Published on: 7 April, 2026

Introduction: Addressing a Challenging Post-Bariatric Complication

Gastro-gastric fistula (GGF) is a rare yet significant complication following Roux-en-Y gastric bypass (RYGB). It often presents with symptoms such as persistent abdominal pain, marginal ulcers, or nutritional decline. While small fistulas sometimes respond to endoscopic therapies, larger or chronic fistulas frequently require surgical revision. This article explores the role of robotic surgery in managing refractory GGF, emphasizing its advantages over conventional approaches. The focus is on a complex case featuring an embedded over-the-scope clip (OTSC), highlighting robotic surgery’s precision and enhanced recovery benefits.

Clinical Presentation and Diagnostic Challenges

A 38-year-old female patient with a history of RYGB presented with persistent upper abdominal pain and malnutrition. Despite multiple endoscopic interventions—including OverStitch closure, fibrin glue application, and OTSC placement—the fistula remained patent. Preoperative imaging and endoscopy confirmed an 8-mm GGF with friable mucosa and an embedded OTSC. Importantly, the existing gastrojejunostomy was patent, and the fistula’s chronicity alongside poor tissue quality compounded the complexity of management.

Robotic surgery was selected due to its superior visualization and dexterity, especially beneficial in dissecting dense adhesions typical in post-bariatric surgery patients. This approach allowed thorough preoperative planning and intraoperative confirmation of fistula anatomy.

Robotic Surgical Technique: Precision in Complex Anatomy

During surgery, dense adhesions involving the Roux limb, gastric pouch, and liver were carefully lysed. Intraoperative endoscopy guided precise identification of the fistula and embedded OTSC. The fistula tract was meticulously dissected and excised, and the OTSC was successfully removed.

The gastrojejunostomy-fistula complex was resected using a stapler, preserving a healthy 4 cm gastric pouch. Subsequently, a new hand-sewn gastrojejunostomy was constructed robotically in four layers. The use of an endoscope as a bougie during anterior closure ensured optimal anastomotic calibration. Additionally, the remnant stomach was mobilized and resected to reduce recurrence risk. A leak test confirmed an intact anastomosis, affirming the procedure’s success.

Advantages of Robotic Surgery in Revisional Bariatric Procedures

Robotic surgery offers distinct benefits for managing gastro-gastric fistula after RYGB. Enhanced dexterity facilitates safe adhesiolysis and precise suturing, critical in redo bariatric operations. The robotic platform enables surgeons to navigate altered anatomy effectively and manage embedded foreign bodies such as OTSCs.

Moreover, robotic instrumentation aids in remnant stomach resection, minimizing operative risks. Early postoperative recovery is notable; in this case, the patient tolerated oral intake by postoperative day one and was discharged the same day. Such outcomes underscore robotic surgery’s alignment with enhanced recovery after surgery (ERAS) protocols, even in complex revisional cases.

Clinical Outcomes and Long-Term Success

At six months postoperatively, the patient remained asymptomatic with improved nutritional status. Follow-up imaging and endoscopy confirmed no recurrence of the fistula. This positive outcome highlights robotic surgery’s efficacy in refractory GGF cases, especially after failed endoscopic management.

The case also demonstrates that robotic resection combined with immediate reconstruction can resolve symptoms and enable early recovery. For healthcare professionals managing post-bariatric complications, this approach offers a promising surgical option.

Conclusion: Embracing Robotic Surgery for Complex GGF Cases

Gastro-gastric fistula remains a challenging complication after Roux-en-Y gastric bypass, particularly when refractory to endoscopic treatments. Robotic surgery provides enhanced visualization, precise dissection, and superior anastomotic techniques, making it an ideal choice for complex revisions.

By integrating robotic technology, surgeons can achieve safe fistula takedown, effective clip removal, and durable gastrojejunostomy reconstruction. Early diet advancement and same-day discharge illustrate the procedure’s alignment with modern recovery principles. As this case suggests, robotic management of GGF should be considered a valuable tool in the surgical armamentarium for post-bariatric complications.

Source: https://pubmed.ncbi.nlm.nih.gov/41945514/

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