JNJ with OTTAVA are now claiming that HYBRID is the way forwards for stapling - Really?

So the immediate cynic inside of me comes back to say that “Getting a stapler to actually work on a robot is way more difficult than people think.”

This week Johnson & Johnson dropped a string of Linked In posts and articles explaining why they feel that using a manual bedside stapler in a Hybrid manner is better than using a fully robotic stapler.

IMMEDIATE NOTE: I’m about to dig in deep and do not confuse two things. The evidence based rationale and the “I don’t care…. I want to fire my stapler from my console.”

So let’s dig into HYBRID

Technically a pure robotic procedure is where once the ports (Trocars) are placed into the patient - everything is then done via the robot with no manual laparoscopy.

So imagine a robotic prostatectomy is performed - and every single part of it is done using the robot. Including placing clips. The console surgeon controls 100% of the instruments. That Ould classically be considered a fully robotic procedure.

But the reality for most cases is that a bedside assistant would place clips, drop sutures in, suction and then remove the specimen. So if we are to take the purist view of this nearly every robotic producer is actually assisted by some manual laparoscopic manoeuvres by the bedside. And technically that is why it is deemed RAS - Robotic assisted surgery. It’s all subtle and shades of “how hybrid.”

So we need to take a bit of a broader definition for today’s arguments. I think what many people say as Hybrid is where the console surgeon gets off the console and performs part of the procedures from a bedside. The either start with a part of the procedure as manual lap - drop out of being scrubbed and go to console. Or they do console and then scrub in for parts of the procedure, start, middle or even end.With some systems such as DistalMotion Dexter you remain scrubbed and do part manual lap and part robotic and part manual lap and part robotic and switch seamlessly.

There is no purist reality to hybrid from a procedural point of view.

A second emerging viewpoint is “Hybrid tools” where you can say did we use pure robotic instruments or did we do some of the case with manual instruments - such as advanced energy or staplers. Again it’s another cut at Hybrid. It is irrelevant who does the stapling - the primary surgeon of the bedside assistant. But this is another way that Hybrid procedures are being tagged. 

So yes - it’s a broad term that is ill defined; and irritates some people by the way.

For today’s discussion as we are discussing “Staplers” in the main I’m going to define it as using the robot for a lot of the case and then either the console surgeon scrubs in and fires the stapler - or the bedside (if qualified and legally allowed) fires a manual stapler. When I discuss Hybrid today this is what I’ll be referencing if that’s okay with you.

I will use this as it is the term used by JNJ in their Hybrid paper: “a hybrid approach has been suggested whereby laparoscopic surgical devices are used instead of a fully robotic-assisted approach.”

Read this very carefully first:  the JNJ Hybrid marketing piece: https://p1.aprimocdn.net/jjamp/en/us/surgery/value-analysis-brief/a-hybrid-approach-to-stapling-in-robotic-assisted-bariatric-thoracic-and-colorectal-surgery--hybrid-surgery-value-brief-c-us-srg-stap-407534-1-en-407534.1.en.pdf

Credit: Johnson & Johnson - see link in article

Why is talking HYBRID a possible red flag?

So here is where my analytical brain starts to speculate a little. No Shit!

If there’s one thing I know - it is just how hard it is to get a fully wristed stapler on a robot. Now getting a simple YAW (Side to side movement) and rotation is still difficult but IP wise, mechanically wise, control wise, consistency wise it is whole other ball game to move to a wrist.

So even porting something like an Echelon stapler across from a hand held device to a robotic OTTAVA mounted and driven device is not insignificant. Yes… it can be done - but can it be done at a price point where it will be acceptable. Can performance be as good as the staggeringly good Echelon? That is my question.

Let me put the Elephant on the OTTAVA table. I’m starting to ask why JNJ would have such a full court press on HYBRID when they have just launched their OTTAVA. And that includes shouting loudly about instrument heritage and that their energy and stapling will be exclusives on OTTAVA.

I am wondering if they are hedging a few things here… being the cynic I am.

Are they finding it too hard? Have they tested a yaw only version and got less than hot feedback? Have they worked out the cost per firing becomes excessive? Can they get the same great staple formation as their Echelon hand held? Etc etc etc.All major questions that run through my mind the minute I see them throw shade on robotic stapling.

Companies like JNJ do not randomly do stuff. And more so… no company like JNJ would produce such a heavy Hybrid paper that was partly reliant upon data not related to Echelon, Interestingly a significant part is reliant on Medtronic data. Yep you read that right.

Source category	References	Count
Medtronic-linked research—	7, 10, 13, 14, 16, 18, 19, 20	8
J&J/ECHELON-specific conference evidence	12, 15, 22, 23	4
J&J product website—not a study	11	1
Other academic/background references	1–6, 8, 9, 17, 21	10

This says to me that they are looking deeply into “all stapling hand held vs stapling robotic.”

Hang on… sorry that is a terrible statement. These are many of the papers that are positive towards hand held being better than robotic. Clearly It doesn’t  do the counter argument of all the papers that show robotic stapling is actually better than hand held. Why would they.

I don’t want to make that one sided view a massive issue; as this is the JNJ marketing and they are entitled to present a marketing document with their side of the arguments. But as an independent, I’d just like to say there are many papers that say the exact opposite... to bring a little balance to the force.

Here’s a few examples:

Zervos 2021, robotic lobectomy: robotic stapling was associated with less bleeding: 5.6% versus 9.8%: and fewer conversions to open surgery, with comparable total hospital costs. This was a retrospective Premier study, with Intuitive-affiliated authors.

Tejedor 2020, rectal cancer: among 196 patients, rectal division using one or two firings was achieved in 91% of robotic-stapler cases versus 60% of laparoscopic-stapler cases. The leak difference between stapler groups was not statistically significant. This identifies a relevant technical advantage: access and articulation in the pelvis can change how many firings are needed. A small sigmoid/rectosigmoid hybrid study cannot establish the best approach for difficult low rectal surgery.

Mitzman 2026, robotic lung resection: a newer 15,140-patient analysis found associations favouring robotic stapling, including fewer air leaks, shorter operating time and lower total hospital costs. It included Intuitive employees and a consulting disclosure, and acknowledged residual confounding.

Let me be clear (Damn sound like a politician.) Both sides of this data pond have heavy company involvement directly or indirectly in some of these papers: so I’d be looking at all of this with a pinch of salt. You can go and see all of the industry involvement in these papers and the clear disclosures. References are on the JNJ brief. And to be clear, It's Normal. Not often the best for science... but normal.

But, I just want to pull out some numbers as headlines wise they look amazing at first glance - but if you dig in with a stats view; it needs a little interpretation. And again you have to go back to each source paper and dig in and look with a critical eye… As you have all seen I’m doing that more and more. And I'm doing this as I'll repeat... if these numbers are so powerful... why is anyone still using a robotic stapler?

What the brief’s figures mean in absolute terms:

Credit: Johnson & Johnson - see link in article

83% fewer leaks is actually 1.2% versus 0.2%: 1 percentage point, or 10 fewer per 1,000 operations

55% fewer bleeding complications 1.1% versus 0.5%: 0.6 percentage points, or 6 fewer per 1,000

81% fewer readmissions 4.3% versus 0.8%: 3.5 percentage points, or 35 fewer per 1,000

You need to always look at the % and retro fit it to PPM in my book. I’m not for a minute saying that 6 per thousand is not significant for the 6... but it feels far from 55% etc.

Credit: Johnson & Johnson - see link in article

I am on a crusade to try and ensure I dig deep into every reference and get my statistician mate Chat GPT to help me understand it for the first time in my life. Especially when I'm blown away by numbers. I need to make sure I'm getting hyped about the right numbers.

Why have I raised any of this? What are my concerns about OTTAVA?

I want to state clearly I’m not being an ass here. Every company has the right to pull out data and ensure that they can back up their story. But what got my attention was “Why would they do this at this critical OTTAVA launch time?” When I saw the posts on HYBRID I was a little taken aback to say the least. It's literally had me say "What? Wait. Why?"

JNJ has put significant weight behind this paper at a very interesting time, and the evidence looks super compelling.  And there are many surgeons that think that using a hand held stapler is more cost effective - and many believe that they get better outcomes than with a robotic stapler. I think that some surgeons feel this way is indisputable.

But the reality of the world seems to be moving in a different direction; and I have to ask why.

We must remember that evidence and facts are rarely the market driving forces in technology adoption. I've seen technology take off despite real world, hard facts.

But if the data presented here was “83% fewer leaks” and interpreted as a massive numerical difference… And it felt an enormous difference in leaks - ICU, costs etc etc. Then why on earth would so many educated surgeons be moving to robotic stapling. Why would any right minded clinician keep using a stapler that is 83% less effective? (You see how that number can be read.)

So when I read the brief... even I said “Wow!” Why would anyone use a robotic stapler? But oddly, there is a continuing shift to robotic stapling. USA led but moving OUS fast. Why?

My own personal non scientific feedback from surgeons goes along a few lines:

“I want to control the stapler so my inexperienced bedside assistant is not firing that critical staple line.”

“I’m not getting scrubbed in.”

“My assistant is not qualified to fire a stapler. And I’m not scrubbing.”

“I feel way better precision with a robotic stapler. I get the angle I want.”

“I don’t do hybrid. I’m a robotic surgeon 100%.”

“The cost is not that different if you compare 45 with 45 or 60 with 60mm lines."

“I want all my data in one place and one provider.”

“Sureform is much better now. It works.”

“I love the wristed vs angled staplers.”Etc etc. Not academically palatable but this is the reality of much of the user base in surgery.

So the actual use rate in surgery, the shift from hand held to pure robotic, seems to endorse this sentiment above facts. But this could be transient. Maybe cost. Outcomes will drive them back?…  Or are the facts and reality mis aligned?

And like wise, on the other side of the fence there are many counter arguments I hear that would go with these facts.

Even if these data driven arguments seem to go against the actual trend of movement to robotic stapling.

“I need my resident to keep lap skills.”

“Cost. We think it’s more economical.”

“I love my current brand of stapler and trust it.”

“I want consistency whether a manual lap case or a robotic case.”

“My bedside assistant is so slick it is just way faster.”

“Buttress material is important.”

“The tech in the powered hand held is excellent. I don’t need a robotic stapler.”

Etc etc.

So sentiment wise there are people that love the robotic stance… and those that like the hybrid stance. Data can be spun for hybrid or pure robotic. But the voting community in the USA is voting robotic. I also think next generations of surgeons will not be doing “old fashioned hand held stuff.” Etc etc

I recently had time with a group off young residents. I won’t reveal it all here now. But the robotic train… and all the robotic toys have left the station. That genie is not going back in that bottle. Accept it.

My big question is why JNJ is pushing HYBRID (Now)?

I actually like OTTAVA ,and feel it’s a nice 3rd type of architecture - bed integrated. And after watching stapling and case market share slide to Intuitive for years... and seemingly watch JNJ race to get OTTAVA fully kitted with all the instruments people love, including staplers...

(I have people say they will use OTTAVA if it has Echelon BTW.)

I keep coming back to nagging questions.

Surely with the imminent addition of Echelon to Ottava - why almost cut it off at the knees with this paper?

And it could simply be - they are highlighting Echelon vs Sureform - which is very different than hand held vs robotic. Maybe they are then ready to then say “The Echelon you love and trust works the same on OTTAVA.” And use that inference? Is that the plan?

But my spider sense is tingling for some unknown reason. The devil on my shoulder is saying “It's too hard to get a wristed. Yaw not as accepted. Cost point too high so profit lower than HH Echelon. Too hard… too late.”

Going from mass produced hand help lap consumables to robotic reusables often is hard on engineering and finance teams. I know — I was inside it. And this could be just that. It's what the little voices in my head keep whispering.

I also think there is a much bigger danger here in this positioning.

All of this data (the way it is presented here) plants a flag of “Robotic stapling bad - hand held good.”

And with that backdrop; if you launch a robotic stapler - you now have to unwind that message and show… “Competitive robotic stapler bad… but my robotic stapler good… and all that stuff about hand held we said doesn’t apply to us.”

That is a super hard marketing flip you need to do. That would be such a turn around if in six months you launch your OTTAVA stapler. Again not the first time in medtech history where a short term defensive message to buy time has been made by companies to allow them to keep market share to the launch. And then a flip at launch.

In Ethicon Endo we said for years you don’t need a curved stapler or detachable head…. Until we had one.

But this "strong" piece on Hybrid robotics from JNJ is quite hard hitting, and quite pointed in my mind. And for me the timing is incredibly odd (off.) It pulls me back and back and back to my questions above as “Hmm what’s the real reason?”

Now… today not having a robotic stapler is an issue for JNJ with Intuitive alone.  And it’s a fairly contained to the USA issue. In the USA vs OUS there's higher % of robotic stapling cases in the USA. But I can tell you that nearly every single Chinese company seems to be working on a stapler. In China alone it will be a massive impact to hand help stapling. And many of those companies have already gone hard at OUS markets with hand held staplers - or their Chinese partners have (with success.). If they all load up their robots - or bring out robots with staplers - I believe this hybrid message is going to look isolated everywhere across the globe. And if price point on stapling plummets with good - solid - Chinese robotic staplers… I’m not sure there will be a majority of hand held staplers left to defend… globally. 

I want to also point people to autonomy. You can’t have an autonomous hand held stapler. The future of robotics is not highly skilled bedside assistants doing fancy manoeuvres. It’s the robot being the ultimate bedside assistant. And to be that it must control staplers, energy, suction, clips etc etc. This view of hand held is so counter to the direction of travel it troubles me.

I believe: if you don’t have a stapler on your platform in 3 - 5 years. You don’t have a viable platform.

I personally hope that JNJ is progressing with a launch of Echelon on Ottava - and soon. I hope this is a ploy to stem some market share loss until the cavalry arrives? I hope it’s not a strategy to “not have a robotic stapler,” or “To have hand held first with higher margins - and the robotic for those that really insist?” I think any of the strategies that are not "robotic stapler first" have a short runway.

And I really hope OTTAVA has a fully wristed version coming as a fast follower if they only have a yaw stapler.. It will already be hard to match tender specifications and RFQs without a stapler vs Intuitive. If all the other companies respond with spec for spec matching for staplers in tenders… it could be very tough for any robot without a stapler or a nixed stapler to compete.

In conclusion: (That sounded official)

To me, it is super odd to see this positioning. Plus the way this whole piece is put together with this "core data" is not what I’m personally used to from JNJ.

(There are a few simple calculation errors in the stats claimed just as an FYI…)

Using any competitive data (even some written exclusively by Medtronic employees) to potentially support implied claims on Echelon is not where I would feel comfortable. Yes it's "generic hand held" but this is about promoting Echelon right?

I’ve attached some analysis below of the core papers that might be of interest on why I read this like this…  And to be polite... it’s a stretch. But hey, you tell me - maybe I got it wrong.

And as always these are just my opinions to be used to challenge the industry and act as an education piece.

Community notes for the table higher up in the article on sourcing: Some GPT analysis of the papers so there could be errors in interpretation. Read the papers yourselves is my strongest advice:

Reference and access	What it actually contributes	Main reservations
7. Hafermann 2025 — full text	105 gastric bypass patients, one surgeon/team. Medtronic bedside stapling was associated with shorter operating time and lower stapling costs. No complications in either group.	Sequential change from robotic to bedside staplers, not randomisation. An exceptionally experienced assistant. The authors explicitly say the study was too small to detect complication differences. Seems to be a Medtronic funded manuscript development; the analyst’s company received Medtronic consultancy fees. Useful workflow evidence, not proof of superior safety or an ECHELON benefit.
13. Clapp 2024 — full text	7,268 bariatric operations in the PINC AI database. Bedside stapling was associated with lower costs, shorter operating time and fewer ICU admissions.	Transfusion significance disappeared in a sensitivity analysis. Bleeding, leak and readmission outcomes did not establish bedside superiority. Staple height and reinforcement were unavailable. Medtronic employee coauthor and disclosed industry relationships.
14. Pan & Siddiqui 2025 — full text	18,892 robotic sleeve operations. Medtronic bedside staplers versus SureForm; lower transfusion rates, costs and operating time with bedside stapling.	No significant difference in bleeding or leaks. ICU findings varied by analysis; hospital stay was slightly shorter with robotic stapling. Both authors were Medtronic employees. Important technical variables and contract details were missing.
16. Huynh 2025 — full text	7,606 robotic gastric bypass operations. Bedside stapling associated with approximately $2,119 lower inpatient costs and 41 minutes less operating-room time versus robotic stapling.	Similar measured transfusion, bleeding, leak and ICU outcomes. Despite its “Australian healthcare system” title, the patient data were US data, with Australian implications discussed. All authors were Medtronic employees.
17. Hagen 2018 — abstract and disclosures	49 matched pairs. More reloads and higher stapling costs with the robotic device.	45 mm EndoWrist versus 60 mm ECHELON: the authors attribute extra reloads to the shorter device. The operating-time difference was not statistically significant, p=0.1042. Author ties included both Intuitive and Ethicon. This is older-generation evidence, not a fair test of all current robotic staplers.
18. Clapp 2025 — abstract	27,778 robotic sleeve cases. Lower adjusted inpatient costs with major-brand bedside staplers.	Another PINC AI analysis covering 2018–2022. Shares investigators, database and years with other cited work; it should not be counted as wholly independent confirmation. A coauthor was affiliated with Medtronic.
19. Pan 2024 — original conference poster	4,779 robotic thoracic cases. Less coded bleeding, lower inpatient costs and shorter operating time with bedside stapling.	Conference evidence. The bedside group contained Medtronic staplers only; author affiliated with Medtronic. No demonstrated advantage for air leak, transfusion or pneumothorax. Does not establish an ECHELON-specific benefit.
20. Lazar 2025 — original poster not retrieved; apparently corresponding journal publication found, October 2026	Same 2021–2022 period and 361 matched pairs. Bedside stapling associated with less bleeding, lower costs and shorter operating time.	The later publication reports that another adjustment method reduced the bleeding discrepancy. Medtronic-affiliated coauthor. It appears to be the subsequent publication of the cited work, rather than additional independent evidence.
21. Fukuda 2025 — abstract and disclosures	Japanese colorectal study: 10 patients per group after matching. Hybrid surgery had lower costs and shorter operating time.	Changed multiple instruments, including staplers and ultrasonic devices. It cannot isolate stapling’s effect. Far too small to establish equivalent leak safety. Authors declared no associated conflict of interest.