Clinical Challenges in Robotic Bariatric Surgery: The Robot is Here to Stay!
Behind The Knife: The Surgery Podcast14 Jul 2025

Clinical Challenges in Robotic Bariatric Surgery: The Robot is Here to Stay!

Join us as we dissect the use of robotics in bariatric surgery – where precision meets programming, and the scalpel gets a software upgrade.

Video Clip Link: https://app.behindtheknife.org/video/clinical-challenges-in-robotic-bariatric-surgery-the-robot-is-here-to-stay
This videos includes:
- Robotic RYGB
- Robotic Sleeve Gastrectomy
- SADI: Single Anastomosis Duodenoileostomy

Hosts:
- Matthew Martin, trauma and bariatric surgeon at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California)
- Adrian Dan, bariatric and MIS surgeon, program director for the advanced MIS bariatric and foregut fellowship at Summa Health System (Akron, Ohio)
- Crystal Johnson Mann, bariatric and foregut surgeon at the University of Florida (Gainesville, Florida)
- Katherine Cironi, general surgery resident at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California)

Learning objectives:
  • Strengths of the robot:
    • Surgical robots are at the forefront of technology and continue to improve with detailed, precision cameras and the ability to remove baseline tremors
    • Allows for smooth movements, fine dissection, and precise tissue handling
    • Ergonomics are more advantageous to the surgeon when compared to laparoscopy
  • Weaknesses of the robot:
    • The loss of haptic feedback can be challenging for surgeons early in their learning curve
    • Emphasis on surgical robots means some trainees may be losing exposure to laparoscopic techniques
    • Longer operative time when working robotically, and more time under anesthesia for the patient
    • Increased cost for robotic surgery
  • Outcomes data:
    • Mixed data from the MBSA QIP database (metabolic and bariatric surgery accreditation and quality improvement program)
    • The most recent study looked at 824,000 patients from 2015-2022 who had a sleeve gastrectomy or RNY gastric bypass, either laparoscopically (lap sleeve 61%, lap RYGB 24%) or robotically (robo sleeve 11%, robo RYGB 4%).
      • Robotic sleeves were reported to have higher complication rates compared to laparoscopy, seen as higher overall morbidity and an increased rate of leaks
      • While the robotic RYGBs have lower overall complications, including decreased morbidity and bleeding. Robotic RYGB can be especially advantageous with revisional surgeries when compared to lap.
  • Setting up for success
    • Train your eyes to determine tension on tissue, since there is no haptic feedback
    • Learn how to assist yourself (manipulating the camera and effectively utilizing the fourth arm)
    • Understand how techniques of the surgery change when doing it robotically, as compared to laparoscopy
    • Experienced operating room team
    • When learning, recommend putting all cases feasible on the robot (including easier cases), to master the straightforward cases before moving to technically challenging revision cases.
    • Don’t hesitate to add an additional trocar or assistant port when needed
  • Education in Robotic learning
    • Learning by observation/mirroring – ex: robotic bilateral inguinal hernia (mirroring the attending/instructor)
    • Easy for the attending/instructor in the case to switch instruments seamlessly, then give them back intermittently at the appropriate time
    • Helpful when the attending annotates the screen to depict where to go
    • Data-driven teaching tools on the Davinci system
  • Tips for robotic sleeve gastrectomy:
    • Of the robotic bariatric surgeries, sleeve gastrectomy is most similar to its laparoscopic procedure
    • 30-40 degrees of reverse Trendelenburg
    • Liver hammock stitch instead of a liver retractor (one less trocar), which makes a total of 4 trocars needed for the case
    • Green staple load for the first firing, then the rest are typically blue loads
    • Mixed opinions on reinforced staple loads versus non-reinforced staple loads and oversewing the staple line (discussed cost-benefit)
  • Tips for robotic gastric bypass:
    • Watch videos from colleagues to learn what they do
    • Gastric bypass is a multi-quadrant surgery; thus, you must set yourself up for success so that your arms are not fighting when moving through different quadrants
    • A size 12 trocar on the left can make the formation of the gastric pouch easier
    • GJ and JJ anastomosis formed with a linear fire, then a two-layer closure with absorbable barb suture
    • Don’t forget to close the mesenteric defect (non-absorbable braided suture)
  • Tips for robotic DS and SADI:
    • If doing a duodenal anastomosis hand-sewn, then recommend planning the exact number of sutures and locations of each for ease
    • Hand-sewn anastomosis can have less bleeding and fewer strictures for patients, and is completed in a much more seamless fashion with the robot
  • Future of Robotics
    • Haptic feedback
    • Integrated visual overlays to identify anatomical structures/serve as an intraoperative map
    • Artificial intelligence integration
    • Telesurgery – ex, small surgical robot deployed to space

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

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