Joshi, Devendra

Background: Whether robot-assisted cholecystectomy reduces bile duct injury compared with laparoscopic cholecystectomy remains uncertain because prior studies have inadequately accounted for disease severity and have rarely classified injury severity using standardized criteria. This study compared perioperative outcomes after robot-assisted and laparoscopic cholecystectomy across a large healthcare system while adjusting for operative complexity. Study Design: Adults undergoing robot-assisted or laparoscopic cholecystectomy within the Mayo Clinic Enterprise (2014–2025) were retrospectively evaluated. Propensity score weighting adjusted for demographics, surgeon case volume, learning curve, and disease severity using the Tokyo Guidelines and Parkland grading system in patients with acute cholecystitis. The primary outcome was bile duct injury; secondary outcomes included general and procedure-specific complications. Results: Among 23,513 patients (19,998 laparoscopic; 3,515 robotic), robot-assisted cholecystectomy was used more frequently for Parkland grade ≥3 disease. Overall, 227 bile duct injuries occurred (204 laparoscopic; 23 robotic), corresponding to absolute risks of 1.02% and 0.65%, respectively (absolute risk difference −0.37%, 95% CI −0.72% to −0.02%; number needed to treat, 273). Robot-assisted cholecystectomy was associated with lower odds of conversion to open surgery, 30-day readmission, and mortality, shorter hospital stay (β −0.56, 95% CI −0.66 to −0.45; P<0.001), and a 5-minute longer median operative time. In acute cholecystitis, robot-assisted cholecystectomy was associated with lower adjusted odds of bile duct injury (aOR 0.29, 95% CI 0.07–0.78; P=0.011). Conclusions: After adjustment for disease severity and surgeon-related factors, robot-assisted cholecystectomy was associated with lower odds of bile duct injury in acute cholecystitis and improved perioperative outcomes, including shorter hospitalization and lower conversion rates, despite greater use in more complex cases.

This economic evaluation assesses the costs, reimbursements, and estimated net operating margin of single- and 2-stage strategies for managing bile duct stone clearance to compare the financial outcomes of both strategies.

Background: Common bile duct (CBD) stones associated with cholecystitis can be treated by single-stage CBD exploration at the time of cholecystectomy or a two-stage approach with endoscopic stone extraction before or after cholecystectomy. The ideal management remains a matter of debate. The aim of this study is to analyze our outcomes with transcystic laparoscopic common bile duct exploration (LCBDE). Material and Methods: A retrospective review of patients who underwent transcystic LCBDE between 2015 and 2019 was performed. Results: A total of 106 patients underwent transcystic LCBDE over 5 years. We performed 1192 laparoscopic cholecystectomies with cholangiograms from March 2015 to December 2019. Fifteen patients had a preoperative endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones seen on magnetic resonance cholangiopancreatography that during laparoscopic cholecystectomy with intraoperative cholangiogram (IOC), there were stones and/or sludge found in the CBD, which required clearance through a transcystic approach. Of the 91 patients who did not have a preoperative ERCP, clearance of the CBD was successful through a transcystic approach in 78 patients (86%). In the 13 patients that intraoperative clearance was not achieved ( n = 13, 14%), a postoperative ERCP was performed. A total of 28 patients underwent either pre- or postoperative ERCP ( n = 28, 26%). Choledochotomy was not performed in any of the patients. The mean operative time was 127 minutes (127 ± 48). The mean hospital length of stay (LOS) was 4 days (3.9 ± 2.8) with a median LOS of 3 days. Complications observed include wound infection ( n = 2, 2%), pancreatitis after ERCP ( n = 1, 1%), pneumonia ( n = 1, 1%), and right hepatic duct injury ( n = 1, 1%). Conclusion: Transcystic LCBDE is an effective and safe option for treatment of CBD stones. While a transcystic approach does not guarantee clearance of the CBD, it avoids the morbidity associated with a choledochotomy and can often prevent patients from having to undergo an additional procedure.