Robotics in Bariatric Surgery: Benefits, Limitations, and Challenges; An Umbrella Review of systematic reviews and meta-analyses

doi:10.21203/rs.3.rs-3299017/v1

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Robotics in Bariatric Surgery: Benefits, Limitations, and Challenges; An Umbrella Review of systematic reviews and meta-analyses

https://doi.org/10.21203/rs.3.rs-3299017/v1

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Background: In order to improve the results of weight loss surgeries, robotics in bariatric surgery is a quickly developing method that combines the accuracy and dexterity of robotic technology with the knowledge of surgeons. Surgeons may carry out difficult bariatric procedures with greater accuracy, less invasiveness, and better visualization when using robotic equipment. This review aims to provide wide evidence regarding the benefits, limitations, and challenges of robotics in bariatric surgery.

Methods: A comprehensive search was conducted across multiple databases, namely PubMed, Scopus, Web of Science, and Cochrane Central, in order to identify all relevant systematic reviews and meta-analyses from the inception of these databases until July 15, 2023. The quality assessment of the included studies was performed using the AMSTAR2 tool, and the data analysis was conducted using STATA version 17.

Results: A total of 11 studies, of which 8 were eligible for the analysis. Our findings demonstrated a notable reduction in the occurrence of postoperative complications (OR: 0.88, 95% CI [0.66 to 1.10], P=0.00) as well as a decrease in the occurrence of anastomotic leaks (OR: 0.82, 95% CI [0.55 to 1.10], P=0.00) among patients who underwent robotic bariatric surgery (RBS) in comparison to those who received laparoscopic bariatric surgery (LBS).

Conclusion: robotic bariatric surgery may be a promising technique to decrease most postoperative outcomes compared to the traditional technique. However, further research is needed to fully understand the long-term benefits and cost-effectiveness of this technology.

Robotic

laparoscopic technique

Bariatric surgery

Umbrella review

Meta-analysis

Over the past ten years, there has been a 33% increase in obesity prevalence in the USA. [1] Over 400 000 fatalities each year are attributed to obesity, making it a major preventable cause of death. [1], [2] Body mass index [BMI] > 40 or BMI > 35 kg m-2 in the presence of substantial comorbidities is considered to be morbidly obese and affects about 5% of the US population. Morbid obesity is a significant health issue in developed nations as a result. Type 2 diabetes mellitus (T2DM), dyslipidemia, hypertension, obstructive sleep apnea (OSA), cardiovascular disease (CVD), and various cancers are all strongly associated with morbid obesity. [3–5]

Obesity has many lines of treatment, starting with lifestyle changes like physical activity and diet modification, weight loss medications, balloons, and surgery. [6] Although bariatric surgery typically has good results, morbid obesity is largely resistant to diet and medication therapy. [3], [4] The bariatric operations are laparoscopic adjustable gastric banding (LAGB), laparoscopic Roux-en-Y gastric bypass (LRYGB), sleeve gastrectomy (SG), and BPD-DS (biliopancreatic diversion with duodenal switch). [7–9]

Laparoscopic adjustable gastric banding (LAGB) involves wrapping the stomach in a silicone ring to form a little upper gastric pouch at the base of the esophagus. Since its introduction in the 1970s, this treatment has been found to be safe, well-tolerated, and effective, with a comparatively low risk of major consequences. The flexibility to modify the band to enhance weight loss without compromising safety is another advantage of this technique. The majority of patients find LAGB to be a desirable alternative because it is reversible and a sort of laparoscopic surgery; however, it is not marketed because of the considerable risk of weight gain following removal and the high conversion rate to other types of surgery. [7], [10], [11] The laparoscopic Roux en Y gastric bypass (LRYGB) technique is an effective way of treating morbid obesity. The fact that RYGB has been in use since the 1970s and is still in use now relates to its durability and effectiveness. [12]Because of this result, RYGB is frequently cited as the benchmark bariatric procedure by which other procedures are measured. [13] It was first developed as an open technique, but thereafter, with the introduction of endoscopes, it became minimally invasive to decrease morbidity and mortality. [13] For many years, the gold standard for doing bariatric surgery has been laparoscopy. However, some surgeons now favor robotic surgery over laparoscopy due to a few drawbacks, including two-dimensional visualization, non-articulating devices, and higher surgeon torque on the abdominal wall by the instruments. [12] Among the benefits of robotic surgery are three-dimensional vision, a reduction in surgeon tremor, remote center control, greater ergonomics, and a shortened learning curve. [13–15] Moreover, according to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), robotic bariatric surgery is associated with lower complications compared to other approaches. [16] The aim of this umbrella review is to systematically provide an overview of the available evidence on the robotic bariatric surgery in terms of pre and post operative outcomes.

This umbrella review followed the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). [17]

Data sources and searches

A systematic literature search was conducted by two independent authors on PubMed, Scopus, Web of Science and Cochrane databases from inception to 15th July 2023. Key- words used to perform the search were "robotic", "Roux-en-Y", "gastric bypass", "sleeve gastrectomy", "gastroplasty", "biliopancreatic diversion", "adjustable gastric banding", " bariatric surgery", "Systematic review", "Meta-analysis" combined with Boolean operators were used to find articles. Search strategy was adapted for each database; a complete list of search strings is available in Table 1.

Table 1

Strategy search, inclusion, and exclusion criteria used in searching systematic reviews/meta-analysis
Database	Search strategy	Records	Records Excluded	N of studies	Selection process	N of studies
Pubmed	((("robotic") AND ("Roux-en-Y" OR "gastric bypass" OR "sleeve gastrectomy" OR "gastroplasty" OR "biliopancreatic diversion" OR "adjustable gastric banding" OR " bariatric surgery")) AND ("Systematic review" OR "Meta-analysis"))	34	Duplicates	58	After title and abstract	43
WOS	((("robotic") AND ("Roux-en-Y" OR "gastric bypass" OR "sleeve gastrectomy" OR "gastroplasty" OR "biliopancreatic diversion" OR "adjustable gastric banding" OR " bariatric surgery")) AND ("Systematic review" OR "Meta-analysis"))	32	Wrong study design	25	After full text	75
Scopus	TITLE-ABS-KEY ( ( ("robotic") AND ("Roux-en-Y" OR "gastric bypass" OR "sleeve gastrectomy" OR "gastroplasty" OR "biliopancreatic diversion" OR "adjustable gastric banding" OR " bariatric surgery")) AND ("Systematic review" OR "Meta-analysis"))	46	Different outcomes	11	Total included	11 ( 8 Systematic review and meta-analysis, and 3 systematic review)
Cochrane	((("robotic") AND ("Roux-en-Y" OR "gastric bypass" OR "sleeve gastrectomy" OR "gastroplasty" OR "biliopancreatic diversion" OR "adjustable gastric banding" OR " bariatric surgery")) AND ("Systematic review" OR "Meta-analysis"))	6	Others	13
Total		118		107

Study selection

The inclusion criteria were specified as follows: Systematic reviews and meta-analyses that examined the impact of robotic bariatric surgery compared to laparoscopic methods on individuals undergoing bariatric or metabolic surgeries. The study population consisted of adult males and females (> 18 years old) who were obese and underwent robotic-assisted procedures. The provided effect sizes needed to be in the form of relative risk (RR) or odds ratio (OR) with 95% confidence intervals (95% CI). Only articles with complete text availability were taken into account. There were no limitations on publication dates, but the studies included were exclusively those published in English. Meta-analyses lacking data on mortality were excluded. Separate consideration was given to multiple meta-analyses presented within a single paper, such as those reporting various outcomes or based on different types of studies.

Two separate authors conducted the selection process for the study, and any disagreements were resolved through discussions with the senior author. The titles and abstracts of every article were reviewed to eliminate duplicates, and the full texts of promising articles were assessed for eligibility. The reference lists of eligible articles were manually searched to identify relevant meta-analyses.

Data extraction

The following data from each eligible study were independently extracted by two investigators: Study ID, Study design, Database searched, Time limit in search, Number of studies included, Type of studies, Number of patients, Countries, Type of treatment, Type of technique, Aim of the study, Inclusion criteria, Exclusion criteria, and Key findings.

Data analysis

The statistical analysis was conducted using STATA version 17 for the Windows operating system. We employed a random effect model and utilized the logarithm of the odds ratio (OR). To assess heterogeneity, we computed the I2 index. Based on predetermined thresholds, we categorized heterogeneity as low, moderate, or high, corresponding to I2 values of less than 25%, 25–75%, and greater than 75%, respectively.

Quality evaluation and risk of bias assessment

The quality of each included meta-analysis was evaluated with the assessment of multiple systematic reviews (AMSTAR) 2 tool. [18] The objective of this tool is to assess the quality of systematic reviews by providing responses of "no," "partial yes," or "yes" to 16 different criteria. Among these criteria, items 4, 9, 11, 12, and 15 are considered crucial domains. The quality of the studies is categorized as follows: high (no or only one non-critical weakness), moderate (more than one non-critical weakness), low (one critical flaw with or without non-critical weaknesses), or critically low (more than one critical flaw with or without non-critical weaknesses).

Literature search results

The initial search yielded a total of 118 articles. After removing duplicates, 60 papers were assessed. Following an initial screening, it was determined that 25 studies had an incorrect study design, 11 had different outcomes, and 13 fell into other categories. Ultimately, 11 studies were found to meet the eligibility criteria and were included in the umbrella review. These 11 studies involved a total of 493,210 patients. The strategy search is summarized in the PRISMA flow diagram of the included studies. (Fig. 1).

Characteristics of the included studies

We included 11 studies, their number of included studies ranged from six up to 28 articles including both retrospective and prospective trials. The demographic variations are mostly reported in the USA, Switzerland, Spain, and Italy. The detailed baseline and summary tables are shown in Table 2 and Table 3 respectively.

Table 2

The baseline of the included studies
Study ID	Study design	Database searched	Time limit for strategy search*	N of studies included	Type of studies	N of patients	Countries
Li et al. 2016 [9]	SR & MA	MEDLINE, EMBASE, web of science and the Cochrane Central	May-16	27	P & R	27,997	USA, Switzerland, Brazil, Spain, Greece, and The Netherlands
Bailey et al. 2013 [19]	SR & MA	PubMed, EMBASE, Web of Science, Scopus, and the Cochrane Library	Sep-12	10	P&R	2,557	USA, Switzerland, Spain, Italy and The Netherlands
Wang et al. 2018 [20]	SR & MA	PubMed, EMBASE, and the Cochrane Library	20-Nov-17	19	P & R	177,766	In the USA, there were 14 studies conducted, while in Europe (specifically France, Switzerland, Netherlands, and Italy), there were 5 studies conducted.
Economopoulos et al. 2015 [21]	SR & MA	PubMed, Web of Science, Embase database and Cochrane Library	14-Apr-14	25	P & R	5145	USA, Switzerland, Spain, Italy and The Netherlands
Cirocchi et al. 2013 [22]	SR	PubMed, Cochrane Central Register of Controlled Trials, BioMed Central, and Web of Science.	Nov-12	22	1 RCT and 12 case series	2691	USA, Switzerland, Spain, Italy, The Netherlands, and Brazil
Fourman et al. 2012 [23]	SR	PubMed	Nov-10	18	Case series, comparison studies, retrospective studies and prospective studies	3476
Gill et al. 2011 [24]	SR	MEDLINE, EMBASE, SCOPUS, DARE, BIOSIS Previews, Cochrane Library, EBM, Scopus, Dare, Clinical evidence, TRIP and HTA database	Apr-10	22	case-series, non-randomized controlled trials, randomized controlled trials, prospective cohort series.	1253
Markar et al. 2011 [25]	SR & MA	Medline, Embase and Cochrane Library databases	Feb-11	7	P &R	1686
Zhang et al. 2021 [26]	SR & MA	PubMed and Scopus	31-Mar-20	28	P&R	210,962	There was 1 study from Brazil and a total of 4 studies from Europe, along with 23 studies from America.
Magouliotis et al. 2016 [27]	SR & MA	PubMed, Cochrane Library and EBSCOhost databases	30-May-16	16	P & R	29,787	USA, Switzerland, Brazil, Spain, India, Italy and The Netherlands
Bertoni et al. 2021 [28]	SR & MA	PubMed, Cochrane Library, Web of Science, and Google Scholar	01-Jun-21	6	P & R	29,890
SR: systematic review, MA: Meta-analysis, P&R: prospective & retrospective.
*The intention behind the entry labeled "Time limit in search" in Table 2 is to indicate that we incorporated a specific time constraint in our search approach.

Table 3

The summary of the included studies.
Study ID	Type of surgery	Type of technique	Aim of the study	Inclusion criteria	Exclusion criteria	Key findings
Cirocchi et al. [22]	Roux-en-Y gastric bypass and Sleeve Gastrectomy	Fully Robotic and Laparoscopic-Robotic	evaluate the feasibility and safety of bariatric robotic surgery	patients who underwent robotic bariatric surgery	Studies in which the outcomes of interest were reported	the major strength of the robotic surgery is strongly facilitating some of the surgical steps
Fourman et al. [23]	(RYGB, SG, gastric banding, biliopancreatic diversion with duodenal switch, and revisional surgery)	Fully Robotic and Laparoscopic-Robotic	determine the safety and efficacy of robotic bariatric surgery	English language, human studies, original research, bariatric surgical procedures	studies do not meet with the inclusion criteria	The application of robotics appears to be a safe option within the realm of bariatric surgery
Gill et al. [24]	gastric banding, bypass procedures,	Fully Robotic and Laparoscopic	the efficacy of robotic assisted bariatric surgery in obese patients.	obese adult (> 18 years old) male or female patients undergoing robotic assisted bariatric surgery, both restrictive and bypass procedures. Patients considered clinically obese with a BMI greater than 35	Studies reporting non-bariatric robotic procedures, Pediatric or adolescent bariatric surgery and animal studies	robotic-assisted bariatric surgery is both a safe and feasible option for severely obese patients
Markar et al. [25]	Roux-en-Y gastric bypass	Fully Robotic and Laparoscopic	provide pooled analysis of individually small trials comparing robotic Roux-en-Y gastric bypass (RRYGB) with standard laparoscopic RYGB (LRYGB).	controlled or comparative trial, inclusion in groups with robotic or laparoscopic Roux-en-Y gastric bypass, surgery performed on the morbidly obese population	comprised trials without a control group undergoing laparoscopic surgery, or studies focusing on bypass surgery in the non-obese population and studies reporting an alternative anti-obesity surgical procedure	The incidence of anastomotic stricture was reduced with RRYGB compared with LRYGB
Bailey et al. [19]	Roux-en-Y gastric bypass	Fully Robotic and Laparoscopic	The study focused on laparoscopic RYGB and aimed to compare the rates of complications, operative characteristics, and anticipated costs between robotic and laparoscopic RYGB.	The study included patients between the ages of 18 and 65 who met the criteria set by the National Institutes of Health (NIH) for bariatric surgery.	non bariatric procedures, case series, case reports, reviews, and animal studies	The rates of complications were not significantly different between robotic and laparoscopic RYGB, but the expected costs were higher for robotic RYGB.
Zhang et al. [26]	RYGB (Roux-e-Y Gastric Bypass), SG(sleeve gastrectomy), AGB(adjusted gastric band) and BPD-DS(Biliopancreatic diversion with duodenal switch)	Fully Robotic and Laparoscopic	Assess the safety and effectiveness of robotic bariatric surgery (RBS) versus laparoscopic bariatric surgery (LBS) in patients with obesity.	The objective of this study is to compare the therapeutic effects of RBS and LBS in treating obesity and report at least one of the specified outcomes. The inclusion criteria require patients to be diagnosed with obesity, and only English-language papers are considered.	Excluded from this review are abstracts, letters, and reviews that lack original data, studies focusing on open surgery for obese patients, case reports, studies without control groups, and studies that do not clearly report relevant outcomes.	In this meta-analysis, RBS demonstrated lower mortality within 90 days and longer operative time compared to LBS, while showing similar safety and effectiveness in other outcome measures for obesity treatment.
Economopoulos et al. [21]	Roux-En-Y Gastric Bypass	Fully Robotic and Laparoscopic	Provide a summary of the available literature on patients who underwent robotic Roux-en-Y gastric bypass (RYGB) and compare the clinical outcomes with patients who underwent standard laparoscopic RYGB.	The inclusion criteria for the literature review are: studies written in English, conducted on human subjects, inclusion of a study group that underwent robotic Roux-en-Y gastric bypass (RRYGB), and a study group that underwent laparoscopic Roux-en-Y gastric bypass (RYGB).	studies do not meet with the inclusion criteria	Robotic-assisted RYGB appears to have slightly better performance compared to standard laparoscopic RYGB, while totally robotic RYGB shows similar clinical outcomes to laparoscopic RYGB.
Li et al. [9]	Roux-en-Y gastric bypass surgery, SG sleeve gastrectomy, AGB adjustable gastric banding	Fully Robotic and Laparoscopic	Summarize the available literature on patients who underwent robotic bariatric surgery (RBS) or laparoscopic bariatric surgery (LBS), and compare the clinical outcomes between the two approaches.	The inclusion criteria for the studies are: randomized controlled trials (RCTs) or observational studies (cohort, cross-sectional, and case-control) that compare outcomes between laparoscopic and robotic bariatric surgery, studies written in English, and studies conducted on human subjects.	Excluded from this analysis are reviews, comments, case reports, abstracts, animal studies, and unpublished studies.	Robotic bariatric surgery (RBS) was associated with longer operative times and higher hospital costs compared to other surgical approaches.
Magouliotis et al. [27]	Sleeve Gastrectomy	Fully Robotic and Laparoscopic	Evaluate the available evidence comparing the surgical outcomes of laparoscopic sleeve gastrectomy (LSG) and robotic sleeve gastrectomy (RSG).	The inclusion criteria encompassed studies that involved at least 10 patients, were written in English, were published between 2010 and 2016, focused on human participants, and reported outcomes of either laparoscopic sleeve gastrectomy (LSG) or robotic sleeve gastrectomy (RSG) performed on individuals with obesity.	studies do not meet with the inclusion criteria	The RSG group exhibited notably longer average operative durations and hospital stays.
Wang et al. [20]	Roux-en-Y Gastric Bypass	Fully Robotic and Laparoscopic	Provide a summary of the current body of evidence that examines the differences in surgical outcomes between robotic Roux-en-Y gastric bypass (RRYGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB).	The inclusion criteria consist of: (1) studies written in English, (2) research involving human subjects, (3) original investigations encompassing both retrospective and prospective designs, (4) studies reporting results of Roux-en-Y gastric bypass (RYGB) in individuals with obesity, and (5) comparative research that contrasts laparoscopic RYGB (LRYGB) with robotic RYGB (RRYGB).	(1) Research related to procedures other than bariatric surgery, (2) individual case descriptions and evaluations, (3) studies conducted on animals, and (4) surgical interventions involving the modification of prior procedures are excluded from consideration.	Robotic Roux-en-Y gastric bypass (RRYGB) yielded comparable clinical results and did not demonstrate superiority over laparoscopic Roux-en-Y gastric bypass (LRYGB).
Bertoni et al. [28]	Revisional Bariatric Surgery	Fully Robotic and Laparoscopic	Explored the utilization of robotic-assisted procedures for patients undergoing bariatric surgery revisions (RBS)	If individuals receiving revisional bariatric surgery (RBS) for any reason underwent surgery with robotic assistance and were contrasted with alternative methods.	Data that is either lacking, duplicated, or inadequate, and studies lacking a control group or involving less than 10 participants in their sample size.	There was no notable benefit observed in robotic-assisted revisional bariatric surgery (RBS); however, it exhibited comparable effectiveness to conventional laparoscopy.

Quality assessment results

In the aggregate, among the 11 articles, 2 were ranked as high quality, 1 as moderate, 1 as low, and 7 as significantly low in quality. Specifically, concerning crucial aspects, each paper indicated correct utilization of comprehensive literature search queries and conducted a notable assessment of publication bias (Q4, 11/11, and Q15, 11/11, respectively). Nearly every paper adopted an appropriate methodology for statistically combining the outcomes (Q11, 10/11), although certain crucial aspects were identified in the assessment of bias risk evaluation techniques and determining their influence on the results of the meta-analysis (Q9, 8/11, and Q12, 6/11, respectively). Table 4 shows AMSTAR 2 items evaluation of the included studies.

Table 4

AMSTAR2 tool evaluation of the quality of the included systematic reviews/meta-analyses
Study ID	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12	Q13	Q14	Q15	Q16	Overall quality
Cirocchi et al. [22]	Yes	Partial Yes	Yes	Yes	Yes	Yes	Partial Yes	Yes	No	No	No	No	No	No	No	Yes	Critically Low
Fourman et al. [23]	Yes	Partial Yes	Yes	Yes	Yes	Yes	No	Yes	No	No	No	No	No	No	No	Yes	Critically Low
Gill et al. [24]	Yes	Partial Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	No	No	No	No	No	No	Yes	Critically Low
Markar et al. [25]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	No	Yes	No	Critically Low
Bailey et al. [19]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	No	Moderate
Zhang et al. [26]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	No	No	Yes	No	Yes	Critically Low
Economopoulos et al. [21]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	No	Yes	No	Yes	No	No	No	Critically Low
Li et al. [9]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Low
Magouliotis et al. [27]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	High
Wang et al. [20]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	No	Yes	Yes	No	Yes	Critically Low
Bertoni et al. [28]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	High

Outcomes

Eight meta-analyses were eligible for the analysis, our results showed a significant decrease in the incidence of postoperative complications (OR: 0.88 with 95% CI [0.66 to 1.10], P = 0.00) Fig. 2. And in the incidence of anastomotic leak (OR: 0.82 with 95% CI [0.55 to 1.10], P = 0.00) Fig. 3.

This umbrella review synthesized the evidence from 11 published systematic reviews and meta-analyses on the association between robotics and bariatric surgery outcomes. The results indicate that robotic bariatric surgery is associated with reduced incidence of postoperative complications and anastomotic leak compared to laparoscopic bariatric surgery of different bariatric surgery types such as Roux-en-Y gastric bypass and Sleeve Gastrectomy.

Robotic systems are operated by surgeons during robotic surgery, enabling them to carry out intricate procedures with greater accuracy. Robots are used in bariatric surgery to help with treatments including gastric banding, sleeve gastrectomy, and bypass. One of the most popular robot systems in bariatric surgery is the da Vinci Surgical System. [29]The increased surgical precision provided by robotics in bariatric surgery is one of its main advantages. The improved visualization capabilities offered by robotic devices enable surgeons to see more clearly inside the patient's body. As a result, surgeons can carry out intricate surgeries with more accuracy, lowering the possibility of problems and enhancing patient outcomes. The robotic arms used in these operations are also made to resemble human movements, giving surgeons more dexterity and range of motion than they would have with conventional laparoscopic tools. This makes it possible to suture and staple more precisely throughout the treatment, which promotes faster wound healing and lessens the discomfort that patients experience afterward. [14], [29]

Despite all of these advantages, robotics in bariatric surgery has certain limitations as well. The expense of installing robotic equipment in hospitals is one of the main obstacles. Purchasing and maintaining robotic equipment, as well as instructing surgeons and operating room staff on how to utilize these systems successfully, are important investments needed for robotic-assisted procedures. Some hospitals may find this expense to be prohibitive, which would prevent them from offering patients robotic-assisted bariatric surgery. [30] Semi Disposable robotic instruments, a longer time spent in the operating room, a longer stay in the postoperative ICU, and hospitalization may all be contributing causes to the higher hospital expenses connected with the robotic technique. Robotic surgery has also been viewed as an expensive consumable due to its original purchase price and monthly maintenance expenditures. [31] The learning curve associated with using robotic equipment in bariatric surgery is another limitation. To learn how to use these sophisticated tools with proficiency, surgeons must receive specialized training. The steep learning curve in the beginning may result in longer operating durations and a higher risk of difficulties in the early stages of adoption. [32]The majority of our included studies we reviewed found no significant variations between robotic and laparoscopic procedures in terms of hospitalization time, conversion, reoperation, readmission, and postoperative complications. However, a longer mean operative time was linked to RBS. [19–21]

Strength and limitations

This is the first umbrella review of systematic reviews and meta-analyses evaluating an overview of the available evidence on robotic bariatric surgery in terms of pre and post operative outcomes. We conducted a systematically comprehensive search with a good analysis of the references list. However, several limitations could be detected, most of our studies had included observational articles that may increase the possibility of bias risk, wide range of the follow-up periods between the studies and most of them did not exceed two months in addition to the high heterogeneity between the assessed outcomes.

Areas for Further Research

Despite the potential benefits, further research is recommended to explore the long-term strength and limitations of incorporating robotics in bariatric surgery in a wide timed follow-up period by well-designed and randomized conducted clinical trials.

In summary, this umbrella review has provided valuable insights into the effectiveness of robotic bariatric surgery in comparison to traditional techniques. The review indicates that robotic bariatric surgery demonstrates promise in reducing specific postoperative outcomes. However, it is important to acknowledge the concerns raised regarding the high cost associated with this approach. Additionally, the review highlights that robotic bariatric surgery is burdened by longer operative times and greater hospital costs, which further contribute to the economic considerations.

To address these concerns and gain a more comprehensive understanding of the long-term effects of robotic bariatric surgery, further research is recommended. It is crucial to conduct studies that assess the overall cost-effectiveness and patient outcomes over an extended period. By investigating these aspects, we can better inform clinical decision-making and treatment optimize patient care in the field of bariatric surgery. Further research will also provide a clearer perspective on the potential benefits and drawbacks associated with the utilization of robotic techniques in this context.

Availability of data and material

All data generated or analyzed during this study are included in this published article.

Competing interests

The authors have no competing interests to declare that are relevant to the content of this article.

Funding

This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors Contribution

M.B., A.R., A.A., and A.S. were responsible for writing the main manuscript text. A.R. conducted the statistical analysis and prepared figures 1-3 and tables 2-4. M.B. performed the final review, proofreading, and ensured accurate in-text citations. R.S. provided supervision throughout the entire project and contributed to the clinical debate in the discussion section. All authors reviewed the manuscript.

Acknowledgements

Not applicable.

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No competing interests reported.

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Robotics in Bariatric Surgery: Benefits, Limitations, and Challenges; An Umbrella Review of systematic reviews and meta-analyses

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Abstract

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Introduction

Methods

Data sources and searches

Study selection

Data extraction

Data analysis

Quality evaluation and risk of bias assessment

Results

Literature search results

Characteristics of the included studies

Quality assessment results

Outcomes

Discussion

Strength and limitations

Areas for Further Research

Conclusion

Declarations

References

Additional Declarations

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