Highlights
Robotic cholecystectomy demonstrates equivalent outcomes to laparoscopic cholecystectomy across all grades of acute cholecystitis severity. No significant differences were observed in intraoperative complications, conversion rates, or postoperative outcomes between the two surgical approaches. The only notable difference was a marginally longer postoperative hospital stay in grade II-V patients treated laparoscopically, though this finding was not clinically significant when controlling for confounders.
Background
Acute cholecystitis represents one of the most common biliary disorders encountered in emergency general surgery, with approximately 6-8 million cases diagnosed annually in the United States. Laparoscopic cholecystectomy has long been established as the gold standard treatment for symptomatic gallstone disease and acute cholecystitis, offering reduced postoperative pain, shorter hospital stays, and faster recovery compared to traditional open surgery.
In recent years, robotic surgical platforms have been increasingly adopted across multiple surgical specialties, including hepatobiliary surgery. The potential advantages of robotic systems include enhanced dexterity through articulated instruments, improved visualization with three-dimensional imaging, and greater surgical precision in confined anatomical spaces. These technological benefits have generated considerable interest in whether robotic-assisted cholecystectomy might offer superior outcomes compared to the conventional laparoscopic approach.
However, the clinical impact of robotic surgery adoption in emergency general surgery settings remains incompletely understood, particularly regarding how disease severity might influence comparative outcomes. The American Association for the Surgery of Trauma (AAST) acute cholecystitis grading system provides a standardized framework for stratifying disease severity, ranging from grade I (less severe) to grade V (most severe). Understanding outcomes across this severity spectrum is crucial for informing surgical decision-making and resource allocation.
Study Design
This single-center, retrospective analysis examined patients undergoing cholecystectomy for acute cholecystitis at a major academic medical center between November 2022 and July 2024. The study cohort was stratified according to surgical approach: robotic-assisted cholecystectomy versus conventional laparoscopic cholecystectomy.
Disease severity was systematically categorized using the AAST acute cholecystitis grading system, with grade I representing less severe presentations and grades II through V indicating progressively more severe disease manifestations. Patient demographics, baseline comorbidities, and clinical characteristics were compared between groups to ensure appropriate baseline equivalence.
The primary outcome of interest was the rate of intraoperative complications, encompassing bile duct injury, vascular injury, hemorrhage requiring intraoperative blood transfusions, and bile or stone spillage. Secondary outcomes included the need for subtotal cholecystectomy, conversion to open surgery, intraoperative drain placement, postoperative complications, unplanned return to the operating room, postoperative hospital length of stay, and 30-day readmission rates.
Statistical analyses employed appropriate parametric and non-parametric testing methods, with multivariable regression modeling used to identify independent predictors of prolonged hospitalization.
Key Findings
The analysis included 592 patients undergoing cholecystectomy for acute cholecystitis. Among these patients, 476 (80.4%) presented with AAST grade I cholecystitis, while the remaining 116 patients (19.6%) had grade II-V disease. Baseline patient demographics and comorbidity profiles demonstrated no significant differences between the robotic and laparoscopic surgical groups, supporting the validity of comparative analyses.
Primary Outcome: No statistically significant differences in intraoperative complications were observed between robotic and laparoscopic cholecystectomy across any disease severity category. The rates of bile duct injury, vascular injury, hemorrhage requiring transfusion, and bile or stone spillage were comparable between surgical approaches, regardless of whether patients presented with low-grade or high-grade acute cholecystitis.
Secondary Outcomes: Conversion to open surgery rates showed no significant differences between the robotic and laparoscopic groups. Similarly, the need for subtotal cholecystectomy, intraoperative drain placement, and postoperative complications were equivalent across surgical modalities. Unplanned returns to the operating room and 30-day readmission rates also demonstrated no significant variations between groups.
The sole statistically significant difference identified involved postoperative hospital length of stay. Among patients with AAST grade II-V cholecystitis, those undergoing laparoscopic cholecystectomy experienced a slightly longer median hospital stay compared to their robotic surgery counterparts (2 days versus 1 day, P = 0.048). However, subsequent multivariable regression analysis revealed that laparoscopic surgical approach was not an independent predictor for prolonged hospitalization (odds ratio, 1.079; 95% confidence interval, 0.682-1.707; P = 0.745).
Table 1: Summary of Key Outcomes by Surgical Approach and Disease Severity
The comparative analysis demonstrated equivalent outcomes across the majority of measured parameters. Intraoperative complication rates remained low and comparable between robotic and laparoscopic approaches in both low-grade and high-grade disease presentations. Postoperative outcomes including complication rates, readmissions, and need for additional interventions showed no significant differences that could be attributed to surgical modality choice.
Expert Commentary
The findings from this investigation contribute important evidence to the ongoing discourse regarding robotic surgery adoption in general surgery practice. While robotic surgical platforms continue to gain market share across surgical disciplines, rigorous comparative effectiveness research remains essential for guiding appropriate technology utilization.
Several aspects of this study merit consideration. The use of a validated disease severity classification system (AAST grading) represents a methodological strength, enabling meaningful stratification of outcomes according to clinical complexity. The relatively contemporary timeframe of data collection (November 2022 to July 2024) ensures relevance to current surgical practice patterns and technology generations.
The absence of significant differences in intraoperative complications across disease severity categories suggests that both robotic and laparoscopic approaches can be performed safely for acute cholecystitis. This finding is particularly relevant given historical concerns about increased complication rates in more severe disease presentations.
The marginally longer hospital stay observed in laparoscopic-treated grade II-V patients, while statistically significant, may reflect factors beyond surgical approach alone. The multivariable analysis appropriately demonstrated that surgical modality was not an independent predictor of prolonged hospitalization, suggesting that the observed difference may be attributable to other confounding variables not fully captured in the regression model.
Limitations of this investigation include its retrospective design and single-center nature, which may limit generalizability to other practice settings. Additionally, the study did not report surgeon experience levels or learning curve considerations, which could influence comparative outcomes. Future prospective, multicenter studies would strengthen the evidence base regarding optimal surgical approach selection.
Conclusion
This retrospective analysis of 592 patients demonstrates that robotic cholecystectomy is not associated with better outcomes than laparoscopic cholecystectomy, regardless of acute cholecystitis severity as classified by the AAST grading system. Both surgical approaches demonstrated equivalent safety profiles with regard to intraoperative complications and comparable postoperative outcomes across all disease severity categories.
The findings suggest that surgeon familiarity, institutional resources, and patient-specific factors should remain primary considerations in surgical approach selection for acute cholecystitis. While robotic platforms offer certain technical advantages, these benefits did not translate into measurable clinical outcome improvements in this cohort.
Healthcare systems and surgical departments evaluating robotic surgery investments should consider these findings alongside other factors including cost-effectiveness, training requirements, and operational considerations. The equivalence in clinical outcomes regardless of disease severity provides reassurance that both approaches can be safely employed across the spectrum of acute cholecystitis presentations.
Funding and Disclosures
No specific funding information was reported for this investigation. The authors declared no conflicts of interest relevant to this study.
References
1. Sugiyama A, Dhillon NK, Zakhary B, et al. Outcomes are equivalent between robotic and laparoscopic cholecystectomy in all grades of acute cholecystitis. Surgery. 2026;194:110170. PMID: 41936770.
2. Tokyo Guidelines 2018: updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018.
3. National Institutes of Health. Gallstones. Available at: https://www.niddk.nih.gov/health-information/digestive-diseases/gallstones. Accessed 2024.