Original Investigation 

Outcomes and Costs After Robotic vs Laparoscopic Complex Elective Cholecystectomy

Katharine E. Caldwell, Edie Threlkeld, Joseph Litrel, et al

JAMA Surg 2026 Sep 1;161(9):909-915.

doi: 10.1001/jamasurg.2026.2650

Key Points

Question  Is a robotic approach associated with improved clinical outcomes and equivalent total cost compared with a laparoscopic approach for patients undergoing complex elective cholecystectomy (CEC)?

Findings  In this cohort study, a robotic approach for CEC was associated with fewer postoperative unplanned biliary and interventional radiology interventions. While the operating room cost of robotic CEC was higher, total cost of care, accounting for management of increased complications, was similar.

Meaning  The robotic platform may offer clinical advantages in high-difficulty gallbladder surgery without increasing the overall financial burden because of decreased complication rates.

Abstract

Importance  As the use of robotic cholecystectomy increases, its value remains poorly defined for complex elective cholecystectomy (CEC), where complex gallbladder pathology results in increased technical difficulty.

Objective  To determine whether a robotic approach is associated with improved clinical outcomes and altered total hospital cost as compared with a laparoscopic approach for patients undergoing CEC.

Design, Setting, and Participants  This cohort study analyzed data from an academic hepatobiliary referral center for patients who underwent cholecystectomy from August 2018 to August 2024. CEC was defined by preoperative criteria: prior aborted or partial cholecystectomy, presence of a cholecystostomy tube, and/or history of gallbladder perforation or fistula.

Exposure  Robotic-assisted vs laparoscopic cholecystectomy.

Main Outcomes and Measures  The primary outcome was a composite of an unplanned postoperative endoscopic retrograde cholangiopancreatography or interventional radiology procedure. Secondary outcomes included operative time, postoperative complications, and operative and total hospital costs.

Results  A total of 863 patients underwent cholecystectomy and met inclusion criteria; 525 (60.8%) were female and 338 (39.2%) were male, and their median (IQR) age was 61 (45-71) years. Among patients undergoing CEC, the laparoscopic approach was independently associated with an increased need for unplanned endoscopic or percutaneous intervention compared with the robotic group (odds ratio, 4.24; 95% CI, 1.24-14.52; P = .02). There were no significant differences in postoperative outcomes between the laparoscopic and robotic groups in patients undergoing non-CEC. Patients undergoing the laparoscopic approach had significantly reduced operating room costs when compared with patients undergoing a robotic approach in both the CEC ($7720 vs $8936, respectively) and non-CEC groups ($6368 vs $ 8351, respectively). However, there was no difference in the overall total cost of care between laparoscopic CEC and robotic CEC groups ($14 309 vs $14 476, respectively). The overall total cost of care was significantly higher for patients undergoing robotic non-CEC as compared with laparoscopic non-CEC ($11 416 vs $9925, respectively).

Conclusions and Relevance  This study found that for complex gallbladder disease, robotic cholecystectomy offers a clinical advantage, reducing complications and downstream interventions without increasing the overall costs of care. These findings suggest strategic application of the robotic platform may offer clinical advantages in high-complexity gallbladder surgery, maximizing patient benefit and resource efficiency.