S. M. Kalata1,2, J. Thumma2, J. Dimick1,2, K. Sheetz3 1University of Michigan, Dept Of Surgery, Ann Arbor, MI, USA 2Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA 3University Of California – San Francisco, Dept Of Surgery, San Francisco, CA, USA
Introduction: The adoption of robotic cholecystectomy has increased rapidly in recent years, perhaps in part due to potential safety advantages over the laparoscopic approach such as 3D visualization or intraoperative bile duct visualization tools (e.g., ICG technology). However, the comparative safety of robotic versus laparoscopic cholecystectomy remains unclear.
Methods: We utilized 100% fee-for-service Medicare claims from 2010-2019 to assess trends in the adoption of robotic cholecystectomy and comparative outcomes between robotic and laparoscopic cholecystectomy. Our primary outcome was bile duct injury requiring hepaticojejunostomy. Secondary outcomes included a composite outcome of surgical or endoscopic biliary interventions for bile duct injury and the incidence of 30-day overall complications, serious complications, and reoperations. Hierarchical multivariate logistic regression controlling for patient demographics, comorbidities, and year clustered within hospitals was performed on our outcomes of interest.
Results: A total of 1,047,316 patients underwent a cholecystectomy during the study period, of which 25,085 (1.9%) were performed robotically. Robotic patients were younger (71.2 years vs 72.0 years, p<.0001) and more likely to be Black (10.4% vs 8.8%, p<.001) or Hispanic (4.2% vs 3.8%, p<.001). Robotic patients had a higher comorbidity burden with at least 2+ comorbidities (19,841 [79.1%] vs 783,512 [76.7%], p<.001) The use of robotic surgery increased 37-fold from 211 (0.14%) patients in 2010 to 6,507 (5.2%) patients in 2019. Robotic cholecystectomy was associated with a higher risk of bile duct injury necessitating a hepaticojejunostomy (0.75% robotic vs 0.23% laparoscopic, RR 3.3 [95% CI 2.6-4.0]). Robotic cholecystectomy was also associated with higher rates of post-operative biliary interventions (8.3% robotic vs 6.2% laparoscopic, RR 1.3 [95% CI 1.2-1.4]) and reoperation (2.9% robotic vs 2.5% laparoscopic, RR 1.2 [95% CI 1.1-1.3]). There was no significant difference in overall complication rates.
Conclusion: Robotic cholecystectomies are increasingly being performed in Medicare beneficiaries and are associated with higher rates of bile duct injury. These results suggest that, despite potential technological advantages, robotic cholecystectomy is not safer than laparoscopic surgery. Without potential advantages over an already minimally invasive approach, these data call to question the use of robotics for cholecystectomy.
