Robotic cholecystectomy benefits high-risk and higher-BMI patients but costs more

1. Among surgeons proficient in both techniques, robotic cholecystectomy resulted in fewer conversions and fewer serious complications, with the benefit concentrated in technically difficult cases and in patients with higher body mass index.

2. The robotic approach costs more per case at every risk level, while easier cases in leaner patients gained no outcome advantage over laparoscopy.

Evidence Rating Level: 2 (Good)

Study Rundown: Laparoscopic gallbladder removal ranks among the most frequent operations performed in the United States. However, the enduring art of laparoscopy is in question with the continued adoption of robotic platforms. Prior national analyses raised questions about safety and cost for the robot but incompletely accounted for surgeon experience or case difficulty. The study featured herein tracked surgeons who routinely used both robotic and laparoscopic methods within one health system. After stratifying patients by anticipated technical difficulty, the investigators found that the robotic route produced fewer conversions to open surgery, fewer major complications, and shorter hospital stays. That advantage was most apparent in demanding cases and in patients with higher BMIs. For straightforward cases in leaner patients, the two techniques were no different, and bile duct injuries were uncommon regardless of approach. The robotic option, however, carried a meaningfully larger price tag across every group, driven mainly by disposable supplies. Additionally, the authors created a bedside calculator to estimate a patient’s likelihood of a poor result with either technique. This study was limited primarily by its lack of randomization. Additional limitations were that emergency presentations less often reached the robot owing to equipment availability, post-discharge spending went uncounted, and the conclusions may not extend to surgeons who do not practice both techniques.

Click to read the study in JAMA Surgery

Relevant Reading: Clinical Outcomes of Laparoscopic vs Robotic-Assisted Cholecystectomy in Acute Care Surgery

In-Depth [retrospective cohort]: This retrospective cohort analysis spanned eight hospitals within a single health system between 2020 and 2021. Fourteen surgeons who regularly performed both laparoscopic cholecystectomy (LC) and robotic cholecystectomy (RC) participated. This study included a total of 1828 patients undergoing minimally invasive cholecystectomy, sorted by intended approach (RC, n = 806; LC, n = 1022). Planned open procedures, underlying malignancy, and combined operations were excluded. Technical difficulty was rated with the preoperative Nassar score (low or intermediate, 6 or less; high, 7 or more). The primary endpoints were an adverse outcome (conversion to open surgery and/or Clavien-Dindo morbidity grade 3 or higher complication) and total variable cost. Logistic regression with propensity adjustment and surgeon-clustered errors evaluated adverse outcomes, while inverse probability weighting estimated cost differences. A risk calculator was derived using a 70% training and 30% validation split. Across 1828 patients (mean age 52.9 years; 65.9% female), adverse outcomes occurred in 3.3% of RC versus 8.7% of LC cases (P < .001). Conversion to open occurred in 0.5% versus 3.4% (P < .001), serious complications in 3.1% versus 6.1% (P = .003), and mean postoperative stay was 1.1 versus 1.9 days (P < .001). Bile duct injury rates were comparable (0.1% vs 0.2%, P = .71), and operative time ran longer with RC (70.2 vs 69.1 minutes, P = .003). Surgical approach interacted with Nassar risk (P = .04) and BMI (P = .003): in high-risk cases (RC, n = 304; LC, n = 477) at a BMI of 30, LC carried greater odds of an adverse outcome (OR 3.69, 95% CI 2.04-6.69, P < .001). In low- or intermediate-risk cases (RC, n = 502; LC, n = 545), outcomes were not different at a BMI of 25 (OR 1.17, 95% CI 0.60-2.30, P = .65) but favored RC at a BMI of 35 (OR 3.19, 95% CI 1.62-6.29, P = .001). RC cost more in both low- and intermediate-risk (average treatment effect $2211.60, 95% CI $1521.49-$2901.72, P < .001) and high-risk cohorts (average treatment effect $2417.05, 95% CI $1675.62-$3158.48, P < .001). The risk prediction calculator discriminated well in training (AUC 0.744, 95% CI 0.685-0.803) and testing (AUC 0.750, 95% CI 0.659-0.842) sets. Taken together, RC was associated with fewer adverse outcomes in high-risk and higher-BMI patients yet was lengthier and consistently higher cost, findings that prospective randomized evaluation could help confirm.

Image: PD

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