Robotic-Assisted Cholecystectomy associated with High Bile Duct Injury Rates: JAMA

The adoption of robotic-assisted cholecystectomy, a modern surgical technique, has been on the rise, with proponents claiming improved safety and precision. However, a recent study published in Journal of American Medical Association shed light on the comparative safety of robotic-assisted cholecystectomy versus the traditional laparoscopic approach. This analysis from Medicare beneficiaries over a ten-year period, raises questions about the safety of robotic-assisted cholecystectomy when compared to its laparoscopic counterpart.

The study, conducted between January 1, 2010, and December 31, 2019, examined the records of over one million Medicare beneficiaries aged 66 to 99 who underwent cholecystectomy. It focused on patients with continuous Medicare coverage three months before and twelve months after surgery. The primary objective was to determine the rate of bile duct injury requiring surgical repair within one year after the procedure.

The findings of the study revealed a significant increase in the utilization of robotic-assisted cholecystectomy, soaring 37-fold from 0.1% of cases in 2010 to 5.2% in 2019. However, the critical discovery was that compared to laparoscopic cholecystectomy, the robotic approach was associated with a substantially higher rate of bile duct injuries necessitating surgical reconstruction within one year (0.7% vs. 0.2%). This represented a relative risk increase of 3.16.

Additionally, robotic-assisted cholecystectomy patients faced a higher likelihood of postoperative biliary interventions, such as endoscopic stenting (7.4% vs. 6.0%). Surprisingly, there was no significant difference in overall 30-day complication rates between the two procedures.

To address potential confounding factors, the study employed instrumental variable analysis, leveraging regional variations in the adoption of robotic-assisted cholecystectomy. This analysis also indicated a higher rate of bile duct injury with the robotic approach (0.4% vs. 0.2%).

The study suggests that the increasing popularity of robotic-assisted cholecystectomy may need to be reconsidered, especially when compared to the already minimally invasive and predictably safe laparoscopic technique. While robotic surgery offers certain advantages, including improved precision, these benefits appear to be outweighed by the increased risk of bile duct injuries, a complication that can lead to more invasive and extensive treatments.

Reference:

Kalata, S., Thumma, J. R., Norton, E. C., Dimick, J. B., & Sheetz, K. H. (2023). Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy. In JAMA Surgery. American Medical Association (AMA). https://doi.org/10.1001/jamasurg.2023.4389