Attachable Coolingbis® for Distal Pancreatectomy

Distal pancreatectomy (DP) accounts for 25-35% of all pancreatic resections and remains the standard approach for benign and malignant lesions of the pancreatic body and tail. Management of the pancreatic remnant after transection continues to be an unresolved surgical challenge: conventional stapling techniques fail to achieve a reliable biological seal, and clinically relevant postoperative pancreatic fistula (CR-POPF) develops in approximately 30-40% of cases, contributing substantially to postoperative morbidity, prolonged hospitalization, and increased healthcare costs.

Radiofrequency (RF)-assisted transection has emerged as a strategy to improve pancreatic stump sealing by inducing controlled coagulative necrosis of the parenchyma prior to division, promoting connective tissue collapse around ductal structures. This approach is supported by preclinical and clinical evidence, including a propensity-matched retrospective cohort showing a reduction in POPF incidence with the laparoscopic Coolingbis® device, and interim results from the multicenter randomized TRANSPAIRE trial (NCT04402346) suggesting a similar benefit. A robotic-adapted version of this technology, the Attachable Coolingbis® (ACB), has recently completed preclinical validation in a large-animal (porcine) model using a robotic platform, with no relevant adverse events observed among survivors followed to 30 days.

This study represents the first clinical application of the ACB device on a robotic surgical platform (Da Vinci) in humans. It is designed as a prospective, multicenter, single-arm, exploratory pilot study (safety and feasibility phase), conducted across four Spanish hepatobiliopancreatic referral centers. All enrolled participants will undergo robotic distal pancreatectomy in which pancreatic transection is performed using the ACB device; there is no concurrent comparator arm, as the study's purpose is to characterize the device's safety and technical performance rather than to test superiority or equivalence against an alternative technique.

The surgical technique will be standardized across participating centers and performed exclusively by surgeons who have completed a defined learning curve with the laparoscopic Coolingbis® device and who have documented prior experience with robotic pancreatic surgery. Intraoperative ultrasound will guide selection of the transection line within healthy proximal parenchyma. Splenic preservation or formal splenopancreatectomy will be selected according to lesion type.

Participants will be followed prospectively through the postoperative hospital course and for 12 months thereafter to characterize both early surgical outcomes and longer-term functional, oncologic, and quality-of-life outcomes. Findings from this pilot cohort are intended to establish a preliminary safety profile for the ACB device, identify clinical or anatomical risk factors associated with RF-assisted robotic transection, and inform patient selection criteria and sample size planning for a subsequent, adequately powered clinical trial supporting future CE certification of the device for robotic use.

Inclusion criteria

• Age 18 years or older
• Diagnosis of solid or cystic pancreatic neoplasm (benign, premalignant, or malignant) with surgical indication
• Requirement for distal pancreatectomy with a planned transection line located more than 2 cm to the left of the medial border of the superior mesenteric vein (SMV), confirmed by CT or MRI performed within 2 months prior to surgery
• Eligible for either splenic-preserving distal pancreatectomy or distal splenopancreatectomy
• Eligible for open or minimally invasive surgical approach (laparoscopic or robotic)
• Able to provide written informed consent

Exclusion criteria

• ASA (American Society of Anesthesiologists) physical status classification greater than 3
• Legal or cognitive incapacity to sign informed consent
• Confirmed or ongoing pregnancy
• Need for emergency surgery (e.g., post-traumatic pathology or acute complications)