Robotic cholecystectomy: fewer adverse events in hard cases, higher cost in all

Design

Retrospective multihospital cohort with risk-adjusted analysis

Population

1,828 adults undergoing robotic (806) or laparoscopic (1,022) cholecystectomy

Primary outcome

Conversion or Clavien-Dindo grade ≥3 complication; total variable cost

Effect

3.3% vs 8.7%; high-risk at BMI 30, laparoscopy OR 3.69 (95% CI 2.04 to 6.69); robotic cost +$2,212 to $2,417

A retrospective study across eight hospitals in one US health system compared 806 robotic and 1,022 laparoscopic cholecystectomies done in 2020 and 2021 by surgeons who routinely performed both. Difficulty was graded with the Nassar preoperative score. Published in JAMA Surgery on 16 September 2026.

The composite of conversion or Clavien-Dindo grade 3 or higher complication occurred in 3.3% after robotic and 8.7% after laparoscopic surgery. The difference depended on difficulty and body mass index: in high-risk gallbladders with a BMI of 30, laparoscopy carried an odds ratio of 3.69 (95% CI 2.04 to 6.69) for an adverse outcome; in low-risk cases with a normal BMI, outcomes were similar. Robotic surgery cost about $2,200 to $2,400 more per case in every stratum.

This is observational, and choice of approach was the surgeon's, so unmeasured selection may remain despite adjustment. It supports reserving the robot, where one is available, for the difficult gallbladder rather than the routine one. For most Indian units laparoscopy remains the standard, and the more transferable message is to score difficulty before surgery and plan accordingly.

• Score cholecystectomy difficulty before surgery, for example with the Nassar score
• Where a robot is available, consider it for high-difficulty gallbladders and higher BMI rather than routine cases
• Expect no outcome advantage from the robot in low-risk cases at normal weight
• Factor the higher per-case cost into any decision to expand robotic cholecystectomy

Why it matters

It reframes the robotic cholecystectomy debate from 'robot or not' to 'which patient'.

Don't overread it

This was a retrospective, non-randomised comparison; it cannot show the robot caused the lower complication rate.

The statistics, in plain English

An odds ratio of 3.69 in high-risk cases means the odds of conversion or serious complication were nearly four times higher with laparoscopy in that subgroup. Because the analysis is observational and the subgroups were defined by interaction terms, the estimates point to where a trial is needed rather than settling the question.

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