Considerations when moving from laparoscopic to robotic assisted bariatric surgery

At the recent IFSO-EC meeting in Venice, Italy, Medtronic hosted an intriguing lunch time symposium that examined the technical and personnel considerations when moving from laparoscopic to robotic assisted bariatric surgery.

Dr Benjamin L Clapp (Associate Clinical Professor Texas Tech HSC El Paso and Director-at-Large - ASMBS Board of Directors) introduced the symposium by comparing the prices and outcomes of laparoscopic staplers in robotic procedure (bedside stapling, BS) versus robotic staplers (RS) in bariatric robotic procedures. He cited a study he co-authored¹ in Surgical Endoscopy that used data from the from PINC AI Healthcare Data system and examined outcomes from Johnson and Johnson’ Echelon Stapler, Medtronic’s Cignia Stapler and the Sureform robotic stapler (Intuitive Surgical).

The adjusted outcomes variations demonstrated that patients that had RS were significantly more likely to have blood transfusions and ICU stays. The sensitivity analysis showed similar results, except there no significant differences in blood transfusion rates in both groups. Overall, the bedside staplers were used 8.5 times less than robotic staplers and when they compared Medtronic’s Cignia Stapler with the Sureform robotic stapler, they found the Cignia Stapler was used 17.2 times less.

In addition, he reported there was also less operative time with bedside staplers (overall 19 minutes less), and when they compared Medtronic’s Cignia Stapler with the Sureform robotic stapler they found that Medtronic bedside staplers reduced operative time by 32 minutes.

Dr Benjamin Clapp

“Now, in the US the cost of one minute of operating time is usually around US$30, so using €30 as a metric, we found that as bedside staplers reduce operating time by 19 minutes less, this translated to a cost saving of €1200 less versus robotic staplers,” he explained. “And the Medtronic stapler resulted in even greater savings (32mins) – a cost saving of $2670.”

After performing propensity score matching, they also found that the ICU stays and blood transfusion rates were higher after robotic stapler vs Medtronic’s manual intelligent bedside stapler (MIBS).

Dr Clapp concluded his presentation by citing a second paper published in SOARD² that specifically looked at the costs between unspecified bedside staplers, robotic staplers and laparoscopic bedside staplers. This paper concluded that unspecified bedside staplers and robotic staplers were critical cost drivers in patients undergoing robotic procedures and it was much cheaper to use Medtronic’s laparoscopic bedside stapler.

Considerations for robotic surgery

In the next presentation, Dr Carlos Vaz (General surgeon, Chief Medical officer Hospital CUF Tejo, Director Robotic surgery unit CUF Hospital Lisbon, Portugal) outlined some of the criteria one should consider when choosing why to use robotic surgery and what to consider (patient selection, procedure selection, stapling selection, bedside approach and the importance of team communication) when performing bariatric procedures.

He began by stating that traditional open bariatric surgery has been around since the 1950s, but the emergence of laparoscopy in the 1990’s began a resurgence, and he believes that robotic assisted surgery is the next step. He acknowledged that currently there is a lack of literature supporting robotic surgery, such as prospective randomised control trials, however, he feels that there is an evolution to have a digital platform to help surgeons do their job. But how does this digital platform help surgeons?

Dr Carlos Vaz

“A digital platform improves a surgeon’s performance with enhanced dexterity and range of motion, facilitating safer dissection in complex anatomical planes and enables more precise manual suturing, potentially leading to better anastomotic outcomes,” he explained. “Compared with laparoscopy, robotic surgery offers a steadier image, no torquing gentle tissue handling and improved accuracy.”

Dr Vaz believes that robotic surgery also offers significant advantages when operating on super obese patients as it effectively neutralises abdominal wall torque, delivers higher precision with longer instruments, reduces the technical difficulties and risks associated with laparoscopy in this challenging patient population and robotic surgery results in similar ease and precision as in standard obesity cases.

“In addition, robotic surgery also offers clear benefits in revision bariatric surgery providing superior visualisation, manoeuvrability and ergonomics in complex revision cases,” Dr Vaz added. “It also facilitates meticulous dissection of adhesions and scar tissue, and reduces technical difficulties and risks associated with laparoscopy in this challenging patient population. For me, robotic revision surgery should be the standard approach if you have this technology and if you have the expertise.”

Patient and procedure selection

In the next part of his presentation, he discussed the considerations for patient and procedure selection and stressed that it is essential whenever one is starting a new technique in any field, in the initial learning curve one should prioritise favourable cases.

“So, in the case of bariatric surgery, don't do difficult revision cases, in primary cases don't do very high BMI, focus on BMI<40,” he commented. “Maybe start with a sleeve and when you get more experience, develop your technique, learn and get used to the robots and the instruments, then you can broaden your cases. Allow yourself to develop proficiency in less complex scenarios, ensuring patient safety and building confidence.”

In his opinion, overtime all patients potentially become eligible for robotic surgery including RYGB, OAGB, BPD, ileal metabolic procedures and complex revisional surgeries.

“Furthermore, if you have cost limitations, prioritise robotic surgery for more challenging cases and procedures where the advantages of robotic surgery are most pronounced.”

Staple selection

Regarding staple selection, he cited the paper by Clapp et al¹ that showed favourable outcomes for the Medtronic Signia TriStaple versus the SureForm stapler. It is his belief that stapler technology for the robot platform has not yet caught up with the robotic technology itself. Therefore, he recommends using the Medtronic Signia TriStaple because it is cost-effective compared to the Intuitive Sureform stapler, it is an advanced stapler cartridge technology, incorporates intelligent tissue sensing technology, real time tissue thickness measurement, autonomously adjusts tissue compression and firing speed, is a more mature and advanced technology compared to the Sureform and offers a more consistent and reliable staple formation across a wider range of tissue types and thickness.

“When I perform bariatric surgery, I prefer to use the bedside assistance technique with the CDHS table. As a robotic surgeon, I would rather use a staple from the console and control it yourself. But if you are using another stapler because you feel that it's better and it's safer, then you must rely on another surgeon because it cannot be directly manipulated by you and it requires the bedside assistance to handle the stapler. To mitigate this problem, we have two mitigation strategies that we use. Firstly, you need to have a bedside assistant that knows how to use the instrument. Ideally, it should be a surgeon, a young surgeon or a resident. But they need to be trained on how to use the stapler, how to negotiate with the arms of the robot and be familiar with different stapler types and proper handling. Secondly, you both have to use clear and standard communication protocols. So, you really have to speak with your assistant and even with your team, and together make it clear what each command means, what each word means. And you have to standardise this communication to minimise misunderstandings and to ensure precise stapler placement and fire.”

For example, he said that when you tell your assistant from the console to rotate the stapler to the left, you need to agree before the operation that rotation means rotating the staple along its longitudinals. Therefore, predefining and standardising the meaning of key commands is vital. It is also important to ensure the patient is positioned optimally for the procedure and stapler access. The bedside assistance should have clear and unobstructive access to the to the surgical field, and the ergonomics for the assistant should also be assessed to minimise fatigue during longer procedures, he concluded.

Experience with the Hugo robotic-assisted surgery (RAS) system

In the final presentation, Professor Marco Raffaelli (Professore Ordinario di Chirurgia Generale - Università Cattolica del Sacro Cuore; Direttore U.O.C. Chirurgia Endocrina e Metabolica Fondazione Policlinico Universitario Agostino Gemelli IRCCS) discussed his experience with Medtronic’s Hugo robotic-assisted surgery (RAS) system. He explained that Hugo is an open console (32-inch-widescreen HD3D display with dedicated glasses) so all the team has the same visuals and this is very important for communication purposes.

The Modular design of the Hugo arm cart empowers surgeons to choose the surgical approach for each patient. For example, three- and four-arm configurations for robotic-assisted surgery or one-arm configuration to assist with standard laparoscopic procedures. Each robotic arm is independent and extendible thanks to six different joints for adjusting the height, angle, tilt of the proximal end of the arm and tilt of the distal end of the arm.

Professor Marco Raffaelli

Professor Marco Raffaelli said it is important to standardise the position because bedside stapling is mandatory. As there is no automatic docking, a surgeon should choose the docking based on the procedure he or she is going to do. This is very important to modulate them on the basis of the surgeon’s experience and preference.

“In the beginning, we choose the easiest case as Dr Vas suggested. This introduced us to the framing and the learning curve. When we are approaching the robotic platform, we have to learn technical skills – such as assisting, laparoscopic port access, console control, use of camera, tying knots, suturing, dissection, etc and then non-technical skills, such as theoretical knowledge, team working, communication and decision-making, and troubleshooting.

He said robotic courses should include very basic knowledge and skills, giving the participants the basic knowledge of the robotic activities. However, he added that there are other levels of competence that should be reached before starting a clinical programme, and animal or cadaveric models offer a good opportunity, not only for surgeons, but for the whole operating team to undergo technical learning, procedural experience and coaching preparation.

He cited that the first Italian, multicentre experience with the Hugo platform (with more than 200 cases from six centres) demonstrated that if the procedure standardised it can be reproducible in different setting with a very minimal complication rate³.

Although he began performing robotic RYGB surgery in 2013, the number of cases remained relatively flat for a number of years, compared with the number of laparoscopic RYGB procedures (90.5% vs 9.5% in 2013) but has increased in recent years (67.3% vs 32.7% in 2024).

“Another factor is costs – most of the papers⁴ in the past were against the utilisation of the robotic platforms in in bariatrics because of the increase in cost. However, what we are observing now is a decrease in operating costs⁵ due to more procedures being performed, as well as greater competition in the market. In fact, the costs are now very close to that of the laparoscopic counterpart.”

“In summary, in our experience RYGB is feasible and safe with Hugo RAS Platform and is replicable in different setting with relatively easy standardisation. It offers significant advantages in terms of visualisation for the surgical team, suturing, modularity and sustainability”, he concluded. “However, there are some things we have to you have to ameliorate including instrumentation. But I think that the robotic bariatric surgery is the future for this century. We have to work with the companies to help them progress their products and they should help us get the best results for our patients.”

References

1. Clapp BL, Billy H, Lutfi RE, Pan IW. Effectiveness of bedside staplers in bariatric robotic procedures. Surg Endosc. 2024 Sep;38(9):5310-5318. doi: 10.1007/s00464-024-11045-w. Epub 2024 Jul 17. PMID: 39020121; PMCID: PMC11362250.

2. Clapp BL, Chaudry S, Billy HT, Lutfi R, Lloyd SJ, Pan IW. Cost drivers of gastric sleeve procedures performed using robotic platform. Surg Obes Relat Dis. 2025 Jul;21(7):768-776. doi: 10.1016/j.soard.2024.12.008. Epub 2024 Dec 17. PMID: 39788855.

3. Pennestrì F, Sessa L, Prioli F, Gallucci P, Ciccoritti L, Greco F, De Crea C, Raffaelli M. Robotic vs laparoscopic approach for single anastomosis duodenal-ileal bypass with sleeve gastrectomy: a propensity score matching analysis. Updates Surg. 2023 Jan;75(1):175-187. doi: 10.1007/s13304-022-01381-8. Epub 2022 Sep 25. PMID: 36161395; PMCID: PMC9834101.

4. Ugliono E, Rebecchi F, Vicentini C, Salzano A, Morino M. Cost-effectiveness analysis of revisional Roux-en-Y gastric bypass: laparoscopic vs. robot assisted. Updates Surg. 2023 Jan;75(1):189-196. doi: 10.1007/s13304-022-01425-z. Epub 2022 Nov 23. PMID: 36422812; PMCID: PMC9834166.

5. Read MD, Torikashvili J, Janjua H, Grimsley EA, Kuo PC, Docimo S. The downtrending cost of robotic bariatric surgery: a cost analysis of 47,788 bariatric patients. J Robot Surg. 2024 Feb 3;18(1):63. doi: 10.1007/s11701-023-01809-2. PMID: 38308699.