Robotic cholecystectomy for acute cholecystitis: slightly more bailouts, same bile duct injury, higher cost

Design

Retrospective cohort, state inpatient databases, 2012–2021

Population

384,617 adults with unscheduled cholecystectomy for acute cholecystitis

Primary outcome

Bailout (conversion, subtotal cholecystectomy or cholecystostomy)

Effect

1.7% vs 1.4%; aOR 1.38 (95% CI 1.21 to 1.58); bile duct injury 1.6% both

A retrospective analysis of state inpatient databases from New York and Florida, 2012–2021, compared 384,617 unscheduled cholecystectomies for acute cholecystitis. Four per cent were robotic.

Robotic operations ended in a bailout slightly more often (1.7% vs 1.4%), with higher odds of conversion to open and of subtotal cholecystectomy, but lower odds of a cholecystostomy tube. Bile duct injury was 1.6% in both groups. Among the 5,448 patients who needed a bailout, those operated robotically needed fewer later endoscopic biliary procedures (3.1% vs 7.7%) and fewer further operations (2.3% vs 7.5%). Median one-year costs were higher with the robot.

This is an administrative database with the usual limits on case selection: surgeons may choose the robot for harder gallbladders, and coding of bile duct injury is imprecise. It gives no reason to favour the robot for acute cholecystitis on safety grounds, and the cost difference matters more in India, where robotic access is concentrated in a few centres.

• Choose the approach for acute cholecystitis on your team's experience; this data shows no bile duct injury advantage for the robot.
• Plan the bailout before starting a difficult gallbladder, whatever the platform.
• Be aware that a subtotal cholecystectomy may be followed by endoscopic or surgical work later, and arrange follow-up.
• Consider cost when counselling patients offered robotic surgery for an emergency gallbladder.

Why it matters

Robotic adoption in emergency general surgery is outpacing evidence that it makes the hard gallbladder safer.

Don't overread it

Administrative data cannot capture how difficult each gallbladder was, so selection may explain part of the bailout difference.

The statistics, in plain English

An adjusted odds ratio of 1.38 for bailout sounds large, but the absolute difference is 0.3 percentage points — about three extra bailouts per thousand operations. With samples this large, small differences become statistically significant without necessarily mattering clinically.

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