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. 2025 Aug;39(8):4848-4856.
doi: 10.1007/s00464-025-11862-7. Epub 2025 Jun 19.

Characterizing advanced stapling technique using objective performance indicators in robotic-assisted sleeve gastrectomy: a retrospective cohort study

Sarah Choksi  1   2   3 , Bishaka Hirachan  4   5 , Mattia Ballo  4   5 , Jon Winalski  4   5 , Kavita Jain  4   5 , Ruben Salas-Parra  4 , Craig Profant  4   5 , Dimitre Stefanov  4   6 , Max Berniker  7 , Mitchell S Roslin  4   5 , Vikrom Dhar  4   5 , Andrew Yee  7 , Marc Bessler  4   5 , Filippo Filicori  4   5
Affiliations

Characterizing advanced stapling technique using objective performance indicators in robotic-assisted sleeve gastrectomy: a retrospective cohort study

Sarah Choksi et al. Surg Endosc. 2025 Aug.

Abstract

Background: Although multiple studies have described the association between the sleeve shape and clinical outcomes, limited objective metrics exist to characterize the creation of the optimal sleeve shape and staple line formation. This study offers a novel, objective method for deconstructing robotic sleeve gastrectomies utilizing advanced stapler-specific metrics with the goal of improving patient outcomes.

Methods: Robotic sleeve gastrectomies were performed using the da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA) at our tertiary referral center. This system and the Intuitive data recorder (IDR) were used to collect procedure-specific data. These data included metrics for technique (pitch and yaw during staple fire) and staple line formation [cartridge height (color), staple fire total duration, and pause for compression]. All patients who underwent robotic sleeve gastrectomy in an operating room with an IDR one of the four board-certified, fellowship trained minimally invasive surgeons were included. Postoperative complications including outflow obstructive complications (leaks and PO intolerance) and bleeding were the primary outcomes analyzed. Univariate and multivariate analysis was used to analyze stapler metrics and postoperative outcomes. This is a retrospective cohort study from November 2020 to April 2023.

Results: Of the 344 patients, 15 had obstructive complications which included postoperative PO intolerance and leaks. Logistic regression demonstrated a ten degree increase in absolute pitch for the first staple fire was associated with an 89% higher risk of obstructive complications (OR = 1.89, 95% CI = 1.33-2.70, p < 0.001). While staple height and pause for compression were not associated with bleeding, there may be associations with leaks while examining the last staple fires.

Conclusion: This is one of the first studies associating objective stapler-specific metrics used to characterize stapling technique with clinical outcomes in robotic sleeve gastrectomy. Further evaluation of postoperative complications using objective metrics will help standardize technique and improve clinical outcomes.

Keywords: Advanced stapler; Objective metrics; Postoperative outcomes; Robotic-assisted sleeve gastrectomy; Staple line formation; Stapling technique.

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Conflict of interest statement

Declarations. Disclocures: Andrew Yee and Max Berniker are employees of Intuitive Surgical. Mitchell Roslin has received consulting fees from Medtronic and Ethicon. Marc Bessler has received consulting fees from Ethicon. Filippo Filicori has received consulting fees from Boston Scientific. Sarah Choksi, Bishaka Hirachan, Mattia Ballo, Jon Winalski, Kavita Jain, Ruben Salas- Parra, Craig Profant, Dimitre Stefanov, and Vikrom Dhar have no conflicts of interest or financial ties to disclose.

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