- Email: [email protected]
Totally Robotic Stapleless Vertical Sleeve Gastrectomy
Surgery for Obesity and Related Diseases 9 (2013) e79–e81
Case report
Totally Robotic Stapleless Vertical Sleeve Gastrectomy Masoud Rezvani, M.D., F.A.C.S.*, Iswanto Sucandy, M.D., Gintaras Antanavicius, M.D., F.A.C.S. Department of Surgery, Institute for Bariatric and Metabolic Surgery, Abington Memorial Hospital, Abington, Pennsylvania Received March 12, 2013; accepted March 25, 2013
Obesity has become a major health issue in the United States [1,2] and worldwide [3]. Zhao et al. reported an increase in the number of people who are candidates for a weight loss procedure [4]. Vertical sleeve gastrectomy (VSG) is accepted as an effective weight loss procedure with relatively low risks of morbidity and mortality compared with other bariatric operations, such as Rouxen-Y gastric bypass or biliopancreatic diversion with duodenal switch [5]. VSG requires multiple sequential applications of linear staples along the greater curvature to create the gastric sleeve. Although a history of allergic reaction to the metallic components of a medical device is not present in most patients, there is a very small subset of patients in whom metallic components can cause concern. To avoid any potential allergic reaction to the metallic component in the staples, we used the alternative technique of totally robotic stapleless VSG. This novel technique circumvents the use of a linear stapler, while maintaining the benefits of a minimally invasive approach. To our knowledge, there have been no other reports on totally robotic stapleless VSG. Case report A 45-year-old man presented to our bariatric center with morbid obesity. At the presentation, he was 69 inches (175 cm) tall, and his weight was 298 pounds (131.5 kg) with excess weight of 144 pounds (65.3 kg). His body mass index was calculated as 44 kg/m2. He was also suffering Video presentation at the Society of American Gastrointestinal and Endoscopic Surgeons 2013 Annual Meeting, Baltimore, Maryland. * Correspondence: Masoud Rezvani, M.D., F.A.C.S., Department of Surgery, Institute for Bariatric and Metabolic Surgery, Abington Memorial Hospital, 1200 Old York Road, Abington, Pennsylvania 19001. E-mail: [email protected]
from multiple obesity-related co-morbidities, including insulin-dependent diabetes, hypercholesterolemia, hypertension, arthritis, sleep apnea, and snoring that required use of a nocturnal continuous positive airway pressure machine. His past surgical history was significant for several orthopedic operations for lower extremity fractures after a motor vehicle accident. Multiple metal-based orthopedic implants had been used during an open reduction and internal fixation of the fractures. Postoperatively, the patient developed a significant allergic reaction to the internal fixation devices and raised the question for device component allergy including nickel. The allergic reaction mandated removal of implants, and the fixation devices were exchanged with stainless steel implants. Because of the patient’s significant concern with his previous allergic reaction to metallic component, the decision was made to proceed with the alternative stapleless approach. Surgical technique The patient was positioned supine on the operating room table. Pneumoperitoneum was established by using a Veress needle in left upper quadrant, followed by trocar placement. Four additional trocars in the supraumbilical, anterior and right mid-axillary line, and right upper quadrant were placed under direct laparoscopic visualization. The robotic arms were placed through the supraumbilical and right upper quadrant trocars, while the camera was inserted through the right mid-axillary trocar (Fig. 1). Other trocars were used interchangeably for retraction and for suctioning by the first assistant during the operation. Greater curvature dissection was started robotically at a point 4 cm proximal to the pylorus by using a harmonic scalpel (Ethicon Inc., Cincinnati, OH) and bowel grasper. After complete dissection of the greater curvature toward the gastric fundus, a 36F bougie was carefully inserted for sizing the
1550-7289/13/$ – see front matter r 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.03.011
e80
M. Rezvani et al. / Surgery for Obesity and Related Diseases 9 (2013) e79–e81
Discussion
Fig. 1. Trocar placement and robot camera, arms positions.
sleeve by anesthesia personnel. Construction of the gastric sleeve was started with application of a laparoscopic linear Bulldog clamp (Aesculap Inc., Center Valley, PA) guided by the intragastric bougie and was fashioned against the lesser curvature. A similar type of laparoscopic clamp was applied on the gastric remnant (specimen) side. The anterior and posterior gastric walls between the 2 clamps were divided using a harmonic scalpel. The gastric sleeve cut edge was closed using a 3-0 Vicryl suture in a running fashion using the robotic arms (Fig. 2). Sequential applications of the laparoscopic linear bulldog clamps using a similar technique were performed toward the gastric fundus until the remnant stomach was completely separated from the gastric sleeve. The gastric sleeve suture line was imbricated using a 3-0 Prolene in a running fashion for reinforcement. A fibrin sealant product was applied along the suture line. A methylene blue intragastric injection test was performed, which revealed no evidence of suture line leak. A 19F abdominal drain was placed next to the gastric sleeve suture line and then the gastric remnant was removed through the supraumbilical port. The operative time was 429 minutes with minimal blood loss (o100 cc). The patient made an uneventful recovery and was discharged home on postoperative day 3. At a 1-month office follow-up visit, he was asymptomatic and had achieved 21% excess weight loss.
VSG was originally described in 1988, when Scopinaro’s technique of biliopancreatic diversion with distal gastrectomy and gastroileostomy was modified by Hess and Marceau [6,7]. This procedure requires multiple applications of linear staples along the greater curvature to create a gastric sleeve. Surgical staples consist of several elements, among which may be traces of nickel. Hypersensitive reactions to implanted devices have been described in various forms [8] in nonbariatric patients, especially with the use of cardiac and orthopedics devices [9,10]. However, this allergy has not yet been described as related to linear staple usage. The use of the robotic system in bariatric surgery, particularly in the Roux-en-Y operation, has been reported [11,12]. Diamantis et al. published a recent series of robotic VSGs with good outcome [13]. Sleeve gastrectomy involves gastric construction, which can be fashioned in a totally manual way by using staples. However, the patient’s refusal of the use of staples because of possible nickel allergy presented a surgical challenge. The 3-dimensional and magnified view of a robotic scope, as well as robotic arms, made the use of the robotic system beneficial from the beginning. Full mobilization of the greater curvature, especially dissection of the gastrosplenic ligament, was made easier and more feasible with a robotic approach. The use of the robotic arms helped overcome the challenge of gastrocolic and gastrosplenic ligament dissection and, more important, meticulous intracorporeal suturing. A robotic approach offered our patient the same laparoscopic advantages, including shorter hospital stay, shorter recovery time, and lower complication risk related to wounds, such as infection and hernia. Conversely, the concern of the duration of the procedure can be improved by advancing the robotic technique and avoiding unnecessary steps, such as sewing the specimen site. The significant cost of robotic surgery can be compensated for in rare cases, such as our patient, by providing a shorter recovery time and lower complication rates compared with an open approach. Laparoscopic gastric plication has been introduced as an alternative weight loss procedure with an acceptable weight loss outcome [14]. This procedure was considered as an option in this case but was not chosen because there are no adequate long-term data available for this procedure, and more important, this procedure has not been recognized as a standard of care in the United States. Conclusions
Fig. 2. Robotic gastrostomy site suturing.
Totally robotic stapleless vertical sleeve gastrectomy is a feasible and well-tolerated alternative in patients with any potential staples component allergy. The utilization of a robotic system facilitates intracorporeal suturing of the
Robotic Stapleless Vertical Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 9 (2013) e79–e81
gastric sleeve with a high degree of precision. A short-term weight loss outcome similar to that of the conventional laparoscopic VSG technique was achieved. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Buchwald H, Avidor Y, Braunnwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;14:1724–37. [2] Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the Unites States, 1999– 2004. JAMA 2006;295:1549–55. [3] Deitel M. Overweight and obesity worldwide now estimated to involve 1.7 billion people. Obese Surg 2003;13:329–30. [4] Zhao Y, Encinosa W. Bariatric Surgery Utilization and Outcomes in 1998 and 2004: Statistical Brief #23. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville, MD: Agency for Health Care Policy and Research (US); 2006–2007 Jan. [5] Lee CM, Cirangle PT, Jossart GH. Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results. Surg Endosc 2007;21:1810–6.
e81
[6] Scopinaro N, Adami GF, Marinari GM, et al. Biliopancreatic diversion. World J Surg 1998;22:936–46. [7] Marceau P, Biron S, ST Georges R, et al. Biliopancreatic diversion with gastrectomy as surgical treatment of morbid obesity. Obes Surg 1991;1:381–7. [8] Basko-Plluska JL, Thyssen JP, Schalock PC. Cutaneous and systemic hypersensitivity reactions to metallic implants. Dermatitis 2011;22: 65–79. [9] Lusini M, Barbato R, Spadaccio C, Chello M. Aortic valve replacement in a patient with severe nickel allergy. J Card Surg 2011;26: 618–20. [10] Van Opstal N, Verheyden F. Revision of a tibial baseplate using a customized oxinium component in a case of suspected metal allergy. Acta Orthop Belg 2011;77:691–5. [11] Hubens G, Balliu L, Ruppert M, Gypen B, Van Tu T, Vaneerdeweg W. Roux-en-Y gastric bypass procedure performed with the da Vinci robot system: is it worth it? Surg Endosc 2008;22:1690–6. [12] Yu SC, Clapp BL, Lee MJ, Albrecht WC, Scarborough TK, Wilson EB. Robotic assistance provides excellent outcomes during the learning curve for laparoscopic Roux-en-Y gastric bypass: results from 100 robotic-assisted gastric bypasses. Am J Surg 2006;192:746–9. [13] Diamantis T, Alexandrou A, Nikiteas N, Giannopoulos A, Papalambros E. Initial experience with robotic sleeve gastrectomy for morbid obesity. Obes Surg 2011;21:1172–9. [14] Niazi M, Maleki AR, Talebpour M. Short-term outcomes of laparoscopic gastric plication in morbidly obese patients: importance of postoperative follow-up. Obes Surg 2013;23:87–92.
Case report
Totally Robotic Stapleless Vertical Sleeve Gastrectomy Masoud Rezvani, M.D., F.A.C.S.*, Iswanto Sucandy, M.D., Gintaras Antanavicius, M.D., F.A.C.S. Department of Surgery, Institute for Bariatric and Metabolic Surgery, Abington Memorial Hospital, Abington, Pennsylvania Received March 12, 2013; accepted March 25, 2013
Obesity has become a major health issue in the United States [1,2] and worldwide [3]. Zhao et al. reported an increase in the number of people who are candidates for a weight loss procedure [4]. Vertical sleeve gastrectomy (VSG) is accepted as an effective weight loss procedure with relatively low risks of morbidity and mortality compared with other bariatric operations, such as Rouxen-Y gastric bypass or biliopancreatic diversion with duodenal switch [5]. VSG requires multiple sequential applications of linear staples along the greater curvature to create the gastric sleeve. Although a history of allergic reaction to the metallic components of a medical device is not present in most patients, there is a very small subset of patients in whom metallic components can cause concern. To avoid any potential allergic reaction to the metallic component in the staples, we used the alternative technique of totally robotic stapleless VSG. This novel technique circumvents the use of a linear stapler, while maintaining the benefits of a minimally invasive approach. To our knowledge, there have been no other reports on totally robotic stapleless VSG. Case report A 45-year-old man presented to our bariatric center with morbid obesity. At the presentation, he was 69 inches (175 cm) tall, and his weight was 298 pounds (131.5 kg) with excess weight of 144 pounds (65.3 kg). His body mass index was calculated as 44 kg/m2. He was also suffering Video presentation at the Society of American Gastrointestinal and Endoscopic Surgeons 2013 Annual Meeting, Baltimore, Maryland. * Correspondence: Masoud Rezvani, M.D., F.A.C.S., Department of Surgery, Institute for Bariatric and Metabolic Surgery, Abington Memorial Hospital, 1200 Old York Road, Abington, Pennsylvania 19001. E-mail: [email protected]
from multiple obesity-related co-morbidities, including insulin-dependent diabetes, hypercholesterolemia, hypertension, arthritis, sleep apnea, and snoring that required use of a nocturnal continuous positive airway pressure machine. His past surgical history was significant for several orthopedic operations for lower extremity fractures after a motor vehicle accident. Multiple metal-based orthopedic implants had been used during an open reduction and internal fixation of the fractures. Postoperatively, the patient developed a significant allergic reaction to the internal fixation devices and raised the question for device component allergy including nickel. The allergic reaction mandated removal of implants, and the fixation devices were exchanged with stainless steel implants. Because of the patient’s significant concern with his previous allergic reaction to metallic component, the decision was made to proceed with the alternative stapleless approach. Surgical technique The patient was positioned supine on the operating room table. Pneumoperitoneum was established by using a Veress needle in left upper quadrant, followed by trocar placement. Four additional trocars in the supraumbilical, anterior and right mid-axillary line, and right upper quadrant were placed under direct laparoscopic visualization. The robotic arms were placed through the supraumbilical and right upper quadrant trocars, while the camera was inserted through the right mid-axillary trocar (Fig. 1). Other trocars were used interchangeably for retraction and for suctioning by the first assistant during the operation. Greater curvature dissection was started robotically at a point 4 cm proximal to the pylorus by using a harmonic scalpel (Ethicon Inc., Cincinnati, OH) and bowel grasper. After complete dissection of the greater curvature toward the gastric fundus, a 36F bougie was carefully inserted for sizing the
1550-7289/13/$ – see front matter r 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.03.011
e80
M. Rezvani et al. / Surgery for Obesity and Related Diseases 9 (2013) e79–e81
Discussion
Fig. 1. Trocar placement and robot camera, arms positions.
sleeve by anesthesia personnel. Construction of the gastric sleeve was started with application of a laparoscopic linear Bulldog clamp (Aesculap Inc., Center Valley, PA) guided by the intragastric bougie and was fashioned against the lesser curvature. A similar type of laparoscopic clamp was applied on the gastric remnant (specimen) side. The anterior and posterior gastric walls between the 2 clamps were divided using a harmonic scalpel. The gastric sleeve cut edge was closed using a 3-0 Vicryl suture in a running fashion using the robotic arms (Fig. 2). Sequential applications of the laparoscopic linear bulldog clamps using a similar technique were performed toward the gastric fundus until the remnant stomach was completely separated from the gastric sleeve. The gastric sleeve suture line was imbricated using a 3-0 Prolene in a running fashion for reinforcement. A fibrin sealant product was applied along the suture line. A methylene blue intragastric injection test was performed, which revealed no evidence of suture line leak. A 19F abdominal drain was placed next to the gastric sleeve suture line and then the gastric remnant was removed through the supraumbilical port. The operative time was 429 minutes with minimal blood loss (o100 cc). The patient made an uneventful recovery and was discharged home on postoperative day 3. At a 1-month office follow-up visit, he was asymptomatic and had achieved 21% excess weight loss.
VSG was originally described in 1988, when Scopinaro’s technique of biliopancreatic diversion with distal gastrectomy and gastroileostomy was modified by Hess and Marceau [6,7]. This procedure requires multiple applications of linear staples along the greater curvature to create a gastric sleeve. Surgical staples consist of several elements, among which may be traces of nickel. Hypersensitive reactions to implanted devices have been described in various forms [8] in nonbariatric patients, especially with the use of cardiac and orthopedics devices [9,10]. However, this allergy has not yet been described as related to linear staple usage. The use of the robotic system in bariatric surgery, particularly in the Roux-en-Y operation, has been reported [11,12]. Diamantis et al. published a recent series of robotic VSGs with good outcome [13]. Sleeve gastrectomy involves gastric construction, which can be fashioned in a totally manual way by using staples. However, the patient’s refusal of the use of staples because of possible nickel allergy presented a surgical challenge. The 3-dimensional and magnified view of a robotic scope, as well as robotic arms, made the use of the robotic system beneficial from the beginning. Full mobilization of the greater curvature, especially dissection of the gastrosplenic ligament, was made easier and more feasible with a robotic approach. The use of the robotic arms helped overcome the challenge of gastrocolic and gastrosplenic ligament dissection and, more important, meticulous intracorporeal suturing. A robotic approach offered our patient the same laparoscopic advantages, including shorter hospital stay, shorter recovery time, and lower complication risk related to wounds, such as infection and hernia. Conversely, the concern of the duration of the procedure can be improved by advancing the robotic technique and avoiding unnecessary steps, such as sewing the specimen site. The significant cost of robotic surgery can be compensated for in rare cases, such as our patient, by providing a shorter recovery time and lower complication rates compared with an open approach. Laparoscopic gastric plication has been introduced as an alternative weight loss procedure with an acceptable weight loss outcome [14]. This procedure was considered as an option in this case but was not chosen because there are no adequate long-term data available for this procedure, and more important, this procedure has not been recognized as a standard of care in the United States. Conclusions
Fig. 2. Robotic gastrostomy site suturing.
Totally robotic stapleless vertical sleeve gastrectomy is a feasible and well-tolerated alternative in patients with any potential staples component allergy. The utilization of a robotic system facilitates intracorporeal suturing of the
Robotic Stapleless Vertical Sleeve Gastrectomy / Surgery for Obesity and Related Diseases 9 (2013) e79–e81
gastric sleeve with a high degree of precision. A short-term weight loss outcome similar to that of the conventional laparoscopic VSG technique was achieved. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Buchwald H, Avidor Y, Braunnwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;14:1724–37. [2] Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the Unites States, 1999– 2004. JAMA 2006;295:1549–55. [3] Deitel M. Overweight and obesity worldwide now estimated to involve 1.7 billion people. Obese Surg 2003;13:329–30. [4] Zhao Y, Encinosa W. Bariatric Surgery Utilization and Outcomes in 1998 and 2004: Statistical Brief #23. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville, MD: Agency for Health Care Policy and Research (US); 2006–2007 Jan. [5] Lee CM, Cirangle PT, Jossart GH. Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results. Surg Endosc 2007;21:1810–6.
e81
[6] Scopinaro N, Adami GF, Marinari GM, et al. Biliopancreatic diversion. World J Surg 1998;22:936–46. [7] Marceau P, Biron S, ST Georges R, et al. Biliopancreatic diversion with gastrectomy as surgical treatment of morbid obesity. Obes Surg 1991;1:381–7. [8] Basko-Plluska JL, Thyssen JP, Schalock PC. Cutaneous and systemic hypersensitivity reactions to metallic implants. Dermatitis 2011;22: 65–79. [9] Lusini M, Barbato R, Spadaccio C, Chello M. Aortic valve replacement in a patient with severe nickel allergy. J Card Surg 2011;26: 618–20. [10] Van Opstal N, Verheyden F. Revision of a tibial baseplate using a customized oxinium component in a case of suspected metal allergy. Acta Orthop Belg 2011;77:691–5. [11] Hubens G, Balliu L, Ruppert M, Gypen B, Van Tu T, Vaneerdeweg W. Roux-en-Y gastric bypass procedure performed with the da Vinci robot system: is it worth it? Surg Endosc 2008;22:1690–6. [12] Yu SC, Clapp BL, Lee MJ, Albrecht WC, Scarborough TK, Wilson EB. Robotic assistance provides excellent outcomes during the learning curve for laparoscopic Roux-en-Y gastric bypass: results from 100 robotic-assisted gastric bypasses. Am J Surg 2006;192:746–9. [13] Diamantis T, Alexandrou A, Nikiteas N, Giannopoulos A, Papalambros E. Initial experience with robotic sleeve gastrectomy for morbid obesity. Obes Surg 2011;21:1172–9. [14] Niazi M, Maleki AR, Talebpour M. Short-term outcomes of laparoscopic gastric plication in morbidly obese patients: importance of postoperative follow-up. Obes Surg 2013;23:87–92.