Robotic laparoscopic sleeve gastrectomy (LSG) results in the resolution of type 2 diabetes, a reduction in hypertension, and carries a low risk of complications, according to Professor Ralf Konstantin Senner, Lindberg Hospital/GSMN,Winterthur, Switzerland.
“The euphoria regarding gastric banding ended in 2005 and sleeve gastrectomy was a new option,” said Senner. “Many bariatric surgeons were skeptical about the procedure and about the results. However, we learned with every new patient and each new surgery, our experience increased.
“At the time, it was recommended that the sleeve was the first stage of the two stage procedure, but the first results were very motivating showing good weight reduction, improvements of comorbidities as well the patients reporting a change in their habits, so we continued to carry out the procedure as a single procedure.”
Senner and colleagues, who began performing LSGs in munuich in 2006, have since performed over 1,000 cases in Munich, Cairo and Winterthur.
The vast majority of patients treated were female (70%) and presented with comorbidities including type 2 diabetes (n=370), hypertension (n=570), as well as coronary artery disease, sleep apnea and infertility.
The baseline BMI ranged from 40 to 45 and at one year the average weight loss was 60kg (ranging from 40 to 100kg).
Weight loss dynamic
There were notable differences between the amounts of weight lost between patient groups. Men lost weight quicker than women even when they are in the same weight class (in some cases up to 10kg more) and according to Senner muscular mass, metabolic balance and hormone status can all influence the length of time to achieve weight loss.
Age also played a factor and patients aged 40 or younger showed the best weight reduction, were highly motivated, demonstrated a high compliance and had fewer comorbidities. Patients aged 40-60, show a good weight reduction but their weight loss is restricted by comorbidities, metabolic balance, hormone status, and a mental component. Patients aged 60-70, demonstrate a slower dynamic of weight reduction influenced by more comorbidities and physiological processes.
The outcomes from 1,000 cases show that from the 43% of patients who had type 2 diabetes prior to surgery (68% oral antidiabetica /32% insulin), 66% no longer required treatment for their diabetes post surgery.
Of the 63% of patients who had hypertension before surgery, 78% required no hypertension therapy following surgery and 22% showed a reduced need for therapy.
Robotic LSG also demonstrated a positive impact on sleep apnoea with 33% of patients no longer requiring continuous positive airway pressure after robotic LSG.
A reported 22% of patients who said they were infertile due to their morbid obesity all successfully conceived following surgery, as a direct result of losing weight and changing their nutrition habits.
Senner explained that the procedure is a standard solo surgery laparoscopic robot assisted sleeve gastrectomy with autonomous lever retractor, with helps to improve the ergonomic work, increases the efficiency of work and the concentration capacity during surgery.
“For the resection, we use a gastroscope which enables an endoview inside of stomach to assist, calibration and control the cut line during the procedure,” he said. “The gastroscope also aids the diagnostic treatment of bleeding after resection, providing very good views in case of His angle high position and a good view of the end of sleeve in cases of high position of His angle.”
Senner and his team begin the resection after intravenous Buscopan 1-2 amp. They choose the staple size (yellow, green, blue) after relaxation of the stomach wall to have a perfect adaptation staple size and stomach wall thickness sise (to avoid hanging and leakage). They perform partial or total omentectomy before preparation of the stomach and before stapling (if is necesary depending on anatomical considerations such as fat content, high position of His angle, size of the abdominal cavity, the low rib position and enlarged liver). An omentectomy is also performed for patients presenting with a difficult anatomical demarcation, and to improve the technical and anatomical conditions facilitating an easier resection and avoiding organ injury.
The patient is also put under controlled (assisted) apnoea via anesthesia for four to six minutes to get more space under the diaphragm (reducing movement amplitude) for the last difficult step of the resection
Senner uses a special staple technique to avoid the shifting phenomenon and uses linear/constant compression on the cut line for improved delimitation of crossing points along the cut line and a lower leakage risk.
There are several complications that can occur during the surgery including difficult placement of the trocar, usually a consequence of a big abdominal wall or low rib position. These can be resolved with the use of an additional trocar or adopting an atypical position.
Senner also warned against hanging from staple in the stomach wall during the cut procedure, which he claimed was “a very dangerous situation and presents a very high risk of leakage”
The group report a post-surgery complication rate of 6%, including 2% bleeding rate, 2% leakage rate and 2% of cases which were postponed due to liver damage (patients received BMI conversion therapy, gastric balloon). Seven per
cent had a pseudo diverticula (in the proximal part of stomach), 30% were symptomatic (reflux, weight increase) and 70% were asymptomatic. The solution was revision surgery recalibration of sleeve stomach, and diverticula resection.
Bleeding was usually on the cut line (sometimes in case of increasing of blood pressure/ bed management of pain after surgery) and four conversions from laparoscopic to open surgery found no evidence of active bleeding.
Leakage was located on the critical point esogastric junction and identified as general peritonitis/sepsis and a switch was made to open surgery. Patents who developed local subfrenic abscess/without sepsis were treated with controlled punction, drainage, stenting/clipping. Five percent of patients were diagnosed during the stay in the hospital between four and six days with an apparent mechanical cause (without general peritonitis) and the remaining 95% of patients were diagnosed after eight to ten days with an apparent ischaemic cause (with peritonitis).
There were no reports of organ injury, assisted respiration or conversions open surgery because difficult anatomical situation.
There were two reported cases of post-incisional hernia. One patient died due to massive cerebral bleeding and a second patient died due to massive pulmonary emboli.
“Robotic LSG improves all enumerated comorbidities and helps our morbidly obese patients achieve a better quality of life with weight reductions of between 40 and 140kgs a year,” concluded Senner. “The procedures also results in a positive change in the character of the patients, as they change their habits their motivation to change becomes more disciplined.”