Comparative effectiveness, safety, and cost of laparoscopic versus robotic minimally invasive cholecystectomy: a...

For over 3 decades, laparoscopic cholecystectomy (LC) has been established as the standard surgical treatment for gallstone disease. Robotic cholecystectomy (RC) has emerged as an innovative alternative designed to overcome technical limitations of LC, offering enhanced visualization, improved instrument articulation, and superior ergonomics. Despite increasing global adoption, robust comparative evidence regarding operative outcomes, complication rates, patient-centered metrics, and economic impact remains limited. This systematic review and meta-analysis synthesizes the most recent evidence through 2025 to provide a comprehensive comparison of the safety, efficacy, and cost-effectiveness of LC versus RC. A comprehensive systematic search was conducted in PubMed, Embase, and the Cochrane Library from inception through December 2024, supplemented by manual searches through January 2025. Randomized controlled trials, prospective cohort studies, and retrospective cohort studies comparing LC and RC in adults were included. Two independent reviewers extracted data on patient demographics, operative outcomes, complications, length of hospital stay, patient-reported outcomes, and cost metrics. Methodological quality was assessed using the Cochrane Risk of Bias 2.0 tool for randomized trials and the Newcastle-Ottawa Scale for observational studies. Meta-analyses were performed for key outcomes, including operative time, blood loss, complications, conversion rates, and hospital stay duration. Heterogeneity was addressed using random-effects models, and subgroup analysis was performed based on study design and geographic region. Population-level context was provided using national databases, including the U.S. National Inpatient Sample (NIS), ACS NSQIP, and Medicare claims. A potential limitation is the exclusion of non-English language studies. 38 studies including over 412,000 patients were analyzed. LC accounted for approximately 85-95% of all cholecystectomy procedures globally, while RC utilization increased from < 1 to 3-26% across regions by 2024. Pooled analysis showed longer operative times for RC in Western centers (75 vs. 60 min; p < 0.001), whereas some Asian institutions reported shorter times with RC (22 vs. 33 min; p = 0.0025). Pooled analysis indicated a higher rate of bile duct injury with RC (0.72% vs. 0.23%; relative risk 3.12, 95% CI 2.34-3.91; p < 0.001) although this finding should be interpreted with caution due to potential confounders, such as early learning curve effects and coding variability in administrative data. RC demonstrated a lower risk of serious complications (odds ratio 0.82, 95% CI 0.69-0.98), reduced conversion to open surgery (odds ratio 0.44, 95% CI 0.32-0.61), and decreased likelihood of hospitalization ≥ 24 h (odds ratio 0.76, 95% CI 0.71-0.81). Overall hospital stay was similar between approaches (1.4-2.7 days). RC incurred higher costs ($5000-6000 vs. $2000-3000 per case; European centers: €2088 vs. €1726). Subgroup analysis suggested potential technical advantages of RC in obese patients or those with complex anatomy, with improved patient-reported outcomes, including pain and quality of life. While both LC and RC are established minimally invasive approaches, the choice between them is nuanced. LC remains the standard of care for most patients due to its proven efficacy and cost-effectiveness. RC offers potential benefits in complex cases and may improve patient-reported outcomes, but it is associated with significantly higher costs and, based on current data, an increased rate of bile duct injury. Optimal approach selection should consider patient characteristics, surgeon expertise, and institutional resources. Future high-quality studies are needed to clarify the safety profile of RC and define its optimal role in clinical practice.