Robotic Bariatric Surgery: A Critical Review of Clinical Outcomes, Learning Curves, and Economic Considerations.

Abstract

Background: Robotic platforms have been increasingly adopted in bariatric surgery with the aim of overcoming technical limitations of conventional laparoscopy, particularly during complex reconstructive steps such as intracorporeal suturing and multi-quadrant dissection. Despite the rapid expansion of robotic bariatric surgery (RBS), uncertainty remains regarding its clinical value relative to established laparoscopic techniques.

Summary: This review critically evaluates the current evidence comparing robotic Roux-en-Y gastric bypass (RRYGB) and robotic sleeve gastrectomy (RSG) with their laparoscopic counterparts. Recent meta-analyses and large registry studies demonstrate broadly comparable perioperative outcomes between RRYGB and laparoscopic RYGB (LRYGB) across major clinical endpoints. Modest advantages for RRYGB have been reported in selected intraoperative and postoperative measures, including reduced anastomotic stricture rates, reduced marginal ulceration, reduced blood loss, lower conversion rates, and improved recovery in higher-risk patient groups such as in revisional surgery and high-BMI patients. However, these findings are inconsistent and largely derived from retrospective observational studies with heterogeneous methodology and limited long-term follow-up. In contrast, current evidence does not demonstrate clear clinical advantages for RSG over laparoscopic sleeve gastrectomy (LSG), and in fact suggest inferiority in terms of short-term outcomes. Although temporal analyses suggest improvement in robotic outcomes over time, similar trends have been noted in laparoscopic cohorts, suggesting broader improvements in perioperative bariatric care. Economic analyses consistently report higher procedural costs for robotic approaches, driven primarily by operative time and consumable expenditure, although these differences may decrease with transition to totally robotic techniques, increasing institutional experience and workflow optimisation in high-volume centres.

Key messages: Robotic bariatric surgery achieves outcomes comparable to laparoscopy but currently demonstrates selective advantages primarily in complex procedures such as RYGB and revisional surgery. The role of robotics in routine sleeve gastrectomy remains uncertain. Higher procedural costs and limited high-quality comparative data spanning different time periods continue to limit the ability to draw definitive conclusions. Future research should prioritise multicentre randomised trials, standardised reporting frameworks, and comprehensive economic evaluation across different emerging robotic platforms with consideration of learning curve effects.