Totally Extramucosal Hand-Sewn Robotic Gastrojejunostomy for Roux-en-Y Gastric Bypass

Abstract

Background:

Roux-en-Y gastric bypass is an established metabolic-bariatric procedure performed using minimally invasive approaches, including laparoscopy and robotic assistance. Robotic platforms provide technical advantages that facilitate hand-sewn gastrojejunostomy, allowing surgeons to implement a consistent and reproducible technique.

Methods:

The surgical technique of a single-layer, continuous, extramucosal hand-sewn gastrojejunostomy performed during fully robotic Roux-en-Y gastric bypass is described. Consecutive primary and revisional procedures were performed by a single bariatric surgeon using the da Vinci X, Xi, or 5 robotic platforms. Perioperative outcomes were analyzed. An accompanying video is accessible to demonstrate our operative technique.

Results:

Between April 1, 2024, and January 31, 2026, 73 consecutive Roux-en-Y gastric bypass procedures were performed by a single surgeon, including 34 primary and 39 revisional cases. Using the described suturing technique, no anastomotic leaks or gastrojejunostomy-related bleeding were observed. One anastomotic stricture occurred within the 30-day postoperative period and was successfully managed with endoscopic dilation.

Summary:

The described single-layer, continuous, extramucosal robotic hand-sewn gastrojejunostomy in Roux-en-Y gastric bypass was feasible and safe in a consecutive series of primary and revisional procedures.

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) is an established procedure in metabolic and bariatric surgery and is routinely performed using minimally invasive techniques. While laparoscopic approaches remain standard, robotic assistance has gained increasing acceptance, particularly in revisional and technically complex cases, where enhanced dexterity and precision may be advantageous.^1–3

Construction of the gastrojejunostomy represents a critical step of the procedure and remains an area of ongoing debate, particularly regarding stapled versus hand-sewn techniques.^4,5 Mechanical stapling devices offer efficiency and reproducibility and have contributed significantly to the evolution of minimally invasive gastrointestinal surgery. However, their use relies on nonabsorbable staple material and may be limited by instrument geometry and range of motion in anatomically confined operative fields.⁶

Robotic platforms provide wristed instrumentation, motion scaling, and improved ergonomics, enabling precise hand-sewn anastomoses in minimally invasive surgery. These technical advantages facilitate controlled needle angles, accurate tissue handling, and consistent suture placement, even in restricted spaces, making manual anastomosis a feasible alternative to stapling in selected cases.⁷

Extramucosal, mucosa-sparing intestinal anastomosis has long been recognized as a fundamental surgical principle, with the potential to preserve tissue perfusion and reduce ischemic injury at the anastomotic site.^8,9 The precision afforded by robotic assistance allows for the consistent application of a fully extramucosal hand-sewn gastrojejunostomy during RYGB.

The purpose of this paper is to describe a standardized, single-layer, continuous, extramucosal hand-sewn gastrojejunostomy performed during fully robotic RYGB and to report the associated perioperative outcomes.

MATERIALS AND METHODS

Since April 1, 2024, RYGB procedures for metabolic bariatric surgery have been performed using a fully robotic approach at the University Department of General and Visceral Surgery, University Hospital OWL, Campus Lippe, Detmold. Both primary and revisional procedures were carried out using the da Vinci X, Xi, or 5 robotic platforms (Intuitive Surgical, Inc., Sunnyvale, CA), with intracorporeal robotic hand-sewn gastrojejunostomy and jejunojejunostomy.

Primary RYGB procedures are performed using a standardized technique. Patients are positioned supine with extended legs in a 15° reverse Trendelenburg position. Pneumoperitoneum is established using a Veress needle (Ethicon, Johnson & Johnson MedTech) in the left upper abdomen, followed by diagnostic laparoscopy through a right paramedian midabdominal Xcel trocar (Ethicon, Johnson & Johnson MedTech) placed under direct visualization. The procedure is then carried out using additional 8- and 12-mm da Vinci robotic trocars (Intuitive Surgical, Inc.) and an epigastrically placed liver retractor, with an intra-abdominal pressure maintained at 15  mmHg.

A tubular gastric pouch with an approximate volume of 30  mL is fashioned after placement of a 36-French gastric tube, using robotic staplers (1 horizontal 60-mm blue cartridge followed by 2–3 vertical 60-mm blue cartridges). The biliopancreatic limb is measured to 150  cm and the alimentary limb to 80  cm.

The gastrojejunostomy is then constructed robotically and calibrated to a diameter of 2  cm using a continuous, single-layer, hand-sewn technique with absorbable barbed suture material (V-Loc, 3-0; Medtronic), performed over a 36-French gastric tube.

On the lateral side of the planned gastrojejunostomy, the gastric pouch, proximal to the transverse staple line, and the jejunum, elevated with a band, are approximated and secured using an absorbable barbed suture (V-Loc, 3-0; Medtronic). The initial stitch is placed in a seromuscular fashion in the jejunum and then through the seromuscular layer of the distal vertical staple line of the gastric pouch, immediately proximal to the horizontal staple line, incorporating the staple line (Figure 1). This suture is subsequently continued as a single-layer, continuous posterior row, progressing medially toward the lesser curvature of the gastric pouch. The needle direction is from the jejunum to the gastric pouch, placed seromuscular and incorporating the staple line of the gastric pouch. The suture exiting on the right side of the posterior wall is left in place.

Figure 1.

Posterior seromuscular layer.

On the lateral side of the gastrojejunostomy, the anterior layer is initiated using an absorbable barbed suture (V-Loc, 3-0), placed in a seromuscular fashion in both the jejunum and the gastric pouch (Figure 2). Next, following the creation of a 2-cm gastrotomy and enterotomy openings (Figure 3), the anterior wall of the gastrojejunostomy is sutured continuously in a seromuscular fashion over a 36-French Bougie (Figure 4).

Figure 2.

Lateral anchor suture.

Figure 3.

Robotic hook creating a gastrotomy and enterotomy.

Figure 4.

Anterior extramucusa closure of the anastomosis.

Using the previously placed posterior wall suture, the anterior suture line is then continued toward the lateral aspect of the anastomosis to secure and reinforce the corners, after which the sutures are divided. Perfusion and integrity of the gastrojejunostomy are assessed using intravenously administered indocyanine green (ICG) and intraluminal methylene blue instilled via the gastric tube. Methylene blue is used to evaluate luminal integrity and exclude anastomotic leak, whereas ICG fluorescence is used to confirm adequate tissue perfusion at the gastrojejunostomy. This is particularly useful in revisional procedures, where the appearance of tissue after extensive adhesiolysis may be misleading.

The jejunojejunostomy is subsequently created robotically using the same continuous, single-layer, seromuscular hand-sewn technique with absorbable barbed suture material.

After completion of the jejunojejunostomy, the afferent limb is transacted using a robotic linear stapler (da Vinci EndoWrist stapler; Intuitive Surgical, Inc.), 2  cm distally from the gastrojejunostomy to complete the Roux reconstruction.

All mesenteric defects are closed with continuous sutures using nonabsorbable suture material (V-Loc, 3-0).

RESULTS

From April 1, 2024 to January 31, 2026, a total of 73 fully robotic RYGB procedures were performed as primary (n = 34) or revisional procedures (n = 39).

Operative times were 145 ± 23 minutes for primary RYGB without hiatoplasty, 176 ± 37 minutes with hiatoplasty, and 213 ± 59 minutes for revisional procedures. Operative times include additional procedures in both groups (Table 1).

Table 1.

Robotic Roux-en-Y Gastric Bypass: Patient Data and Operative Procedures

Patients		Operative Time
(n $=$ 73)	n (%)	Minutes
Sex
Female	63 (86)
Male	10 (14)
Age (years)	47 ± 11,3
BMI (kg/m2)	39,1 ± 8,6
Roux-en-Y gastric bypass
Primary procedure
Without hiatal hernia repair	26	145 ± 23
With hiatal hernia repair	8	176 ± 37
Revisional procedure		213 ± 59
SG to Roux-en-Y bypass	14
OAGB to Roux-en-Y bypass	15
SASI to Roux-en-Y bypass	2
Recreation of gastrojejunostomy	8
Average gastrojejunostomy time		16

Abbreviations: BMI, body mass index; OAGB, one anastomosis gastric bypass; SASI, single anastomosis sleeve ileal bypass; SG, sleeve gastrectomy.

The mean time required to complete the gastrojejunostomy was approximately 16 minutes. This included approximately 2 minutes for creation of the gastrotomy and enterotomy and 14 minutes for completion of the hand-sewn anastomosis.

No anastomotic leaks or bleeding at the gastrojejunostomy occurred. One gastrojejunostomy stricture was observed within 30  days postoperatively and was treated endoscopically (Table 2).

Table 2.

Robotic Hand-Sewn Gastrojejunostomy in Fully Robotic Roux-en-Y Gastric Bypass: Complications

	Robotic Roux-en-Y Gastric Bypass
	Hand-Sewn Gastrojejunostomy
	Primary Procedure	Revisional Procedure
	n	n
	34	39
Complications
Anastomotic leak	-	-
Bleeding	-	-
Stricture	-	1

Median length of hospital stay was 2 days for primary procedures and 4 days for revisional procedures.

DISCUSSION

Construction of the gastrojejunostomy remains a critical step in RYGB, with anastomotic complications such as leak, bleeding, and stricture continuing to contribute to postoperative morbidity.^10,11 Although stapled techniques are widely adopted because of their efficiency and reproducibility, hand-sewn anastomoses allow greater control over tissue handling, suture placement, and anastomotic geometry. However, the technical difficulty of intracorporeal suturing has historically limited the routine use of hand-sewn techniques in minimally invasive bariatric surgery.

The present technique emphasizes a fully extramucosal, single-layer, continuous hand-sewn gastrojejunostomy. The rationale for this approach is rooted in well-established surgical principles demonstrating that intestinal healing depends primarily on accurate seromuscular apposition and preservation of tissue perfusion, rather than transmural incorporation of the mucosa.^8,9 Experimental and clinical observations have shown that mucosa-sparing anastomoses provide sufficient mechanical strength while minimizing tissue trauma and ischemic injury, which are key contributors to anastomotic failure.⁸

Robotic assistance plays a pivotal role in enabling the reproducible application of an extramucosal technique. Wristed instrumentation, motion scaling, and tremor filtration facilitate precise needle control, consistent bite depth, and controlled backhand suturing in anatomically confined spaces. These technical advantages allow deliberate mucosa-sparing suturing that is technically demanding to perform reliably using conventional laparoscopic instruments.¹² As a result, robotic platforms may expand the feasibility of standardized hand-sewn anastomoses in both primary and revisional bariatric procedures.

Robotic assistance plays a pivotal role in enabling the reproducible application of an extramucosal technique. Wristed instrumentation, motion scaling, and tremor filtration facilitate precise needle control, consistent bite depth, and controlled backhand suturing in anatomically confined spaces, allowing deliberate mucosa-sparing suturing that is technically demanding to perform reliably using conventional laparoscopic instruments.¹² In this context, analyses of primary and revisional procedures performed using a fully robotic approach, with either robotic stapled or robotic hand-sewn gastrojejunostomy, as well as hybrid robotic techniques employing laparoscopic stapling, have demonstrated comparable perioperative outcomes.¹³

In addition, routine ICG fluorescence assessment served as a confirmatory step to validate adequate perfusion, particularly in revisional surgery, and as a teaching adjunct in the university setting to reinforce resident and fellow understanding of tissue perfusion during anastomotic construction.

A practical strength of this series is that the technique was performed across 3 generations of the da Vinci robotic platform, including the X, Xi, and 5 systems. This suggests that the described extramucosal hand-sewn gastrojejunostomy is not dependent on a single robotic configuration and may be applicable across centers operating with different platform generations. While platform-specific ergonomics and instrumentation may vary, the core technical principles of exposure, tissue handling, and controlled seromuscular suturing remained consistent across systems.

These findings suggest that robotic platforms expand the technical feasibility and standardization of hand-sewn anastomoses without compromising safety in both primary and revisional bariatric procedures.

In this consecutive series, the described technique was associated with no anastomotic leaks or gastrojejunostomy-related bleeding and a single postoperative stricture managed endoscopically. Although this study is not designed to compare outcomes with stapled techniques, these findings support the feasibility and safety of a fully extramucosal robotic hand-sewn gastrojejunostomy. Larger comparative studies will be necessary to determine whether this approach offers measurable advantages over established stapled methods.

The choice between hand-sewn and stapled gastrojejunostomy extends beyond technical preference and reflects a complex interplay of factors including surgeon training, technical proficiency, institutional resources, operative workflow, and cost considerations. While stapling devices offer efficiency and standardization, hand-sewn techniques may provide greater control over tissue handling and anastomotic construction, particularly in anatomically challenging or revisional cases. The adoption of robotic platforms may help bridge this gap by lowering the technical barrier to intracorporeal suturing, potentially reintroducing hand-sewn techniques into minimally invasive practice. However, these considerations remain highly context-dependent and warrant further investigation in comparative and multi-institutional settings.

The clinical relevance of gastrojejunostomy technique selection is further underscored by contemporary literature on marginal ulceration after metabolic and bariatric surgery, which identifies marginal ulcers as an important long-term complication following RYGB and other anastomotic bariatric procedures. In addition, recent global benchmark data for primary robotic bariatric surgery provide useful context for interpreting perioperative outcomes and operative efficiency in robotic RYGB. Together, these data support the need to evaluate technical refinements such as extramucosal hand-sewn gastrojejunostomy not only by early safety outcomes, but also by longer-term endpoints, including marginal ulceration, late stricture, operative efficiency, and reproducibility across centers.^14,15

LIMITATIONS

This study has several limitations that warrant consideration. First, this represents a single-surgeon experience at a single institution with a relatively small sample size and a short follow-up period, which significantly limits the generalizability of the findings. While this approach ensures technical consistency and standardized application of the described extramucosal technique, outcomes may differ with broader adoption across surgeons with varying levels of robotic experience.

Second, the study design is observational and lacks a contemporaneous comparison group. As such, no direct conclusions can be drawn regarding superiority or equivalence relative to stapled or alternative hand-sewn gastrojejunostomy techniques. The favorable outcomes observed should therefore be interpreted as supportive of feasibility and safety rather than comparative effectiveness.

Third, the sample size is limited, and follow-up is restricted to the early postoperative period. Although anastomotic leaks and bleeding typically manifest early, 30-day follow-up is insufficient to fully characterize the complication profile of this technique. A longer follow-up will be necessary to evaluate late gastrojejunostomy-related outcomes, particularly delayed stricture formation and marginal ulceration, which are among the most clinically consequential long-term complications related to gastrojejunostomy technique selection.

Finally, this study does not address variability in operative time across levels of surgical expertise, learning-curve effects, cost implications, or operating-room workflow considerations. These factors are critical in the broader comparison between hand-sewn and stapled techniques and should be evaluated in future studies.

SUMMARY

This study describes a standardized, single-layer, continuous, extramucosal hand-sewn gastrojejunostomy performed during fully robotic RYGB. The technique leverages the technical advantages of robotic assistance to enable precise, mucosa-sparing suturing in both primary and revisional procedures. In this consecutive series, the approach proved feasible and safe, with a low rate of anastomosis-related complications. However, a longer follow-up is required to assess late gastrojejunostomy-related outcomes, including delayed stricture formation and marginal ulceration. These findings support the use of a fully extramucosal robotic hand-sewn gastrojejunostomy as a reproducible technical option within contemporary minimally invasive bariatric surgery, warranting further evaluation in comparative studies.