Evaluating trends and outcomes between robotic and laparoscopic bariatric surgery in patients with BMI ≥ 60 kg/m2: an MBSAQIP analysis of 32,295 cases

BACKGROUND: Bariatric surgery patients with body mass index (BMI) ≥ 60 kg/m2 present unique technical and perioperative challenges. While robotic-assisted bariatric surgery is thought to offer potential technical advantages, direct comparisons between robotic and laparoscopic approaches (R-BS and L-BS) in this population remains limited. METHODS: An analysis of the 2020-2023 MBSAQIP database was conducted and all patients with BMI ≥ 60 kg/m2 who underwent primary laparoscopic or robotic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) were included. Baseline demographics, operative characteristics, and 30-day postoperative outcomes were compared. Multivariable logistic regression identified independent predictors of serious complications. RESULTS: Of 32,295 patients, 22,211 (68.8%) were L-BS and 10,084 (31.2%) were R-BS. Significant baseline differences existed between groups, including higher rates of gastroesophageal reflux disease (28.6% vs. 26.1%, p < 0.001), and hypertension (54.7% vs. 52.8%, p = 0.001) in the R-BS group. From 2020 to 2023, the proportion of R-BS doubled from 20.4% to 41.3%, whereas the proportion of L-BS declined slightly from 79.6% to 58.7%. There was no significant difference in robotic versus laparoscopic utilization for RYGB. (27.4% vs 26.4%, p = 0.059) and operative time was significantly longer in R-BS (106.5 ± 51.4 min vs. 83.5 ± 47.0 min, p < 0.001). Rates of individual 30-day complications, including leaks, bleeding, reoperation, and readmission, were low with no significant difference between cohorts. Independent predictors of serious complications included older age, hypertension, gastroesophageal reflux disease, prior myocardial infarction, therapeutic anticoagulation, longer operative time and RYGB. The robotic approach was neither independently associated with nor protective against serious complications. CONCLUSIONS: In patients with a BMI ≥ 60 kg/m2 undergoing elective bariatric surgery, there were no significant differences in 30-day postoperative outcomes between laparoscopic and robotic approaches despite baseline patient differences between groups. Although operative times were 27% longer for the robotic approach, its utilization increased substantially over the study period. These findings suggest that perioperative outcomes in this high-risk population are primarily determined by patient comorbidities and procedural factors rather than surgical approach, and that neither approach demonstrates superior short-term safety.