Erik B. Wilson, MD, FACS Associate Professor of Surgery
Bariatric Surgery Medical Director Memorial Hermann Hospital
Division Chief, Minimally Invasive and Elective General Surgery
University of Texas Medical School at Houston Robotic Bariatric
Surgery: Ok, When Do I Have to Deal with This
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1999 2000 2001 2002 2003 da Vinci Surgical System U.S.
Installed Base 1999 2010 2004 Alaska 2005 Hawaii Puerto Rico
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Annual Worldwide Procedures ~300,000
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Where is Robotics for General Surgery? Market Penetration
EmergenceAdoptionStandard of Care Time Low High Prostate #1
Treatment Option for Prostate Cancer GS & ENT New, developing
area for Robotic Surgery Thought leaders are gravitating to the
system Opportunity to be a first mover in this area Benign GYN
Rapid Adoption for Complex anatomy Rapid adoption by GYOs across
the US Highly attractive to recent fellows GYN - ONC
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General Surgery Procedures (WW) 2010 dV Gen Surg Growth =
67%
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da Vinci General Surgery Procedures (WW) LAR, APR Colectomy
Rectopexy Gastric Bypass Sleeve Gastrectomy Bands Hernia Pancreas,
Liver Gastrectomy Transplant Cholecystectomy Nissen Fund. Heller
Myotomy
My Biases Digital platforms are the future of elective surgery
They make good surgeons better and more comfortable Complications
and conversions to open surgery will become less acceptable
Bariatric surgery has become comprehensive in its procedures and
services Failures and revisions of bariatric surgery will continue
to grow
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My Bias The Day of Open Elective Surgery and Open Conversions
is Coming to a Close
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Eliminates Counter-intuitive motion Instrument tremor Provides
Improved ergonomics Hand / eye alignment 3 hands in 2 Transforms
2-D vision to true 3-D 5 DOF instruments to 7 DOF (greater
endoscopic dexterity) What Can Robotic Surgery Do?
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Challenges to RoboticsWhat Cant It Do? Increased costs Only one
company in the market Large footprint No haptic feedback Limited in
multi-quadrant procedures Longer set-up times Longer operative
times
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Challenges to RoboticsWhat Cant It Do? Increased costs Only one
company in the market Large footprint No haptic feedback Limited in
multi-quadrant procedures Longer set-up times Longer operative
times
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General Surgeons in Robotics Its a been hard sell because of
the general surgery laparoscopic skill set Possible candidates
Surgeon looking for a marketing advantage Open Surgeon trying to
get into MIS Skeptical Laparoscopic Surgeon Early Adopter
Technology Junkie Laparoscopic Surgeon
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Robotic Gastric Bypass Outcomes 2002-2007 Curet et al.
California, USA. 75 patients. Totally Robotic. 140 minute operative
time, 0 leaks, 3 GI bleeds, 0 deaths. Morel et al. Switzerland. 54
patients. Totally Robotic 310 minute operative time, 0 leaks, 1 GI
bleeds, 0 deaths. Parini et al. Italy. 70 patients. Hybrid Robotic
132 minute operative time, 2 fistula/leaks, 10 GI bleeds, 0 deaths.
Hubens et al. Netherlands. 45 patients. Hybrid Robotic 212 minute
operative time, 0 leaks (5 sb injuries), 0 deaths. Berger, Horgan
et al. Illinois. 110 patients. Hybrid Robotic 190 minute operative
time, 0 leaks, 3 GI bleeds, 0 deaths. Wilson, Yu et al. Texas. 249
patients. Hybrid Robotic 217 minute operative time, 0 leaks, 2 GI
bleeds, 0 deaths.
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Robotic Gastric Bypass Early Outcomes 603 Total patients 201
minute average operative time 2 fistula or leaks (0.3%) 19 GI
bleeds (3%) No Mortality Standard LRYGB 5 % leak rate 0.3 to 2%
mortality
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Prospective Comparison of Robotic versus Standard Laparoscopic
Roux-en-Y Gastric Bypass Erik Wilson, MD, FACS Sherman Yu, MD, FACS
Terry Scarborough, MD, FACS Brad Snyder, MD Journal of Robotic
Surgery 2008
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Demographics 605 total patients Mean Age % Male Mean BMI
Revisions 356 lap patients 42 years (18-68) 20% male 50.4 (34-88)
65 (18%) 249 robot patients 43 years (19-72) 21% male 50.2 (34-92)
38 (15%) No significant differences
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Complications 356 lap patients 4 (1.1%) 8 (2.2%) 19 (5.3%) 6
(1.7%) 37 (10.4%) 4 (1.1%) 0 2 (0.6%) 1 (0.3%) 0 6 (1.7%)* 14
(3.9%) 249 robot patients 1 (0.4%) 8 (3.2%) 13 (5.2%) 4 (1.6%) 26
(10.4%) 2 (0.8%) 1 (0.4%) 2 (0.8%) 0 2 (0.8%) 0* 9 (3.6%) 605 total
patients Wound Infection Stricture Vomiting/Dehydration Abdominal
Pain Total Minor Intraluminal Bleed Abdominal Wall Bleeding Trocar
Hernia Rhabdomyolysis Stroke Pulmonary Embolism Leak Total Major No
significant differences except *p=0.040 All complications are
reported over 90 days postop No mortalities in either group
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Retrospective review of prospective databases University of
Texas Houston (538 patients) Database 2002-2010: Remedy MD Three
robotic surgeons (E. Wilson, T. Wilson, B. Snyder) Eastern Maine
Medical Center (562 patients) Database 2005-2010 : LapBase One
robotic surgeon (Toder) Mean BMI 47.9 2010--1100 Robotic
Bypasses
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Weight Loss %EWL Months
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Major Complications
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Houston, Texas All cases are training cases Average time 196
minutes Bangor, Maine All cases with same personnel Average time
114 minutes First thirty : ~200 minutes Last 100 : ~90 minutes
Operative Times
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The Robotic RYGB is a safe and effective technique 1100
patients, no mortalities (Standard 0.3-2% for LRYGB) The robotic
approach has a lower gastrojejunal leak rate (In this case series 1
leak) 1/1100 versus standard published rates of 2-5% Complications
are few and may be less than conventional laparoscopic techniques
The robot RYGB has good weight loss results The learning curve for
a safe surgery is quick Conclusion
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Revisional Bariatric Surgery Revisional Cases (136) Band to
Bypass(27) Band to Sleeve (5) Band to Lap Band (6) VBG to Bypass
(75) Sleeve to Bypass (2) Bypass to Bypass (14) Bypass to
Biliopancreatic Diversion (7) The keys to success are meticulous
dissection and careful staple line evaluation
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Robotic Revisional Bariatric Surgery Robot approach with
advantages Dissection versus Reconstruction
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Robotic Revisional Bariatric Surgery Severe adhesions
Revisional Gastric Bypass Complications Total Complication Rate
16% Minor 8% Major 8% Leaks 0% or 1% Compares favorably to
literature reported leak rates of 15% (Higa) and 12%
(Rosenthal)
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Learning Curve-Definition The Case Volume necessary to
normalize outcomes Complications Very few cases Operative Time
Docking times Trocar positioning accuracy Interference
understanding Console experience
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Robotic Surgery Team BuildingLearning Curves Docking and set up
is the key of the safety and efficacy learning curve Simulation and
practice with the console is the key to the efficiency learning
curve Adoption is dependent upon the surgeon and operating room
team A negative OR team can kill adoption Find Champions at each
level Administration, Surgeon, Surgical Staff Who has the
passion?
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Training in Robotic Surgery Assessment of Goals Case
Observation System Training Proctoring of Cases Adoption
Measurement Memorial Hermann Texas Medical Center Surgical
Innovation and Robotics Institute >1000 surgical teams
trained
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Surgeon Ergonomics A New Push to Get Comfortable 4 ergonomic
settings
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Renal Arteries in white light mode Renal arteries -
fluorescence mode (NIR) Fluorescence Imaging on da Vinci Laser
Excites IC-Green and Fluoresces New camera head can pass
fluorescence signal Fluorescing signal overlaid with green hue in
surgeon console
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Robotic Stapler 13 mm diameter EndoWrist 45 mm reload White,
green, blue reloads Product has not yet been submitted for FDA
Clearance
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Single-Site Instruments da Vinci Si System 8.5 mm Si Scope
Curved instrument cannulae 5 mm, non-wristed, semi-rigid
instruments Single-Site Port CE mark approved Product cleared by
the FDA
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Single Port Single Port Give da Vinci like performance through
a single incision True multi-quadrant access Perhaps enable
flexible devices for NOTES and SILS Future Robotic
Architectures
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Flexible Single Port Flexible Single Port Give da Vinci like
performance through a single transendoscopic incision True
multi-quadrant access NOTES can really work Future Robotic
Architectures
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Whats the Point of Robotic Bariatric Surgery? Precise two-layer
hand suturing for optimal anastomoses to reduce leakage and
stricture rates Standardized and reproducible surgery for the
entire spectrum of BMI: 1) Large abdominal walls 2) Large visceral
fat 3) Large livers Meticulous dissection and suturing for complex
revision cases Dramatically improves surgeon ergonomics to minimize
fatigue compared to laparoscopy Open elective operations will soon
be no longer acceptable when digital platforms are fully matured.
This time is closer than many might believe Single Incision and
NOTES techniques will mature on robotic platforms
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Summary Digital Platforms are enabling technology that allow
for increased precision. This allows for eventual improved outcomes
in minimally invasive surgery for surgeons committed to embracing
the technology.
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Summary I may NOT win this debate today, but in 3-5 years I
will have won it. Its just a matter of time; after 20 cases come
and tell me it cant help your practice of bariatric surgery.
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Thank You Erik B. Wilson, MD, FACS Associate Professor and Vice
Chair of Surgery Division Chief, Minimally Invasive Surgeons of
Texas University of Texas Health Science Center at Houston