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Robotic versus laparoscopic stapling during robotic Roux-en-Y gastric bypass surgery: a case-matched analysis of costs and clinical outcomes



The purpose of this analysis is to compare the robotic EndoWrist Stapling System (EWSS) 45 mm (Intuitive Surgical Inc. Sunnyvale, CA, USA) and the ECHELON FLEX ENDOPATH® Staplers (EFES) 60 mm (Ethicon, Cincinnati, OH, USA) for gastric pouch formation during robotic gastric bypass surgery.


Patients who underwent robotic gastric bypass surgery with stapling using EWSS were matched with patients who underwent the same procedure with the EFES. Demographic, intra- and postoperative, and cost data were collected and analyzed.


A total of 49 patients were identified who had undergone robotic gastric bypass surgery using EWSS. They were matched with 49 patients who underwent the equivalent procedure using EFES. With similar demographic parameters, corrected operating room time without cholecystectomy took longer for the patients that underwent surgery with EWSS (+22 min, p = 0.1042). Stapler clamping was unsuccessful in 19.0% of all recorded attempts with EWSS. Two intra-operative complications unrelated to stapling and one complication due to stapling were observed in the EWSS cohort, while none was observed for the EFES group. Significantly, more recharges were needed with EWSS to complete the gastric pouch (4.9 vs. 4.1, p = 0.0048) and overall stapling costs for the procedure were significantly higher (2212.2 vs. 1787.4 USD, p = 0.0001).


Gastric pouch formation using EWSS during robotic gastric bypass surgery is feasible. Due to the shorter length of EWSS compared to EFES, more stapling recharges are required to complete gastric pouch formation and the stapling costs for gastric bypass surgery are higher. Further systematic research should be conducted to precisely determine the value of the robotic EWSS for gastric bypass surgery.

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  1. 1.

    Cadiere GB et al (1999) The world’s first obesity surgery performed by a surgeon at a distance. Obes Surg 9(2):206–209

  2. 2.

    Kim K, Hagen ME, Buffington C (2013) Robotics in advanced gastrointestinal surgery: the bariatric experience. Cancer J 19(2):177–182

  3. 3.

    Economopoulos KP et al (2015) Robotic vs. laparoscopic Roux-En-Y gastric bypass: a systematic review and meta-analysis. Obes Surg 25(11):2180–2189

  4. 4.

    Hagen ME et al (2012) Reducing cost of surgery by avoiding complications: the model of robotic Roux-en-Y gastric bypass. Obes Surg 22(1):52–61

  5. 5.

    Tieu K et al (2013) Robotic-assisted Roux-en-Y gastric bypass: update from 2 high-volume centers. Surg Obes Relat Dis 9(2):284–288

  6. 6.

    Ayloo S et al (2016) Laparoscopic, hybrid, and totally robotic Roux-en-Y gastric bypass. J Robot Surg 10(1):41–47

  7. 7.

    Aggarwal S et al (2015) Totally robotic Roux-en-Y gastric bypass: technique. Indian J Surg 77(2):164–166

  8. 8.

    Shikora SA et al (2015) Clinical benefit of gastric staple line reinforcement (SLR) in gastrointestinal surgery: a meta-analysis. Obes Surg 25(7):1133–1141

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We thank Francoise Bernardi (University Hospital Geneva) for data collection.

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Correspondence to Monika E. Hagen.

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Monika E. Hagen received personal fees and non-financial support from Intuitive Surgical Inc., outside this project. Monika E. Hagen received personal fees from Ethicon Inc., outside this project. Minoa K. Jung received non-financial support from Intuitive Surgical Inc., outside this project. Jassim Fakhro, Nicolas C. Buchs, Leo Buehler, Jona Mendoza, and Philippe Morel have no conflicts of interest or financial ties to disclose.

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Hagen, M.E., Jung, M.K., Fakhro, J. et al. Robotic versus laparoscopic stapling during robotic Roux-en-Y gastric bypass surgery: a case-matched analysis of costs and clinical outcomes. Surg Endosc 32, 472–477 (2018).

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  • Stapling
  • EndoWrist
  • Echelon
  • da Vinci
  • Robotic
  • Robotic surgery
  • Gastric bypass
  • RYGB