationwide trends in utilization and outcomes improvement for robotic and laparoscopic bariatric surgery over a four-year period.Methods We identified all adult patients who underwent robotic or laparoscopic primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from 2015 to 2018. Those with previous bariatric/foregut surgery or open conversion were excluded. Trends in clinical outcomes of different surgery types over years were compared through multivariable regression models. Subgroup analysis was performed for patients in 2018, comparing outcomes among different surgery types.ResultsA total of 571,417 patients underwent bariatric surgery, of which 46,764 (8.2%) were performed robotically. Utilization of the robotic platform increased annually, from 6.7% in 2015 to 10.3% in 2018 (p < 0.0001). The majority of patients underwent SG (n = 33,891, 72.5%). Perioperative outcomes improved over time for both robotic and laparoscopic procedures. Improvement was more pronounced in the robotic cohort for extended length of stay (OR 0.76 vs 0.8, p < 0.0001) and operative time (OR 0.98 vs 0.99, p < 0.0001). In the 2018 subgroup, multivariable analysis found laparoscopic RYGB was associated with increased bleeding (OR 2.220, p = 0.0004), overall complications (OR 1.356, p = 0.0013), and extended LOS (OR 1.178, p < 0.0001) compared to robotic surgery. Laparoscopic SG was associated with decreased anastomotic/staple line leak (OR 0.718, p = 0.0321), 30-d readmission (OR 0.826, p = 0.0005), 30-d reintervention (OR 0.723, p = 0.0014), overall event (OR 0.862, p = 0.0009), and extended LOS (OR 0.950, p = 0.0113). Across the board, laparoscopic surgery was associated with decreased operative time (Adjusted Ratio = 0.704, p < 0.0001).Conclusion Robotic utilization for bariatric surgery is increasing and outcomes continue to improve with time. There is a differential impact of the robotic approach on SG and RYGB, which requires further assessment.
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Outcomes in conventional laparoscopic versus robotic-assisted primary bariatric surgery: a retrospective, case–controlled study of the MBSAQIP database
Article
Full-text available
  • Jun 2019
  • SURG ENDOSC
Introduction Robotic-assisted bariatric surgery is increasingly performed. There remains controversy about the overall benefit of robotic-assisted (RBS) compared to conventional laparoscopic (LBS) bariatric surgery. In this study, we used a large national risk-stratified bariatric clinical database to compare outcomes between robotic and laparoscopic gastric bypass (RNYGB) and sleeve gastrectomy (SG). Methods A retrospective analysis of the 2015 and 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use Data File (PUF) was performed. Primary robotic and laparoscopic RYNGB and SG were analyzed. Descriptive analysis was performed of the unmatched cohorts, followed by 1:3 case-controlled matching. Cases and controls were matched by patient demographics and pre-operative comorbidities, and peri-operative outcomes compared. Results 77,991 Roux-en-Y gastric bypass (RnYGB) (7.5% robotic-assisted) and 189,503 SG (6.8% robotic-assisted) cases were identified. Operative length was significantly higher in both the robotic-assisted RnYGB and SG cohorts (p < 0.0001). Outcomes were similar between the robotic-assisted and laparoscopic RnYGB cohorts, except a lower mortality rate (p = 0.05), transfusion requirement (p = 0.005), aggregate bleeding (p = 0.04), and surgical site infections (SSI) (p = 0.006) in the robotic-assisted cohort. Outcomes were also similar between robotic-assisted and laparoscopic SG, except for a longer length of stay (p < 0.0001) and higher rates of conversion (p < 0.0001), 30-day intervention (p = 0.01), operative drain present (p < 0.0001), sepsis (p = 0.01), and organ space SSI (p = 0.0002) in the robotic cohort. Bleeding was lower in the robotic SG cohort and mortality was similar. Conclusion Both robotic-assisted and laparoscopic RnYGB and SG are overall very safe. Robotic-assisted gastric bypass is associated with a lower mortality and morbidity; however, a clear benefit for robotic-assisted SG compared to laparoscopic SG was not seen. Given the longer operative and hospital duration, robotic SG is not cost-effective.
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Adopt or Abandon? Surgeon-Specific Trends in Robotic Bariatric Surgery Utilization Between 2010 and 2019
Article
  • Jan 2022
Background: It is unknown if surgeons are more likely to adopt or abandon robotic techniques given that bariatric procedures are already performed by surgeons with advanced laparoscopic skills. Methods: We used a statewide bariatric-specific data registry to evaluate surgeon-specific volumes of robotic bariatric cases between 2010 and 2019. Operative volume, procedure type, and patient characteristics were compared between the highest utilizers of robotic bariatric procedures (adopters) and surgeons who stopped performing robotic cases, despite demonstrating prior use (abandoners). Results: A total of 44 surgeons performed 3149 robotic bariatric procedures in Michigan between 2010 and 2019. Robotic utilization peaked in 2019, representing 7.24% of all bariatric cases. We identified 7 surgeons (16%) who performed 95% of the total number of robotic cases (adopters) and 12 surgeons (27%) who stopped performing bariatric cases during the study period (abandoners). Adopters performed a higher proportion of gastric bypass both robotically (22.9% versus 3.1%, P < .001) and laparoscopically (27.5% versus 15.1%, P < .001), when compared with abandoners. Surgeon experience (no. of years in practice), type of practice (teaching versus nonteaching hospital), and patient populations were similar between groups. Conclusions: Robotic bariatric utilization increased during the study period. The majority of robotic cases were performed by a small number of surgeons who were more likely to perform more complex cases such as gastric bypass in their own practice. Robotic adoption may be influenced by surgeon-specific preferences based upon procedure-specific volumes and may play a greater role in performing more complex surgical procedures in the future.
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