Invited Commentary
Surgery
March 25, 2025
Robotic-Assisted Cholecystectomy—for Whom?
David R. Urbach
JAMA Netw Open. 2025;8(3):e251711. doi:10.1001/jamanetworkopen.2025.1711
To assess whether robotic-assisted cholecystectomy is superior to laparoscopic cholecystectomy in the prevention of bile duct injury, Mullens and colleagues1 conducted a retrospective study of 737 908 Medicare beneficiaries, including 295 807 in an experimental cohort and 442 101 in a training cohort, who underwent either robotic-assisted or laparoscopic cholecystectomy. Analyses stratified by the risk of postoperative complications found that patients undergoing robotic-assisted surgery had a higher risk of bile duct injury than those undergoing laparoscopic surgery in each category of risk. Risk categories were carefully identified and validated in the independent training cohort. Patients in the lowest-risk category who underwent robotic-assisted cholecystectomy had a risk of bile duct injury even higher than those in the highest-risk category who underwent laparoscopic surgery. With respect to bile duct injury—the most feared complication of gall bladder surgery—robotic-assisted surgery, based on these data, is inferior to laparoscopic cholecystectomy.
A new health technology should be used only if it offers advantages over existing treatments with respect to measures such as clinical effectiveness, safety, patient experience, cost, or social benefit. To date, it has been difficult to identify any of these factors as a rationale for adopting robotic-assisted cholecystectomy. Robotic-assisted cholecystectomy is more costly and lacks any meaningful short-term benefit compared with the gold standard procedure of laparoscopic cholecystectomy.2 Still, enthusiasts had argued that the improved visualization and dexterity of robotic-assisted surgical platforms should allow for better safety. When previous research suggested that robotic-assisted cholecystectomy resulted in an increased risk of serious complications such as bile duct injury,3 critics suspected a potentially spurious finding from observational study designs: robotic-assisted cholecystectomy surely was being used preferentially in more complex or higher-risk clinical settings. Might a true benefit of robotic-assisted cholecystectomy simply be obscured by selection bias? The article by Mullens and colleagues1 has provided as definitive an answer to this question as we are likely to get: No.
What are we to make of this? What role, if any, remains for robotic-assisted cholecystectomy? If robotic-assisted cholecystectomy is no better than laparoscopic cholecystectomy and is more expensive and more hazardous, there are 2 remaining arguments for its continued use: (1) as a training procedure surgeons can use for skill development for application in more complex procedures for which robotic-assisted surgery does, in fact, have benefit or (2) because patients express a preference specifically for robotic-assisted surgery.
Advocating for the use of robotic-assisted cholecystectomy for surgeons’ technical skill development raises ethical concerns. The primary responsibility of surgeons is to their patients, and it is inappropriate to subject patients to unnecessary risk. Just over 3% of patients in the study by Mullens and colleagues1 underwent robotic-assisted surgery. More widespread adoption of robotic-assisted cholecystectomy to train the surgical workforce raises the possibility of substantial iatrogenic harm to the population along the way.
The remaining argument—patient preference—is also highly problematic. In an era of growing popular mistrust in institutions, when people are encouraged to “do your own research,” patients increasingly express preferences for aggressively marketed health interventions that are not aligned with their treatment goals and values. What does it mean for a patient to “prefer” the use of a specific health technology, such as robotic-assisted surgery, especially when the health technology is one that most surgeons would avoid if they needed a cholecystectomy themselves?4Whose needs are being served? Patient perceptions are highly influenced by concepts such as novelty and innovation, and we must be mindful of the extraordinary power we exert in framing these perceptions, potentially swaying patients toward riskier treatments.5
A surgeon’s recommendation to a patient with gallbladder disease who would benefit from surgery should be based on the patient’s treatment goals and values as well as a consideration of the relative risks and benefits of the various treatment options. In light of recent evidence, this recommendation should not be a robotic-assisted cholecystectomy.
