Video-based OSATS and GEARS assessment of pancreatic transection and stump closure predicts clinically relevant pancreatic fistula after robotic distal pancreatectomy.

Abstract

Background: Clinically relevant postoperative pancreatic fistula (CR-POPF) remains a major source of morbidity after distal pancreatectomy. Existing risk models rely on clinical and anatomical variables and may not capture operative performance. We evaluated whether technical performance during pancreatic transection and stump closure was associated with CR-POPF after robotic distal pancreatectomy (RDP).

Methods: We conducted a multicenter retrospective study of consecutive RDPs performed between 2020 and 2024 at two high-volume hepatopancreatobiliary centers. Cases with complete videos of pancreatic transection and 90-day follow-up were included. Two blinded graders assessed performance using modified Objective Structured Assessment of Technical Skills (mOSATS) and Global Evaluative Assessment of Robotic Skills (GEARS). Stapler type, number of firings, application time, available gland texture data, and case difficulty were recorded. Technical skill comparisons were adjusted for case difficulty. The primary outcome was CR-POPF within 90 days.

Results: Seventy-four patients were included, and 12 developed CR-POPF. Two stapler firings were more frequent in patients with CR-POPF (25.0% vs. 1.6%, p = 0.004), whereas stapler type and application time were not associated with CR-POPF. Total mOSATS and GEARS scores were lower in the CR-POPF group (22.3 ± 2.3 vs. 24.5 ± 2.5, p = 0.004; 22.5 ± 2.4 vs. 24.9 ± 2.6, p = 0.005). After adjustment for case difficulty, time and motion, instrument handling, tissue exposure, summary mOSATS, depth perception, bimanual skill, efficiency, and robot control remained significantly lower in patients with CR-POPF. Higher total mOSATS and GEARS scores were associated with lower odds of CR-POPF on univariable analysis; adjusted estimates were similar but did not reach statistical significance.

Conclusion: Lower technical performance during pancreatic transection was associated with CR-POPF after RDP, independent of measured case difficulty. Structured video-based assessment may complement existing risk models by capturing operative factors not reflected by baseline characteristics.