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Robotically assisted SADI

Report: Robotically-assisted SADI Bypass after LSG

The da Vinci Surgical System (Intuitive Surgical) was used to perform the procedure
Researchers from the Vall d’Hebron University Hospital, Barcelona, Spain, have unveiled a novel technique - SADI (single anastomosis duodenoileal bypass-sleeve). via totally intracorporeal robotically assisted SADI using five ports and a liver retractor

Researchers from the Vall d’Hebron University Hospital, Barcelona, Spain, have unveiled a novel technique - SADI (single anastomosis duodenoileal bypass-sleeve). via totally intracorporeal robotically assisted SADI using five ports and a liver retractor. In their paper, ‘Robotically Assisted Single Anastomosis Duodenoileal Bypass after Previous Sleeve Gastrectomy Implementing High Valuable Technology for Complex Procedures', published in the Journal of Obesity, the researchers said they wanted to assess whether robotic technology offers more advantageous anastomosis and dissection obtained by the robotic approach in comparison to standard laparoscopy including safety, feasibility, and reproducibility of the procedure.

The authors write that sleeve gastrectomy (SG) constitutes the first stage of the duodenal switch and also of the SADI-S (single anastomosis duodenoileal bypass-sleeve) procedure. SADI-S is a bariatric procedure based on the principles of biliopancreatic diversion (BPD). However, the development of robotic surgical platforms such as the da Vinci Surgical System (Intuitive Surgical), introduced in the surgical practice, has gained popularity in different specialities, including bariatric surgery. Following the implementation of the robotic technology in their bariatric department, they wanted to study the feasibility, learning curve, and outcomes in robot-assisted sleeve gastrectomy. One of the major issues related to the robotic technology is to know if it offers more advantageous anastomosis and dissection obtained by the robotic approach in comparison to standard laparoscopy as some authors have already mentioned. In their paper, they present the first three cases of robotic SADI bypass as a second stage using a five-port technique and a liver retractor.

Three patients’ records were reviewed and all had a previous laparoscopic SG. A decision was made to undergo a robotic SADI bypass after completing a preoperative care assessment. All patients had medical criteria for revisional surgery (staged surgery), including patients with an insufficient weight loss (excess weight loss <50% after 18 months).

Technique

SADI bypass includes a single duodenoileal anastomosis performed 300 cm from the ileocecal valve (Figure 1a) and trocar placement according to the described technique (Figure 1b).

Figure 1a: The SADI bypass includes a single duodenoileal anastomosis performed 300 cm from the ileocecal valve

The pneumoperitoneum was achieved by a Veress needle inserted at the left hypochondrium. The first trocar (camera trocar) was inserted slightly left of midline and 16 cm from the xyphoid and a 150mm long trocar was used as the camera port (Xcel Trocar, Ethicon-Endosurgery) that allowed the right connection with the robotic arm. All other trocars were inserted under direct vision. A 12mm working port was inserted about 6cm left of the previous trocar and the right 12mm working port was positioned 6cm from the camera port. Two 8mm robotic trocars were placed on the anterior axillary lines and a Nathanson liver retractor was placed to elevate the left lateral segment. An extra 5mm trocar was placed in the left iliac fossa. With this set-up in place, the left 8mm robotic trocar could be used through the 12mm trocar in a double-cannulation technique which allows deciding easily the best direction to perform the stapling of the duodenum (Figure 1b).

Figure 1b: Trocar placement according to the described technique

The bedside surgeon then measured a 300cm ileal loop laparoscopically and the robot was docked over the patient’s head (covered with a head protection designed for this purpose). The da Vinci camera was locked in the midline trocar with placement of other instruments. The console surgeon inspected the previous sleeve and dissected all the inferior part of the previous sleeve identifying the old stapling line. All posterior adhesions to the top of the pancreas were freed. For this purpose, the authors explained a grasper was used in the left hand and the da Vinci modified harmonic scalpel was installed in the right hand. The third da Vinci arm (the one placed on the left midaxillary line) was used with another pair of forceps in order to retract the previous sleeve and allow better exposition.

An important step of the SADI procedure is the complete dissection of the duodenum by identifying also the pyloric artery coming from the gastroduodenal arter, which the authors preserved. Once the duodenal dissection was performed over 2cm after pylorus, a laparoscopic stapler was used (Echelon 60 Endopath Stapler, Endoscopic Linear Cutter Straight, Ethicon-Endosurgery) with a green cartridge including Seamguard buttress material reinforcement (Figure 2a). The complete transection of the duodenum was performed.

Once transected, the duodenum was left in place and the buttress material reinforcement material located on the gastric part was cut by the use of robotic scissors (Figure 2b). The bedside surgeon introduced then a robotic needle holder in the left trocar. A totally robotic four-layer duodenoileal anastomosis was performed using polypropylene (3/0) (Prolene, Ethicon-Endosurgery). First a posterior polypropylene layer was made (Figure 2c); then the duodenum and the ileum were opened by the use of monopolar. A posterior continuous resorbable suture (vicryl 3/0 Ethicon-Endosurgery) was performed (Figure 2d) and then the anterior layer was constructed in similar fashion, first with a vicryl continuous layer (Figure 3a) and finally with a polypropylene 3/0 anterior closure (Figure 3b).

A methylene blue test was performed. For this manoeuvre, the console surgeon blocks the outlet at the level of the ileal loop in order to visualise the shape, the apparent volume, and any leak of the anastomosis (Figure 3c). A drain was left in place under the anastomosis and close to the duodenal stump (Figure 3d).

Figure 2a: Complete transection of the duodenum

Figure 2b: Excision of the buttress material reinforcement material located on the gastric part

Figure 2c: Duodenoileal anastomosis, posterior polypropylene layer

Figure 2d: Posterior continuous resorbable suture

Figure 3a: Duodenoileal anastomosis: anterior layer first with a vicryl continuous layer

Figure 3b: Duodenoileal anastomosis: anterior layer with a polypropylene 3/0 anterior closure

Figure 3c: Anastomosis leak test

Figure 3d: Drain placement

The operative times of the three cases were 124, 174, and 138 min, respectively, with no conversions, mortalities or perioperative complications in the first 30 days.

“Complete robotic adhesiolysis must be performed in these patients, including liver dissection on previous sleeve gastrectomy and dissection of the antrum of the gastric sleeve,” the authors note. “A clear dissection of the posterior sleeve, which is always adhered to the anterior part of the pancreas, must be performed avoiding pancreatic injury.”

In addition, they write that a surgeon might consider placating the previous sleeve or re-sleeving the sleeve. Once this step is performed, a clear dissection of the duodenum including visualisation and preservation of the gastroduodenal artery must be performed. They add that a complete SADI-S procedure as a first step could be performed in their experience.

“SADI-S procedure, compared to DS, eliminates the Roux-en-Y reconstruction and includes a Billroth II-type one-loop duodenoileostomy instead…The elimination of one anastomosis should have further benefits: the reduction in the operation and anesthesia time, the reduction in the probability of postoperative leak. Furthermore, the use of the robotic system to perform this procedure facilitated and enhances the surgical work,” they add. “The robotic platform can play a significant role in improving surgeon’s ergonomics thus increasing the quality of the operation. We believe that robotic technology will allow performing much more complex procedures, including revisional surgeries.”

“Robotic technology can be applied to perform SADI-S procedure. Standard technique can be applied in order to perform revisional surgery after failed or second-stage robotic SG,” they conclude. “Larger case series and comparing to standard laparoscopic series will be required to analyse the impact of robotic surgery in more demanding procedures such as revisional bariatric surgery.”

To access this paper, please click here

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