What question did this study set out to answer?

The aim is to evaluate the efficacy of a quadruple reinforcement technique in reducing postoperative pancreatic fistula (POPF) rates during robotic distal pancreatectomy.

April 1, 2026Open Access

Quadruple reinforcement technique for pancreatic stump during robotic distal pancreatectomy

Key Points

The aim is to evaluate the efficacy of a quadruple reinforcement technique in reducing postoperative pancreatic fistula (POPF) rates during robotic distal pancreatectomy.
Conducted a prospective study with 44 patients undergoing robotic distal pancreatectomy.
Divided patients into quadruple reinforcement group (27) and control group (17).
Implemented four types of reinforcement including staple line reinforcement and fibrin sealant.
Compared outcomes based on the incidence of clinically relevant POPF and complications.
The quadruple reinforcement technique resulted in a 3.7% incidence of CR-POPF compared to 41.2% in controls (P = 0.002).
Major complications ≥ Clavien-Dindo grade IIIa occurred in 0% of the reinforcement group versus 23.5% in controls (P = 0.004).
Median hospital stay was shorter in the reinforcement group, 5.0 days compared to 7.0 days (P = 0.007).
No reoperations or mortalities within 30 or 90 days were reported in either group.

Abstract

Postoperative pancreatic fistula (POPF) remains a significant challenge in robotic distal pancreatectomy (RDP). We developed a novel “quadruple reinforcement technique” to mitigate this risk and evaluated its clinical efficacy compared to conventional techniques. In this prospective study of 44 consecutive RDP patients (March 2020–September 2025), outcomes were compared between a quadruple reinforcement group (n = 27) and a control group (n = 17). The reinforcement technique involved: (1) staple line reinforcement; (2) absorbable reinforcement felt; (3) U-shaped sutures using a 3–0 non-absorbable double-armed monofilament; and (4) sprayed fibrin sealant. Clinically relevant POPF (CR-POPF) was defined per 2016 ISGPS criteria. Pancreatic texture was comparable between the groups. The quadruple reinforcement group demonstrated a significantly lower incidence of CR-POPF (3.7% vs. 41.2%, P = 0.002) and fewer complications ≥ Clavien-Dindo grade IIIa (0% vs. 23.5%, P = 0.004) compared to controls. Median hospital stay was significantly shorter in the reinforcement group (5.0 vs. 7.0 days, P = 0.007). There were no 30-day reoperations or 90-day mortalities in either group. The quadruple reinforcement technique is a safe and feasible strategy that significantly reduces CR-POPF and major complications. This systematic combination effectively optimizes postoperative outcomes in RDP.

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