HJBR May/Jun 2024

HEALTHCARE JOURNAL OF BATON ROUGE  I  MAY / JUN 2024 43 Daryl Marx, MD General Surgeon Our Lady of the Lake Regional Medical Center through the abdominal wall and advanced to the surgical site, which can sometimes be up to a foot away from the incision in the abdomen. There is often extreme stress placed on the instruments, the abdominal wall, and the surgeon’s hand. With this in mind, the surgeon must complete very accurate, articulate, and small movements to perform a gastroje- junostomy. This is defined as an anasto- mosis. The stomach pouch is sewn to the small bowel for a portion of the gastric bypass procedure. This is done with a nee- dle and a suture. Accomplishing this task is fatiguing and complicated to perform. Utilizing the da Vinci robot with longer in- struments, the highly magnified 3D view, and the fact that there is no tension felt by the operator from the abdominal wall, al- lows the operator’s hands tomove precise- ly and accurately to complete these very fine motor skill tasks. There could be as many as six suture lines needed for a gas- tric bypass procedure. This is an example of how much of an improvement robotics can bring to bariatric surgery. The use of robotics in bariatric surgery demonstrates similar or lower complication rates when compared with laparoscopy. Two studies found a significantly lower leak rate for robotic gastric bypass compared to lapa- roscopic method. 1 Utilization of the robot allows dexterity, vision, and less postop- erative pain. Robotic instruments operate unlike laparoscopic instruments by rotat- ing and maneuvering in ways the human hands cannot. This results in less friction, less torque, and less discomfort at the in- cision sites. ICG, or indocyanine green, is a tricarbo- cyanine dye that is used in real time in the operating room as an injectable material. This dye fluoresces (emits light) or glows green under near infrared light at 806 nm light. It is excreted through the liver, which has the added benefit of being visualized in the bile ducts in the event the gallblad- der needs to be removed during a bariat- ric procedure. This fluorescein dye is also used in real time to check perfusion or blood flow to the area of the small bowel and stomach. This assists in determining viability of tissue during bariatric proce- dures. The surgeon is now able to identify areas that could potentially be a problem due to poor blood flow and address them intraoperatively. ICG can also be instilled inside the gastric pouch or gastric sleeve to identify leaks from the staple line. Most bariatric procedures require some degree of surgical stapling. This is again where robotic technology demonstrates superior function. The stapling device for the robot has a smart stapling feature. It continuously measures tissue stress and thickness to allow the surgeon to choose the appropriate staple size during the sleeve gastrectomy or gastric bypass. This is estimated by the surgeon in a laparo- scopic procedure. However, with robotic technology, the surgeon obtains real-time information regarding what staple load would be required for a given thickness. As the staple load is fired, the tissue thickness is assessed 1,000 times per second. The robot will stop stapling if the tissue is too thick and prompt the surgeon to choose a different load. It can also prevent the sur- geon from stapling with an improper load, prompting the surgeon to change the sta- ple height. Benefits extend to much more com- plicated bariatric procedures as well. Re- visional procedures such as conversion from sleeve gastrectomy to gastric bypass, gastric pouch revision, and managing perforations and strictures are also com- monly performed using robotic systems. The ability for the surgeon to sit at the console for such complicated operations decreases fatigue and increases dexterity. In some extremely complicated revisions, two surgeons can operate together with a dual console. The gastric sleeve and the gastric bypass are the most performed bariatric surgical procedures in the U.S. The duodenal switch and the single-incision duodenal switch are also common. All these procedures are highly complicated and require an extreme amount of dexterity to complete laparoscopically. As previously stated, the da Vinci robotic system and the hands of a trained experienced surgeon result in a unique and rewarding patient and surgeon experience. n REFERENCES 1 Caiazzo, R.; Bauvin, P.; Marciniak, C. “Impact of Robotic Assistance on Complications in Bar- iatric Surgery at Expert Laparoscopic Surgery Centers: A Retrospective Comparative Study With Propensity Score.” Annals of Surgery 278, no. 4 (Oct. 1, 2023): 489-496. doi: 10.1097/ SLA.0000000000005969 Daryl Marx, MD, is a general surgeon specializing in general, bariatric, and robotic-assisted surgery. He is a diplomate of theAmerican Board of Surgery, is board-certified by the American College of Sur- geons,and is a fellow of the Society of Laparoscopic Surgeons. Marx is the No.1 robotic surgeon in the South based on da Vinci surgical statistics and has performed over 4,000 robotic cases. He received a Doctor of Medicine from and completed surgical internship and residency at Louisiana State University School of Medicine in New Orleans. Marx complet- ed a fellowship in advanced laparoscopic surgery at LSUMedical Center in Shreveport in conjunctionwith Willis Knighton Medical Center.