Evaluation of hemorrhage risk and the volume-outcome relationship following vertical sleeve gastrectomy amidst robotic-assisted surgery adoption.

Background: Robotic-assisted surgery (RAS) holds promise for maintaining bariatric outcomes, while offering a shorter adoption learning curve relative to conventional laparoscopy. However, low RAS procedure volume relative to a laparoscopic approach has limited our understanding of its impact, and the transition from laparoscopic to RAS entails a volume-outcome relationship that is not fully characterized.

Methods: This is a retrospective cohort study in a MBSAQIP accredited, bariatric surgery program. The incidence of hemorrhage following vertical sleeve gastrectomy (VSG) was observed from 2020 to 2023. This period was divided into an early adoption period (RAS 31% of cases) and a late adoption period (RAS 82% of cases).

Results: A total of 1250 patients underwent VSG over the study period. Laparoscopic VSG (L-VSG) and robotic-assisted VSG (RA-VSG) groups were similar in age, sex, and risk factors for postoperative bleeding. They differed in race (P < 0.0001) and ASA category (P = 0.007). The overall postoperative hemorrhage rate was 1.04% (n = 13). Hyperlipidemia was predictive of hemorrhage on univariate analysis (P = 0.045). The relative risk of hemorrhage in the robotic group dropped from 4.38 (CI 0.577-3.24) during the early adoption period to 0.28 (CI 0.083-0.96, P = 0.063) during the late adoption period. This shift with respect to hemorrhage risk was not associated with a significant reduction of hemorrhage in the RA-VSG approach (1.5% vs. 0.98%; P = 0.636), but with an increase in L-VSG risk (0.35% vs. 3.5%, P = 0.0245).

Conclusion: As RA-VSG became the more frequently utilized approach within a single program, the risk of hemorrhage with L-VSG significantly increased. This suggests an unanticipated risk associated with a transition to the robotic approach. Specifically, the risk of complication increased when performing L-VSG in a practice dominated by RA-VSG.