Dr. Maher El Chaar, is one of the more prominent bariatric surgeons in the US. He is an active and productive member of multiple committees in the bariatric societies. He also has multiple publications in bariatric surgery. Recently, he published 3 main studies comparing robotic to laparoscopic bariatric surgery. He has been using the robot in his bariatric practice and contributed multiple video posts to the IBC Facebook group. These publications along with these videos and his noticeable role in the bariatric world led to this interview.
1- Dr. El Chaar, when did you adopt the robotic platform? Please elaborate on the training as well as the early experience with the robot.
We started using the da Vinci robotic platform in 2017, our start was very rocky because of lack of patient outcome data to support the adoption of robotics and because of the concern that the administration had in relation to cost. After much debate and numerous meetings and after the foundation of a robotic steering committee at St Luke’s University Hospital we decided to start slow and collect outcome and cost data to see where we stand and how this will affect our patients moving forward.
We started with the old Si platform and a hybrid approach but quickly progressed to the new Xi platform and a fully robotic technique which I believe revolutionized the way we do our cases now. We were also among the first centers in the world to use the new innovative smart Sureform stapling technology. We collected and published our data in the process and demonstrated that robotic surgery is advantageous and cost effective. Our published data showed no statistical difference in cost between robotic and laparoscopic surgery. That data was based on our initial experience with the Si platform. We are in the process of collecting more data using the new Xi platform and I can confidently say that based on the preliminary results I have seen so far we are getting definitely better, faster and cheaper!
2- How many cases it took to go beyond the learning curve?
It took about 25 cases to get beyond the learning curve and develop a reproducible and consistent system and also train the OR staff. When we switched to the Xi platform we had to modify the technique and change port placement and docking site which led to another learning curve. However, at this point we have a very well trained and extremely efficient OR team which have led to a huge reduction in the overall OR time and subsequently overall cost.
3- When counseling a patient for bariatric surgery, do you give them both options of laparoscopic and robotic?
When I started doing robotic surgery I used to give patients both options and I used to discuss the advantages and disadvantages of both approaches. I also used to disclose that there is no data to suggest that robotic surgery is superior to laparoscopic surgery. At this point I make it clear that my preference is to do all cases robotically unless I don’t have access to the robot.
4- How is your practice divided: laparoscopic vs robotic for sleeves, bypasses, revisions and bariatric emergencies?
At this point I perform all cases robotically whether it’s a sleeve, bypass or a complicated tough revision case. However, I advise bariatric surgeons who want to start doing robotic surgery not to start with difficult cases. I recommend that surgeons start with simple procedures like sleeve gastrectomy to learn the intricacies of the robot and develop some confidence driving the machine before tackling more difficult cases. Laparoscopic surgeons are a very talented group of surgeons but there is definitely a learning curve to robotics and once you are beyond the learning curve the robotic platform will offer multiple advantages in terms of visualization, wristed instrumentation, smart stapling technology, third arm for retraction and many others.
5- During which surgeries does the use of this higher technology really make a difference?
My practice, being a tertiary center, is almost 30% revisional cases (the national average of revisions in the US based on recent ASMBS estimates is 13.6%) and the use of the Xi platform to perform those revisional cases truly makes a huge difference for me. However, as mentioned previously I caution surgeons not to limit the use of robotic surgery to tough complicated revisional cases. Surgeons need to be very facile in performing simple primary cases prior to tackling more complicated revisional cases. Matter of fact, most of the cases we are presenting this year during the 2019 IFSO meeting in Madrid depict the performance of revisional cases
6- In one of your publications, you mention that the robotic sleeve is associated with longer operative times and higher organ space infections. Isn’t this a cause-effect? And if it is, why a technically feasible laparoscopic surgery needs the robot?
The publication you are talking about is the one that was published in SOARD this past January comparing Robotic Sleeve Gastrectomy (RSG) to Laparoscopic Sleeve Gastrectomy (LSG) based on 107, 726 patients who underwent Sleeve Gastrectomy and were entered in the 2016 MBSAQIP data. In that paper we found a higher organ space infection rate (including leak) following RSG (Odds Ratio 2.07). I believe that this higher infection rate may reflect the early experience of surgeons who were mostly using the old Si platform and a hybrid approach. Unfortunately, we didn’t not have information regarding the platform or the stapler used. In addition, the PUF data that was used to do our analysis did not have any information on surgeon experience or hospital volume which I believe make a difference in terms of outcome. We are in the process of analyzing 2017 and 2018 MBSAQIP data and I believe that the new data may be more favorable.
Also, in our hands robotic surgery resulted in better patient outcomes and shorter hospital stay so to answer the second part of the question I believe that the question should be why wouldn’t you use a superior technology even for simple cases that can be performed laparoscopically if this may potentially result in better outcomes.
7- Another study of yours compares cost of robotic vs laparoscopic. It seems your cost is comparable. Why do you believe this is different nationwide?
Cost is institution specific, therefore, surgeons need to collect their own cost data and make an informed decision based their own data but I can tell you that with time and experience I know that surgeons tend to get better and faster which translate into lower costs.
8- The conclusion of the study comparing robotic and laparoscopic bypasses in your publications showed that the robot does not have any advantage over the laparoscopic approach (more operative time for the robot). How can a surgeon justify to the health system the use of robotic platform in this operation?
This is the study that we published in SOARD in September 2018 and yes you are correct, in that study, we found no difference in primary outcomes between robotic and laparoscopic RYGB but again this was based on old data reported to MBSAQIP in 2016. I believe that the new data coming out may paint a different picture especially that since 2016 we had access to a better platform and better stapler that is fully integrated. I think surgeons interested in robotic surgery need to make the argument that this is the future, the technology is evolving quickly, there is no level I evidence to suggest superiority but there is many advantages to the technology and I believe that overtime robotic surgery will prove to be better and safer.
9- We highlighted on Dr. Ben Clapp’s publication in the IBC Newsletter June issue regarding revisional bariatric surgery. Laparoscopy showed better results over robotic. Do you see this in your practice?
I congratulate Dr. Ben Clapp on his work however I believe that his methodology was flawed. In his paper, robotic and laparoscopic revisional surgery cases were compared directly without being matched which may have introduced a selection bias. We recently studied that same issue and compared both groups but performed a propensity match based on a high number of significant preoperative patient factors including BMI, age, co-morbidities…etc. and found no difference in 30-day serious adverse events and lower (albeit not significant) 30-day intervention, organ space infection and reoperation rates. This will be presented at IFSO this coming September.