Editor’s note: The 14 ACS Advisory Councils, which serve as liaisons in the communication of information to and from surgical societies and the Regents, periodically submit articles on notable initiatives taking place in their respective specialties.
This week’s issue features a submission from the Advisory Council for General Surgery.
Bryan K. Richmond, MD, MBA, FACS
Robotic-assisted cholecystectomy has exploded on the scene as an alternative to conventional laparoscopic cholecystectomy, offering three-dimensional visualization, wristed instrumentation, and improved surgeon ergonomics. However, these technological advantages must be weighed against concerns regarding cost, operative efficiency, and, most importantly, patient safety.
Bile duct injury remains one of the most consequential complications of cholecystectomy, with potentially devastating long-term effects on quality of life, healthcare utilization, and survival. Reports suggesting higher rates of bile duct injury with robotic-assisted cholecystectomy compared with laparoscopy raise important questions regarding the widespread adoption of this technology.
Enhanced visualization and instrument dexterity do not necessarily translate into improved anatomic recognition or safer dissection within the hepatocystic triangle. Indeed, the complexity of biliary anatomy, inflammatory distortion, and surgeon decision-making remain critical determinants of operative safety, regardless of platform.
Mullens and colleagues addressed this concern in their 2025 study, “Patient Complexity and Bile Duct Injury After Robotic-Assisted vs Laparoscopic Cholecystectomy.” Among 737,908 Medicare beneficiaries, robotic-assisted cholecystectomy was associated with an approximately threefold higher relative risk of bile duct injury requiring operative intervention. The association persisted across low-, medium-, and high-risk patient groups. These findings challenge the argument that differences in patient complexity alone explain the observed safety signal.
Nevertheless, observational studies cannot fully account for surgeon experience, institutional practices, or evolving learning curves. Ongoing prospective study is needed to clarify whether these associations persist as robotic experience matures and whether particular patient populations derive measurable benefit.
The appropriate response is not necessarily to abandon robotic cholecystectomy, but to demand evidence of clinical benefit commensurate with its risks and costs. Until such evidence emerges, surgeons should prioritize established safety practices, including the critical view of safety, appropriate intraoperative imaging when indicated, and early adoption of bailout strategies when anatomy is unclear. Innovation in surgery must ultimately be judged by patient outcomes rather than technological sophistication.
