Additional post-operative complications occur at rates similar to that of laparoscopic RYGB. These include major complications such as bleeding, anastomotic stricture, bowel obstruction, marginal ulcers, and pulmonary embolism. Minor post-operative complications include dehydration, edema, dysphagia , kidney insufficiency, nausea, vomiting, infection, rhabdomyolysis, and deep vein thrombosis.

Increased operating room time has long been an argument against robotic surgery. The time to set up the room, dock the robot, and increased operative time have all been repeatedly used as arguments against robotic surgery. However, in the literature, the findings regarding operative times for RRYGB were mixed. Average robot setup time ranged from 7 to 30 min [1, 6]. Reported times for the RRYGB ranged from 105 to 252 min but overall time was about 177 min [5–7, 18]. In reports that compared robotic and laparoscopic cases, two reports stated that robotic RRYGB took longer, four reported robotic RRYGB were faster, and two reported no statistical difference in mean operative times [1, 5, 10, 14, 17].

Several additional points should be made regarding operative times. First, the cases reported in the literature were largely from immature robotic programs. The operating room staff, the surgeons, and the first assistants were all novices in robotic surgery in the year 2000. At that time, it was not just the surgeon undergoing a learning curve ; it was the entire operative team.

Most of the cases documented in the literature from 2000 to 2010 were performed on the original da Vinci S model. This model was notoriously difficult to dock, suffered from a bulky camera, and was burdened by frequent collisions of the operating arms. All of these were improved in the 2009 release of the Si model. One study reported that their operative time decreased by 65 min after purchasing the Si model [8]. It should be noted that all of the aforementioned issues are nearly completely resolved with the 2015 release of the Xi model. The ports neatly click into place, the camera is a lean 8 mm scope, and the new linear design allows working ports to be placed closer together with nearly unlimited mobility of the arms in relation to each other.

Robotic surgery may offer two particular cost advantages in RYGB. Because the anastomotic leak rate in RRYGB is far below that of the laparoscopic RYGB, there is a cost-saving by performing the procedure robotically. Anastomotic leaks incur significant medical costs. If the robotic leak rate remains below 2% and the laparoscopic leak rate is at or above 2%, it is cost-effective to use the robot [16]. Furthermore, the advantage of hand-sewn anastomoses furthers the cost-savings. Surgical suture is far less costly than staples. If three staple fires are used in creating the gastric pouch, and all anastomoses are hand-sewn, it is more cost-effective to perform the procedure robotically even when considering the cost of the disposables.

The robotic learning curve is another benefit of robotic surgery in bariatrics. RYGB is notorious for its learning curve of 75–100 cases. Because it mimics human hand motions, use of the robot drastically shortens the learning curve. This has been borne out in multiple studies about RRYGB [5]. The learning curve for the RRYGB was approximately ten cases [5, 17]. Indications that the learning curve has been overcome include mortality <1%, conversion to open 1–3%, major morbidity rates <5%, leak rate <2%, operative times <2 h, and robotic operative time being equal to laparoscopic operative time [3, 16, 19–22]. At teaching institutions, the learning curve appears to be the function of the attending surgeon [23]. Once the attending surgeons had overcome their own learning curves, the curves of subsequent trainees were significantly shorter than that of their prior colleague.

Below are some principals of the RRYGB. The literature regarding RRYGB is very supportive of the procedure. But there were several cautionary themes repeated among the reports that are mentioned below.

Patient selection for RYGB is critical to optimal outcomes. The most important factor in choosing a RYGB over other bariatric surgical procedures is patient choice. In most institutions, patients will attend a bariatric surgery seminar where all the surgical options are offered. Patients are encouraged to research these options prior to their initial consultation. When patients come in for their initial consultation, they generally know which operation they prefer. As we tell our patients, this operation is completely elective. They have no surgical issues and can live out their lives without ever having this operation. As such, it is important that they satisfied with their operation of choice. Furthermore, they should be well prepared for their course after surgery.

Adequate pre-operative workup is essential to a safe and successful operative and post-operative course. This starts with the first visit. The patient should have a full history and physical examination performed. Patients who are actively smoking are not eligible for a RYGB. Targeted questions should be asked about the patient’s cardiac history and health, taking note of their metabolic equivalent of daily tasks. They should be asked about their history of venous thromboembolism and the lower extremities should be examined for venous stasis changes. If they previously have had a venous thromboembolism, pre-operative retrievable inferior vena cava filter can be considered, although this is controversial. Their pulmonary function should be interrogated and the obstructive sleep apnea screening questions should be asked. Any patient with four or more positive answers needs a sleep study to evaluate for sleep apnea. Sleep apnea is a significant risk for sudden post-operative death in the bariatric population. The patient’s ability to understand and cope with life changes after bariatric surgery should be evaluated. A patient who claims that their whole life will be better after bariatric surgery should be counseled about limiting expectations.

Pre-operative endoscopic evaluation has been advocated by many. The advantages include delineating gastroesophageal anatomy and obtaining gastric biopsies to determine H. pylori status which may decrease leak rate. The disadvantage is the time and cost to the patient. Others have advocated endoscopy only for patient with gastroesophageal reflux or patients over age 50, or for those who wish to have a sleeve gastrectomy.

Pre-operative care begins with a 2-week very low calorie diet. Patients are instructed to take one low carbohydrate, high protein drink for breakfast, one for lunch and a small, protein-rich dinner. This type of diet assists in shrinking the liver, assisting the surgeon, but has also been demonstrated to improve post-operative outcomes [24]. Patients are made NPO to solids and full liquids the night before surgery but are encouraged to drink clear liquids up until 2 h before surgery. This regimen is approved by the American Society of Anesthesiologists and has been shown to reduce patient anxiety and post-operative nausea without increasing complication rates [25].