Robotic technique shows promise in performing complex weight-loss surgery
BY MATTHEW EARLY WRIGHT
Stanford surgeons have developed a safe and efficient way to use a surgical robot to perform gastric bypass operations. Their report, published in the August issue of the Archives of Surgery, documents the first totally robotic technique to complete this technically challenging procedure.
The method, developed by associate professor of surgery Myriam Curet, MD, is an improvement on a more conventional technique called laparoscopic surgery. In both instances, specialized tools with cameras attached are inserted through small holes in the patient's body. But while traditional laparoscopic tools are held in the surgeon's hand, the robotic tools are operated remotely from a control station.
"It makes the surgery easier," said Curet, noting that the da Vinci robotic surgical system, manufactured by Intuitive Surgical Inc. in Sunnyvale, Calif., offers several advantages over hand-held laparoscopic tools. For example, it has a 3-D camera to aid visualization, as opposed to the 2-D fiber optic cameras used in conventional tools. The robotic arms also have highly flexible wrists, making precise maneuvers possible.
The robot also offers a benefit specific to gastric bypass surgery, which is often performed on morbidly obese patients: the robotic arms are strong enough to stay steady while working in these patients' massive abdomens. "The robot minimizes the torque of the abdominal wall," Curet explained, decreasing the chance that a surgeon would have to switch to open-cavity surgery mid-procedure.
Gastric bypass is the most common form of weight-loss surgery. It drastically reduces the stomach's size to limit food intake and also bypasses a significant portion of the small intestine, decreasing nutrient absorption.
As the obesity epidemic has grown in recent years, so too has the number of gastric bypass operations. In the United States alone, the number of surgeries increased from 29,000 procedures in 1999 to about 141,000 in 2004, according to the American Society for Bariatric Surgery. The procedure poses about a 2 percent risk of mortality and requires lifelong changes in eating habits. But for many morbidly obese individuals, the operation is life-saving.
Gastric bypass procedures are notorious among surgeons for being technically complicated and difficult. Curet and her colleagues therefore wanted to develop a protocol to make the surgery easier on both the patient and the surgeon. To investigate whether the robotic system could safely and effectively streamline the process, the authors compared the results of 10 robotic surgeries with 10 conventional laparoscopic procedures.
They found that the robotic system makes the surgery qualitatively easier. For example, the surgeon can sit comfortably at the robot's control unit and gently operate joysticks, instead of having to stand over the patient for several hours wrestling with hand tools. But the robotic procedure also yielded a quantifiable benefit: median surgical times were approximately 30 minutes shorter using the robot than they were using hand tools.
The robot might also save time for surgeons in the long term. While the first few robotic operations can take longer than conventional methods for an inexperienced surgeon, "the learning curve is shortened with the robot," Curet said.
The robotic surgeries referred to in the study were performed just last year. As such, Curet and her collaborators acknowledge that it is too early to draw any definitive conclusions regarding long-term patient outcomes. However, they are confident that the robotic system will prove to be just as safe and effective as conventional methods over time.
As with all new medical technologies, robotic surgery has been greeted with a degree of cautious skepticism. But the da Vinci system has already been used to perform many other surgeries, including kidney removal, prostate removal and even certain cardiac surgeries.
"People want to see the data and know that it is better," said Curet, regarding the comparison between robotic gastric bypass and conventional laparoscopic bypass. "But they seem open to it."
Curet's collaborators on the study include medical student Catherine Mohr and Geoffrey Nadzam, MD, a former Stanford surgical fellow.