Evolution of Pancreatic Transection Strategy in Minimally Invasive Distal Pancreatectomy

Clinically relevant postoperative pancreatic fistula (CR-POPF) remains a major complication after distal pancreatectomy (DP), including minimally invasive distal pancreatectomy (MIDP). Institutions often introduce multiple technical and perioperative refinements over time; however, the cumulative impact of these practice changes on postoperative outcomes has not been fully characterized. This study evaluated whether stepwise institutional refinements in MIDP were associated with improved postoperative outcomes.

We retrospectively analyzed 124 consecutive patients who underwent MIDP between 2019 and 2025 at a single center. During the study period, several practice changes were implemented, including modification of pancreatic transection strategy using a reinforced stapler platform, transition to robotic assistance, and adoption of continuous negative-pressure drainage. The cohort was divided into an early phase and a late phase reflecting these institutional refinements. The primary outcome was CR-POPF, and secondary outcomes included drain fluid amylase (DFA) levels and postoperative length of stay (LOS). Propensity score matching (PSM) was performed using pancreatic thickness and texture.

CR-POPF occurred less frequently in the late phase than in the early phase (5.3% vs. 24.4%, p = 0.012). DFA levels were consistently lower and declined more rapidly in the late phase. LOS was significantly shorter in the late phase (median 8 vs. 11 days, p < 0.001). These findings remained consistent after PSM.

Stepwise institutional refinements in pancreatic transection technique and perioperative management were associated with improved postoperative outcomes after MIDP. A structured quality-improvement approach focusing on atraumatic transection and rational drain management may contribute to reducing CR-POPF after MIDP.