Can Robots Make Gallbladder Surgery Safer?

WASHINGTON — Robotic-assisted cholecystectomy appeared associated with significantly fewer complications than manual laparoscopic surgery, researchers suggested here.

In a retrospective analysis utilizing National Surgical Quality Improvement Program (NSQIP) records, about 3.7% of patients who underwent laparoscopy for gallbladder surgery experienced complications leading to lasting disability, organ resection, or death (Clavien-Dindo grade III/IV) compared with 2.6% of patients who underwent a similar minimally invasive surgery using robotic technology (P<0.0001).

Similarly, the co-primary endpoint — the percentage of patients whose surgery had to be converted to an open operation — was experienced by 2.0% of the laparoscopy patients compared with 0.8% of the robotic-surgery patients (P<0.0001), reported Felipe Maegawa, MD, of Emory University in Atlanta, in presenting the results at the annual Digestive Disease Week (DDW) conference.

A key secondary endpoint, hospital stays lasting longer than 24 hours, occurred among 48.2% of the laparoscopy patients compared with 32.7% of the robotic-surgery patients (P<0.0001).

Maegawa and colleagues performed the study following reports that robotic surgery was associated with excessive bile duct injury, clouding the acceptance of the use of the robot technology. Using the NSQIP data, the researchers were able to identify nearly 60,000 cholecystectomy cases from 2022 — the first year robotic procedures and laparoscopies were separated in the NSQIP registries — to 2023.

Of those patients, 54,315 underwent laparoscopy, whereas 5,569 were treated using robots, an obvious indication that while robots are gaining a foothold, they are far less utilized in the nation’s healthcare system for gallbladder surgery.

Maegawa said that mortality was not statistically different between the two treatment methods, occurring during or after the procedure in 0.2% of patients getting laparoscopy and 0.1% of patients getting robotic surgery (P=0.2).

In commenting on the study, Syed Adeel Hassan, MBBS, of the University of Kentucky in Lexington, suggested that the imbalance in patients in the retrospective analysis limits the interpretation of the study results.

“With these types of retrospective study, there is always a risk of physician bias that can skew the analysis,” he told MedPage Today. Maegawa noted that the robotic-surgery group included more patients with obesity (57% vs 51%) and more frail individuals (more than two comorbidities on the Modified Frail Index: 14.7% vs 13.1%, P<0.001). On the other hand, 38% of the laparoscopic cases fell into the emergent or urgent care category compared with 15.8% of the cases that went to the robotic category (P<0.0001), Maegawa reported.

“This type of difference,” Hassan explained, “could mean more difficult patients could be in one arm rather than in another.” And the uneven populations in the current study could accentuate those biases.

“What we need is a prospective, randomized study that can more clearly assess the relationship between these two procedures,” he said. “Even more necessary is a cost-benefit analysis to show that using a more expensive device — the robotic technology — reduces complications and hospitalizations enough to make acquiring the device worthwhile and cost-saving in the long run.”

Hassan also said that more data will be needed on the long-term safety of performing robotic cholecystectomy before it goes prime time.