Study: Robotic-assisted cholecystectomy raises complication risk in acute care despite similar injury rates

Editor's Note

Recent research shows robotic-assisted cholecystectomy (RAC) results in similar bile duct injury rates as laparoscopic cholecystectomy (LC), but risks are higher for postoperative complications, longer hospital stays, and more frequent drain use.

Published May 21 in JAMA Surgery, the large-scale cohort study analyzed outcomes from over 844,000 acute care cholecystectomy procedures between 2016 and 2021. Using data from the IBM MarketScan Commercial Claims and Encounter Database, researchers conducted a retrospective analysis of adult patients undergoing either RAC or LC for acute gallbladder disease. To reduce bias from patient differences, they performed 1:1 propensity score matching on 35,037 cases in each group, adjusting for variables such as age, comorbidities, and body mass index. Notable findings include:

• Bile duct injury rates were 37% in RAC vs 0.39% in LC (OR, 0.93; P = .54).
• Major postoperative complications were significantly more frequent in RAC at 8.37% vs 5.50% in LC (OR, 1.57; P < .001).
• Postoperative drain placement rates were 63% in RAC vs 0.48% in LC (OR, 1.66; P < .001).
• Median hospital length of stay was 3 days with RAC vs 2 days in LC (P < .001).
• Use of intraoperative cholangiogram was 72% in RAC vs 0.97% in LC (OR, 0.69; P < .001).
• Surgical site infection rates were 04% in RAC vs 0.09% in LC (OR, 0.47; P = .02).
• Conversion to open surgery was rare in both groups.

Sensitivity analyses confirmed that RAC was associated with higher complication rates across most patient subgroups, particularly among those with higher comorbidity burdens and elevated BMI. The study also documented a rise in RAC use from 2.2% in 2016 to 8.2% in 2021.

While the study’s design cannot determine causality, authors suggest that RAC may be selectively used in more complex cases—potentially explaining the higher complication rates. They also noted that the learning curve associated with robotic surgery, limited use of indocyanine green imaging, and institutional variability may further influence results.