Comparative Analysis of Robotic and Laparoscopic Cholecystectomy

Importance Recent analyses raise concerns regarding the safety and cost of robotic cholecystectomy (RC) relative to laparoscopic cholecystectomy (LC); however, the analyses were limited by varied surgeon experience and inadequate adjustment for procedure difficulty. Objective To compare clinical outcomes and cost between RC and LC across a multihospital health system by surgeons routinely performing both surgeries, and develop a preoperative risk calculator. Design, Setting, and Participants This retrospective study of minimally invasive cholecystectomy (MIC) took place at 8 hospitals within a large health care system between 2020 and 2021. Cholecystectomy difficulty was stratified using the Nassar preoperative scoring (low/intermediate risk, ≤6; high risk, ≥7). Operative outcomes for 90-day follow-up and total variable cost of encounter were compared. Participants included adult patients undergoing LC or RC. Participants with planned open cholecystectomy, malignancy, or MIC performed as part of other procedures were excluded. Analysis was completed in December 2024 and submitted in March 2026. Exposure Surgical approach (RC vs LC) based on initial operative intent. Main outcomes and measures Primary outcomes were adverse event (conversion and/or Clavien-Dindo grade ≥3 complication) and total variable cost. Multivariable models identified detectors of adverse outcome. Inverse probability–weighted estimators predicted average treatment effects (ATE) on cost. Data were used to develop a calculator to estimate the risk of adverse outcomes by operative approach. Results Among 1828 patients (mean [SD] age, 52.9 [17.8] years; 65.9% female and 34.1% male), 806 (44.1%) underwent RC and 1022 (55.9%) underwent LC. RC was associated with shorter length of stay and lower rates of adverse outcome compared with LC (3.3%; 95% CI, 2.2%-4.8% vs 8.7%; 95% CI, 7.0%-10.5%; P < .001). On multivariable analysis, operative approach interacted significantly with Nassar risk level and body mass index (BMI). In high-risk patients with a BMI of 30 (calculated as weight in kilograms divided by height in meters squared), LC was associated with adverse outcome (odds ratio [OR], 3.69; 95% CI, 2.04-6.69; P < .001). In low/intermediate-risk patients, outcomes were comparable for low BMI, but among those with elevated BMI (35) LC was associated with adverse outcomes (OR, 3.19; 95% CI, 1.62-6.29; P = .001). RC was associated with higher total variable cost in both low/intermediate-risk (ATE, $2211.60; 95% CI, $1521.49-$2901.72; P < .001) and high-risk cohorts (ATE, $2417.05; 95% CI, $1675.62-$3158.48; P < .001). A predictive risk calculator demonstrated strong discrimination (AUC, 0.744; 95% CI, 0.685-0.803 for training cohort; AUC, 0.750; 95% CI, 0.659-0.842 for validation cohort). Conclusions and Relevance In this study, RC was associated with fewer adverse outcomes in select patients compared with LC, with the greatest benefit observed in high-risk cholecystectomy and patients with elevated BMI. However, RC was associated with higher cost across all risk strata. A validated risk calculator may assist surgeons in selecting the appropriate operative modality, optimizing outcomes and resource utilization.