Robotic versus laparoscopic cholecystectomy for difficult gallbladders: an observational study of tertiary centre...

Although laparoscopic cholecystectomy (LC) is considered a low-risk procedure, intraoperative bleeding, bile duct injury and bile leak occur frequently in the 'difficult' gallbladder. Robotic cholecystectomy (RC) can overcome difficulties related to poor vision and instrumentation in difficult cases to avoid intraoperative complications and conversion to open surgery. The aim of the study was to evaluate the outcomes of laparoscopic and robotic cholecystectomy in patients with difficult gallbladders referred to a tertiary HPB centre.

We conducted a retrospective review of all patients referred to a senior hepatobiliary and pancreatic surgeon with a 'difficult' gallbladder between December 2013 and March 2024. Primary outcomes were conversion to open procedure, and 30-day post-operative complications.

A total of 88 difficult gallbladder cases (n = 35 laparoscopic, n = 53 robotic) were referred to a tertiary HPB centre during the study period, consisting of 21.7% of cholecystectomies (n = 404). The total complication rate (14.3% vs 3.8%, OR 4.25, 95% CI 0.77-23.28, p = 0.0951) and conversion rate (8.6% vs 0.0%, OR 11.52, 95% CI 0.57-230.32, p = 0.109) were both higher in the laparoscopic group, but these differences were not statistically significant. The median operative time was significantly higher in the laparoscopic group (108.5 min vs 50.0 min, p = 0.001).

Both robotic and laparoscopic cholecystectomy are viable approaches in difficult gallbladder cases, with robotic cholecystectomy being associated with potentially fewer complications and conversions to open surgery. Pre-operative referral of patients with difficult gallbladders and the intra-operative abandonment of difficult cases can both be considered safe exit strategies for difficult gallbladder cases.