Robotic crush and clip technique for pancreatic transection in robotic distal pancreatectomy

Background: Stapler transection during robotic distal pancreatectomy (RDP) has limitations, including device cost, difficulty in thick pancreas, and challenges in pathological assessment of the margin. We developed the crush and clip (CC) technique, in which the parenchyma is crushed using Maryland forceps and the main pancreatic duct is clipped without stump reinforcement. This study aimed to describe the CC technique and assess its non-inferiority to stapler transection regarding postoperative pancreatic fistula (POPF). Methods: We retrospectively analyzed 127 RDP cases at a high-volume center (CC: 23; stapler: 104) between 2010 and 2025. Procedures used included da Vinci Xi, da Vinci SP, or hinotori™ systems. The primary endpoint includes clinically relevant POPF (ISGPS grade B/C). Body mass index, stump thickness, and robotic platform were used to estimate the propensity score, and overlap weighting was applied. Non-inferiority was prespecified as a risk difference (CC − stapler) of less than + 5% with a 90% bootstrap confidence interval (CI). Results: POPF occurred in 13% of CC and 26% of stapler cases (p = 0.280). The weighted analysis revealed incidences of 16.0% and 32.0%, respectively. The weighted risk difference was − 16.0% (90% CI, − 34.0% to + 4.3%), thereby meeting the non-inferiority margin. POPF was significantly lower with CC (6% vs. 47%, p = 0.013) when the pancreatic stump thickness was ≥ 14 mm. Major complications (Clavien–Dindo ≥ III) occurred in 14% of stapler cases but in none of the CC cases (p = 0.071). Conclusions: The CC technique was feasible and safe and statistically non-inferior to stapler transection for POPF, while providing technical advantages.