Results here show that the use of robotic MBS has been steadily increasing from 2015 to 2019 with the most pronounced increment observed in 2018 to 2019. Specifically, there was a 217% increase in number of primary robotic MBS completed from 2015 to 2019. After stratifying by MBS type, the rate of utilization of both robotic SG and RYGB procedures doubled from 2015 to 2019. Analysis showed a higher 30-day reintervention and readmission rates as well as a longer surgery time (26-38 min) in comparison to laparoscopic approaches.
Performing MBS in patients with high degrees of obesity comes with surgical challenges such as space constraints caused by increased liver size, presence of intra-abdominal fat, and a thick abdominal wall which complicate the handling of manual instruments . Robotic MBS has been proposed to overcome these issues, potentially improving surgery outcomes but these claims have not been supported by the presented results.
Previous research using the MBSAQIP database shows a significant improvement in operative time from 2015 to 2018 in the robotic cohort of MBS . However, our analysis using 2015-2019 data, shows that after stratifying by surgery type, robotic surgeries were significantly shorter by ~11 min only in the SG but not the RYGB group, where time marginally but significantly increased by ~2 min from 2015 to 2019. According to a recent world-wide systematic review and meta-analysis, robotic surgeries have ~27.6 min longer operative times in comparison to laparoscopic procedures . Our analysis shows a similar trend in surgery duration between robotic versus laparoscopic procedures for both SG (28.3 min longer in the robotic SG) and RYGB (~34.9 min longer in the robotic RYGB) with a more pronounced difference in the later one. When comparing robotic SG versus robotic RYGB we observed ~ 59.7 min longer surgery time in the RYGB group, whereas comparison of laparoscopic SG versus laparoscopic RYGB led to ~48.2 min longer duration in the RYGB group. These results show longer surgery duration in robotic procedures, particularly when utilized to perform an already longer MBS surgery, RYGB.
When using the MBSAQIP 2015-2018 data, similar rates were observed in 30-day readmission and 30-day reintervention between robotic and laparoscopic approaches . However, with the addition of 2019 data, a significantly higher rate of 30-day reintervention and readmission were observed in the robotic surgery group. It is possible that the higher reintervention and readmission rates could be driven by the higher comorbidity rate present in this group. Having a higher number of risk factors pre-MBS has shown to increase post-MBS complication rates [11–13]. Likewise, reintervention and readmission reasons are unknown and therefore it is difficult to speculate if causes, other than the surgical procedure, are involved.
Several studies have been published using the MBSAQIP database, however, this is the only study that has compared the trends and outcomes of robotic versus laparoscopic procedures using the most recent dataset 2015-2019 containing a total of 775,258 cases. We present both crude and adjusted covariates to control for any potential confounders. Despite these strengths, this review has several limitations that should be mentioned. First, bariatric surgeons generally perform only one type of MBS procedure (either robotic or laparoscopic), therefore, comparison between procedures is indirectly also comparing surgeons’ skills. Second, this is a retrospective analysis on a prospectively collected database and thus is vulnerable to the biases associated with retrospective analyses, such as 1) coding errors and missing data, 2) models adjustment limited to variables that have already been collected, and 3) lack of relevant variables such as: surgeon’s experience, surgery cost, stapler or robotic platform utilized (newer platform involves a shorter learning curve), as well as information on weight loss, comorbidity resolution, and long-term complications >30-days post-surgery. Third, since statistical significance is largely dependent on sample size and since the present analysis was performed on a large database, it is possible that we observe significant statistical differences that are not clinically relevant. Lastly, there is no standardization on the quantity of robotic system utilization for procedures listed as “robotic” and therefore, it is not possible to determine the percentage of robotic system use in a “robotic-assisted” surgery. Future data collection should separate hybrid surgeries from surgeries involving a single approach.