Robotically-assisted surgery of Obesity

Assoc. Prof. Dr. Umut Barbaros, operating the first robotic bariatric surgery in the world through a single incision, tells the story of operation. Estimating robots used for surgical purposes may become smaller in the near future, Assoc. Prof. Dr. Umut Barbaros says that surgeons will be able to operate surgeries even through their own offices.

(Reporter: Lecturer Esma Demirer, “Robotically-assisted surgery of Obesity”, Istanbul Unıversıty Science Culture And Arts Magazine, Issue: 8, Istanbul University Press and Public Relations Department, Year: 2012, p: 66-71) 

Turkish doctors under the leadership of Assoc. Prof. Dr. Umut Barbaros, Member of Istanbul University Medical Faculty, Depart­ment of General Surgery, performed the first robotic bariatric surgery in the world through a single incision from stomach. Assoc. Prof. Dr. Umut Barbaros tells us the importance and story of this operation lasting about five hours.

Could you give us some details about the surgery you operated?

There are many techniques used in bariatric surgery. These techniques range widely, such as laparoscopic gastric banding, sleeve gastrec­tomy, gastric, by-pass and biliopancreatic di­version. This technique we performed is named biliopancreatic diversion and it is performed because of problems with malnourishment on patients having nutritional deficiency. In this operation, 2/3 of stomach is resected and then connected to the end of small intestine. This operation has been performed since 1978 and it has a very high success rate. Laparoscopy is more recommended compared to the open sur gery. Laparoscopic surgery is also performed with 4 or 5 incisions. In this operation, abdo­minal cavity is filled with carbondioxyde and stomach is blown up about 12-13 mm. You create there a surgery area just like you are working inside a dome. Then, you enter the stomach through 1-5 cm incisions and perform surgery without using your hands.

We are a generation trained by academic philosophy breaking the grounds in the world. Since 2009, we perform single-incision sur­gery. After single-incision laparoscopy surgeries on various organs such as spleen, pancreas and liver, we thought that all kinds of intervention we made in stomach especially on obese patients have infection and hernia risks. To minimize such risks, we decided to perform single-incision surgeries and planned to combine robotic sur­gery and single-incision operation.

We thought that when we combine robotic and single-incision surgery, it would be more comfortable for us to operate the surgery and we can minimize abdominal trauma risks on patients. By doing so, we could minimize post-surgical pain, ensure early operation of bowel movements and patient could start eating earlier. Also, the benefits of such technique are much more in terms of cosmetic as the 2-cm incision inside the stomach disappears in a month’s time. For 5-6 months, we are working on this issue. To become leader in this area, we should act early as we compete with the world. This was the first case on which we performed such operation and we still did not perform the second or third one. It is a difficult techni­que. We tested it to observe its practicability. We also consider writing a scientific paper on this operation. Hope it’ll be a part of science literature.

We performed this operation in a private hospital. Our Rector, Professor Yunus Söylet supports us in providing robotic surgery in our university. I think a robot will be purchased in a short time and we’ll be able to make such interventions in our university.

In the meantime, there are works to start an obesity group in Istanbul University. People who are engaged in obesity want to be a part of such group. Our aim is to develop this group and treat patients with an interdisciplinary approach. Surgeon is a part of such treatment but surgery is not the only solution. Diets, nutrition and treatment of behavioral disor­ders, and increasing physical activity are very important for obese patients.

What’s the importance of robotic surgery?

In early 2000, surgeons started to use robotic surgery in their operations. This is the second revolution in this field after the laparoscopy. Laparoscopy means closed-surgery, insufflating the stomach and performing surgeries on inci­sions there. This procedure has some difficulties as the monitors used to enter through incisions provide 2D vision. To make this process easier, robotic surgery which is performed through 3D vision was explored.

In the system used in robotic surgery, the surgeon can be away from patient (sometimes even in another room). There’s a consul equ­ipped at the surgeon’s room and a surgeon can see every surgery-related activity as 3-dimen­sional through such consul. The arms of robot enter in the patient but surgeon controls these arms remotely by means of joysticks and thus performs operation. Shortly, you perform a remote laparoscopic surgery. In other words, surgeon performs the operation through the arms of robot, not by using his or her own hands.

Actually, this technique was planned for surgical operations to be made at military environment and space. Then, it was realized that 3-dimensional vision makes the laparos­copy easier. Robotic surgery makes laparoscopy operations easier on many organs such as pancreas, stomach, colon and rectal surgeries. Therefore, robotically-assisted surgery offers great advantages. If you don’t perform the surgery through single incision, then it doesn’t give better results than laparoscopy because again there are 3-4 incisions. However, diffi­cult surgical procedures which are considered as cannot be performed through laparoscopic surgery are easily made with robots. In a sense, we can say that robots ease laparoscopic surgeries.

What’s the superiority of robotic surgery over laparoscopic surgery?

Laparoscopic surgery is identical with the robotic surgery in terms technique, but there is robot assistance in the latter one. The techni­que is the same; abdominal cavity is filled with carbondioxyde, equipments enter through the stomach, and if a surgeon uses such equipments manually, then it is laparoscopic surgery, but if a surgeon controls them remotely, then it is robotic surgery. In robotically-assisted surgery, surgeon operates by sitting and it’s a great advantage. The long sticks used by a surgeon in laparoscopic surgery have limited rotation capacity. However, in robotic surgery, robot arms are used and they have 360° rotation capacity. Also, in laparoscopic surgery, surgeon watches the operation on a small monitor and it’s a 2-dimensional video. It’s difficult to un­derstand 2-dimension as there’s limited depth in video but the consul used in robotic surgery gives you 3-dimensional video. So, you can ea­sily see the distance between organs.

What do you think about the future of robotic surgery? I mean, what’s the next level?

Single-incision surgery and robotic surgery are now in their infancy. I think this procedure will be easier as a result of technologic advan­cements and will be more standard, because, in my opinion, in 3-5 years from now, robot technology will develop greatly. The robot arms which are big now will become smaller. Maybe that large consul will be equipped on a small laptop. Maybe you’ll be able to operate the sur­gery at your office. I think those will happen in near future.

What’s obesity?

Obesity is the disease of our time. It means that body fat exceeds the normal level and results in disease. Actually, obesity is mostly a genetic disease. Together with nutritio­nal deficiency and genetic factors, the rate of obesity increases. There’s a body mass index established as a criterion. Body mass index is found by dividing weight into square of height (kilogram/square meter). If the height of a patient with 100 kg weight is 1.84 m, then his or her body mass index is the square of 100/1.84. People with body mass index over 25 and 30 are over-weight and obese, respec­tively. The red line is 40. If a person has 40 or higher body mass index, then he or she has morbid obesity and it requires surgical indi­cation. If it’s 50 or higher, then it’s called as super obesity, and patients with super obesity need surgeries requiring severe malabsorption. According to studies, diets, sport activities, tre­atment of feeding habits, behavioral disorders do not work on patients with body mass index higher than 40. Even they lose weight, they gain more. At this point, surgical intervention is required

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