One Surgical Approach May Be Better for Complex Gallbladder Disease

Robotic cholecystectomy for complex gallbladder disease was linked with reductions in further interventions and complications, without increasing the total cost of care, a cohort study suggested.

Among patients undergoing complex elective cholecystectomy at a single center, a laparoscopic approach was independently associated with an increased need for unplanned endoscopic or percutaneous intervention compared with a robotic approach (OR 4.24, 95% CI 1.24-14.52, P=0.02), reported Katharine E. Caldwell, MD, of the Medical University of South Carolina in Charleston, and colleagues.

Patients in the robotic group also had a significantly reduced rate of overall complications compared with the laparoscopic group (14.5% vs 28.6%, P=0.04), they wrote in JAMA Surgery.

While patients in the laparoscopic group had significantly reduced operating room costs compared with the robotic group ($7,720 vs $8,936, respectively), there was no difference in the overall cost of care between the two groups ($14,309 vs $14,476, respectively).

“These findings support risk-stratified surgical planning, where robotic technology is used for the patients most likely to benefit, optimizing both clinical outcomes and resource allocation in an era of increasing demand for value-based care,” Caldwell and colleagues concluded.

Rates of complex elective cholecystectomy are increasing as the population ages, yet “the role of robotics … remains unclear,” the authors noted. “While some series have demonstrated the feasibility of robotics to complete these operations, no large series has compared postoperative outcomes and evaluated the impact on operative and total cost of care for these patients.”

In a commentary accompanying the study, Brian S. Zuckerbraun, MD, of the University of Pittsburgh, and colleagues noted that, unlike this study, evidence from population-level claims data has shown “a much lower-value landscape” for robotic cholecystectomy.

“These findings have been interpreted as evidence of a long learning curve, but it is increasingly apparent that this curve itself is evolving, influenced by shifting case selection, surgeon experience, and institutional patterns of use,” they wrote. “Contemporary data on robotic cholecystectomy are therefore less a final verdict on the technology than a snapshot of an ongoing, real-time chronicle in which case selection, surgeon experience, and institutional culture are all changing faster than our ability to measure value.”

For this study, Caldwell and colleagues used data from an academic hepatobiliary referral center for patients who underwent cholecystectomy from August 2018 to August 2024. Complex elective cholecystectomy was defined by preoperative criteria: prior aborted or partial cholecystectomy, presence of a cholecystostomy tube, and/or history of gallbladder perforation or fistula.

Of the 863 patients included, median age was 61, and 60.8% were women; 230 patients underwent complex elective cholecystectomy (168 with the laparoscopic approach and 62 with the robotic approach) and 633 underwent non-complex elective cholecystectomy (489 with the laparoscopic approach and 144 with the robotic approach). Patients who underwent complex cholecystectomy were significantly older, more likely to be male, had higher Eastern Cooperative Oncology Group (ECOG) performance status scores, and were more likely to have had previous surgery.

For patients undergoing non-complex elective cholecystectomy, there were no significant differences in postoperative outcomes between the laparoscopic and robotic groups. Patients in the laparoscopic group had significantly reduced operating room costs versus those in the robotic group ($6,368 vs $8,351), and the overall total cost of care was significantly higher for patients in the robotic group compared with the laparoscopic group ($11,416 vs $9,925, respectively).

Caldwell and team acknowledged that their study had limitations. For example, the patient sample came from a single academic medical center where all cholecystectomies were performed by hepatobiliary surgeons, “increasing the likelihood of selection bias for patients deemed to be especially high risk.”

In addition, they pointed out that these surgeons routinely performed complex minimally invasive liver and biliary procedures, suggesting that the study results may not translate to lower-volume settings or surgeons.