Is robotic surgery ready for emergency cholecystectomy? A systematic review and meta-analysis of robotic versus...

Acute cholecystitis is typically managed with laparoscopic cholecystectomy, though inflammation and distorted anatomy can increase operative difficulty. Robotic cholecystectomy may offer technical advantages through improved visualisation and instrument dexterity, yet current evidence is limited, heterogeneous, and entirely observational, with no randomized trials comparing the two approaches in the emergency setting. This systematic review and meta-analysis synthesises existing comparative data to determine whether robotic assistance confers meaningful operative or postoperative benefits over standard laparoscopy in acute cholecystitis.

A PRISMA-compliant systematic review and meta-analysis was performed. Comprehensive searches of major databases (2015-2025) identified comparative studies of robotic versus laparoscopic cholecystectomy for acute/emergency cholecystitis in adults. Eligible studies reported at least one perioperative or postoperative outcome; elective, paediatric, single-incision, and non-comparative designs were excluded. Outcomes included operative time, conversion, intra-operative complications, bile duct injury, length of stay, readmission, reoperation, and mortality. Risk of bias was assessed using ROBINS-I. Meta-analyses were conducted in RevMan using random-effects models, with heterogeneity assessed by I² and standard continuity corrections applied for zero-event studies.

Seven observational studies comprising 143,717 patients met the inclusion criteria. Operative time and length of stay could not be meta-analysed due to inconsistent reporting and were therefore summarised narratively, with both outcomes appearing broadly comparable between robotic and laparoscopic groups. Meta-analysis demonstrated a significantly lower risk of conversion to open surgery with robotic cholecystectomy (RR 0.61, 95% CI 0.50-0.75; I² = 44%). No significant differences were observed between robotic and laparoscopic approaches for intra-operative complications (RR 0.72, 95% CI 0.38-1.36; I² = 40%), bile duct injury (RR 0.97, 95% CI 0.77-1.21; I² = 0%), overall postoperative complications (RR 1.10, 95% CI 0.80-1.52; I² = 95%), 30-day readmission (RR 0.88, 95% CI 0.50-1.54; I² = 18%), reintervention or return to theatre (RR 0.33, 95% CI 0.04-2.48; I² = 78%), or 30-day mortality (OR 1.28, 95% CI 0.86-1.90; I² = 0%). Event rates for bile duct injury, major complications, reintervention, and mortality were uniformly low across all cohorts, limiting the precision of pooled estimates. Risk-of-bias assessment using ROBINS-I indicated a moderate to serious overall risk of bias in six of the seven studies, primarily due to residual confounding, non-random treatment allocation, and incomplete reporting of disease severity and operative complexity.

Robotic cholecystectomy is a safe and feasible alternative to laparoscopy for acute cholecystitis, demonstrating a consistent reduction in conversion to open surgery and comparable intra-operative and postoperative safety outcomes. However, as current evidence is limited to heterogeneous observational studies with incomplete clinical detail, robust prospective research-with detailed severity grading, surgeon-experience assessment, workflow evaluation, and cost-effectiveness analysis-is needed to more clearly define its role in emergency biliary surgery.