Skip to main content
SpringerLink
Log in

Multifactorial Analysis of the Learning Curve for Totally Robotic Roux-en-Y Gastric Bypass for Morbid Obesity

  • Original Contributions
  • Published:
Obesity Surgery Aims and scope Submit manuscript

Abstract

Background

Laparoscopic Roux-en-Y gastric bypass is one of the most commonly performed bariatric operation worldwide for the surgical management of obesity. Totally robotic Roux-en-Y gastric bypass (TR-RYGBP) has been considered to be a better approach by some groups especially early in a surgeon's experience. However, the learning curve associated with TR-RYGBP has been poorly evaluated yet. The aim of this study was to evaluate the learning curve of patients who underwent TR-RYGBP.

Methods

This is a prospective study of 154 first consecutive patients undergoing TR-RYGBP to analyze the influence of surgeon experience, bedside first assistant, and patient factors on operative time and postoperative complications. To give a comprehensive view of success related to the learning process, a single hybrid variable was generated. Multivariate analysis predicted the risk factors for complications and operative time. A risk-adjusted cumulative sum analysis estimated the learning curve.

Results

The learning curve for TR-RYGBP was 84 cases. Case rank and first assistant level were independent predictors of total operative time. Overall 30-day postoperative morbidity rate was 33.1 % and decreased over time. Surgeon experience (OR 2.6; CI 95 [1.290 to 5.479]; p = 0.0081) and first assistant level (OR 2.42; CI 95 [1.197 to 4.895]; p = 0.0139) remained independent predictors of composite event (operative time and complications).

Conclusions

This study identifed criteria that should be assessed in future studies about TR-RYGBP. Both surgeon experience and bedside first assistant level affected operative duration, but surgeon experience was the most significant factor in reducing complication rates.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Zevin B, Aggarwal R, Grantcharov TP. Simulation-based training and learning curves in laparoscopic Roux-en-Y gastric bypass. Br J Surg. 2012;99:887–95.

    Article  PubMed  CAS  Google Scholar 

  2. Iordens G, Klaassen R, Van Lieshout E, et al. How to train surgical residents to perform laparoscopic Roux-en-Y gastric bypass safely? World J Surg. 2012;36:2003–10.

    Article  PubMed  Google Scholar 

  3. Livingston EH. The incidence of bariatric surgery has plateaued in the U.S. Am J Surg. 2010;200:378–85.

    Article  PubMed  Google Scholar 

  4. National Institutes of Health (NIH). Gastrointestinal surgery for severe obesity. NIH Consens Statement Online. 9:1-20 1991 Mar 25-27 [cited 2012 January 8]; available at: http://consensus.nih.gov/1991/1991gisurgeryobesity084html.htm.

  5. Puzziferri N, Austrheim-Smith I, Wolfe B, et al. Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Ann Surg. 2006;243:181–8.

    Article  PubMed  Google Scholar 

  6. Haute Autorité de Santé (HAS). French guidelines for morbid obesity surgery. 2009 [cited 1 janvier 2012]; Available from: http://www.hassante.fr/portail/jcms/c_765529/obesite-prise-en-charge-chirurgicale-chez-l-adulte.

  7. Buchs NC, Pugin F, Bucher P, et al. Learning curve for robot-assisted Roux-en-Y gastric bypass. Surg Endosc. 2012;26:1116–21.

    Article  PubMed  Google Scholar 

  8. The Fellowship Council. Guidelines for the Fellowship Council Accredited Fellowships in Surgery. Updated April 2012 [cited May 2012]; Available at: http://fellowshipcouncil.org/wp-content/uploads/2012/02/Accreditation-Updated-Guidelines-and-Definitions-Final-for-Web-April-2012.pdf.

  9. Zevin B, Aggarwal R, Grantcharov TP. Volume–outcome association in bariatric surgery. A systematic review. Ann Surg. 2012;256:60–71.

    Article  PubMed  Google Scholar 

  10. Sanchez BR, Mohr CJ, Morton JM, et al. Comparison of totally robotic laparoscopic Roux-en-Y gastric bypass and traditional laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2005;1:549–54.

    Article  PubMed  Google Scholar 

  11. Tieu K, Allison N, Snyder B, et al. Robotic-assisted Roux-en-Y gastric bypass: an update from two high volume centers. Surg Obes Relat Dis. 2013;9:284–8.

    Article  PubMed  Google Scholar 

  12. Benizri E, Renaud M, Reibel N, et al. Perioperative outcomes after totally robotic gastric bypass: a prospective non-randomized controlled study. Am J Surg. 2013. doi:10.1016/j.amjsurg.2012.07.049.

  13. Hubens G, Balliu L, Ruppert M, et al. Roux-en-Y gastric bypass procedure performed with the da Vinci robot system: is it worth it? Surg Endosc. 2008;22:1690–6.

    Article  PubMed  CAS  Google Scholar 

  14. Mohr CJ, Nadzam GS, Alami RS, et al. Totally robotic laparoscopic Roux-en-Y gastric bypass: results from 75 patients. Obes Surg. 2006;16:690–6.

    Article  PubMed  Google Scholar 

  15. Park CW, Lam EC, Walsh TM, et al. Robotic-assisted Roux-en-Y gastric bypass performed in a community hospital setting: the future of bariatric sugery? Surg Endosc. 2011;25:3312–21.

    Article  PubMed  Google Scholar 

  16. Yu SC, Clapp BL, Lee MJ, et al. Robotic assistance provides excellent outcomes during the learning curve for laparoscopic Roux-en-Y gastric bypass: results from 100 robotic-assisted gastric bypasses. Am J Surg. 2006;192:746–9.

    Article  PubMed  Google Scholar 

  17. Bolsin S, Colson M. The use of the CUSUM technique in the assessment of trainee competence in new procedures. Int J Qual Health Care. 2000;12:433–8.

    Article  PubMed  CAS  Google Scholar 

  18. Poloniecki J, Valencia O, Littlejohns P. Cumulative risk adjusted mortality chart for detecting changes in death rate: observational study of heart surgery. BMJ. 1998;6:1697–700.

    Article  Google Scholar 

  19. Ziegler O, Sirveaux MA, Brunaud L, et al. Medical follow up after bariatric surgery: nutritional and drug issues. Diabetes Metab. 2009;35:544–57.

    Article  PubMed  CAS  Google Scholar 

  20. Olbers T, Fagevik-Olsen M, Maleckas A, et al. Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic vertical banded gastroplasty for obesity. Br J Surg. 2005;92:557–62.

    Article  PubMed  CAS  Google Scholar 

  21. Germain A, Reibel N, Brunaud L. Totally robotic gastric bypass. J Visc Surg. 2011;148:e267–72.

    Article  PubMed  CAS  Google Scholar 

  22. Dindo D, Demartines N, Clavien PA. Classification of surgical complications. Ann Surg. 2004;240:205–13.

    Article  PubMed  Google Scholar 

  23. Bege T, Lelong B, Esterni B, et al. The learning curve for the laparoscopic approach to conservative mesorectal excision for rectal cancer. Ann Surg. 2010;251:249–53.

    Article  PubMed  Google Scholar 

  24. Grunkemeier GL, Wu YX, Furnary AP. Cumulative sum techniques for assessing surgical results. Ann Thorac Surg. 2003;76:663–7.

    Article  PubMed  Google Scholar 

  25. Noyez L. Control charts, CUSUM techniques and funnel plots. A review of methods for monitoring performance in healthcare. Interact Cardiovasc Thorac Surg. 2009;9:494–9.

    Article  PubMed  Google Scholar 

  26. Sudan R, Bennett K, Jacobs D, et al. Multifactorial analysis of the learning curve for robot-assisted laparoscopic biliopancreatic diversion with duodenal switch. Ann Surg. 2012;255:940–5.

    Article  PubMed  Google Scholar 

  27. Mohr CJ, Nadzam GS, Curet MJ. Totally robotic Roux-en-Y gastric bypass. Arch Surg. 2005;140:779–86.

    Article  PubMed  Google Scholar 

  28. Snyder BE, Wilson T, Leong BY, et al. Robotic-assisted Roux-en-Y gastric bypass: minimizing morbidity and mortality. Obes Surg. 2010;20:265–70.

    Article  PubMed  Google Scholar 

  29. Ayloo SM, Addeo P, Buchs NC, et al. Robot-assisted versus laparoscopic Roux-en-Y gastric bypass: is there a difference in outcomes? World J Surg. 2011;35:637–42.

    Article  PubMed  Google Scholar 

  30. Scozzari G, Rebecchi F, Millo P, et al. Robot-assisted gastrojejunal anastomosis does not improve the results of the laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2011;25:597–603.

    Article  PubMed  Google Scholar 

  31. Addeo P, Buchs N. Robotic and laparoscopic gastric bypass: are they comparable? Surg Endosc. 2012;26:576–7.

    Article  PubMed  Google Scholar 

  32. Richards W. Is robotic-assisted Roux-en-Y gastric bypass better than laparoscopic gastric bypass? Surg Obes Relat Dis. 2012. doi:10.1016/j.soard.2012.01.005.

  33. Brunaud L, Ayav A, Zarnegar R, et al. Prospective evaluation of 100 robotic-assisted unilateral adrenalectomies. Surgery. 2008;144:995–1001.

    Article  PubMed  Google Scholar 

  34. Buchs NC, Pugin F, Chassot G, et al. Robot-assisted Roux-en-Y gastric bypass for super obese patients: a comparative study. Obes Surg. 2013;23:353–7.

    Article  PubMed  Google Scholar 

  35. Vonlanthen R, Slankamenac K, Breitenstein S, et al. The impact of complications on costs of major surgical procedures. Ann Surg. 2011;254:907–13.

    Article  PubMed  Google Scholar 

  36. Chandra V, Nehra D, Parent R, et al. A comparison of laparoscopic and robotic assisted suturing performance by experts and novices. Surgery. 2010;147:830–9.

    Article  PubMed  Google Scholar 

  37. Chang L, Satava M, Pellegrini A, et al. Identifying the learning curve through objective measurement of skill. Surg Endosc. 2003;17:1744–8.

    Article  PubMed  CAS  Google Scholar 

  38. Narazaki K, Oleynikov D, Stergiou N. Robotic surgery training and performance. Surg Endosc. 2006;20:96–103.

    Article  PubMed  CAS  Google Scholar 

Download references

Conflict of Interest

N Reibel received support for teaching and research in the institution through Ethicon Endosurgery. L Bresler is a proctor (robotic rectopexy) for Intuitive Surgical. Other authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Digestive, Hepato-Biliary and Endocrine Surgery, Hopital Brabois Adultes, pôle UND, Université de Lorraine—CHU Nancy, Vandoeuvre les Nancy, 54511, France

    Myriam Renaud, Adeline Germain, Ahmet Ayav, Laurent Bresler & Laurent Brunaud

  2. Multidisciplinary Unit of Bariatric Surgery (UMCO), Université de Lorraine—CHU Nancy, Vandoeuvre les Nancy, 54511, France

    Nicolas Reibel, Didier Quilliot & Laurent Brunaud

  3. Division of Endocrine and Minimally Invasive Surgery, Department of Surgery, Weill Cornell Medical College, New York, NY, USA

    Rasa Zarnegar

  4. School of Medicine, INSERM U954, University of Nancy I Henry Poincaré, Vandoeuvre les Nancy, 54511, France

    Didier Quilliot & Laurent Brunaud

  5. Department of Diabetology, Metabolic Diseases and Nutrition, Hopital Brabois Adultes, pôle UND, Université de Lorraine—CHU Nancy, Vandoeuvre les Nancy, 54511, France

    Didier Quilliot

Authors
  1. Myriam Renaud
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nicolas Reibel
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Rasa Zarnegar
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Adeline Germain
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Didier Quilliot
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ahmet Ayav
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Laurent Bresler
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Laurent Brunaud
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Laurent Brunaud.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Renaud, M., Reibel, N., Zarnegar, R. et al. Multifactorial Analysis of the Learning Curve for Totally Robotic Roux-en-Y Gastric Bypass for Morbid Obesity. OBES SURG 23, 1753–1760 (2013). https://doi.org/10.1007/s11695-013-1020-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11695-013-1020-1

Keywords

Search

Navigation