---
title: Two meta-analyses published weeks apart disagree about whether robotic gallbladder surgery injures more bile ducts. Read the confidence intervals
publication: Medical Insights Korea
section: news
category: Gallbladder
canonical_url: https://medicalinsightskorea.com/news/robotic-cholecystectomy-evidence-disagreement
author: David Seo
published: 2026-09-01T15:00:00+09:00
modified: 2026-09-01T15:00:00+09:00
content_type: reporting
license: Quotation permitted with attribution to Medical Insights Korea and a link to the canonical URL.
---

# Two meta-analyses published weeks apart disagree about whether robotic gallbladder surgery injures more bile ducts. Read the confidence intervals

One pooled 1.77 million patients and found no difference. The other pooled 412,000 and found triple the risk. They are less contradictory than they look, and neither settles the question.

## Answer

A 2025 meta-analysis of 25 studies and 1,770,300 patients found no statistically significant difference in major bile duct injury between robotic and laparoscopic cholecystectomy (odds ratio 1.42, 95 percent confidence interval 0.43 to 4.66), while a 2026 meta-analysis of 38 studies and more than 412,000 patients reported bile duct injury in 0.72 percent of robotic cases against 0.23 percent of laparoscopic ones (relative risk 3.12, 95 percent confidence interval 2.34 to 3.91).

## Key takeaways

- A meta-analysis of 25 studies covering 1,770,300 patients reported no statistically significant difference in major bile duct injury between robotic and laparoscopic cholecystectomy, with an odds ratio of 1.42 and a confidence interval running from 0.43 to 4.66.
- A second meta-analysis of 38 studies covering more than 412,000 patients reported bile duct injury in 0.72 percent of robotic versus 0.23 percent of laparoscopic cases, a relative risk of 3.12 (95 percent confidence interval 2.34 to 3.91), while cautioning that learning-curve effects and coding variability in administrative data may explain part of it.
- The first review's confidence interval includes the second review's point estimate, so the two findings are compatible: the larger analysis was imprecise on this outcome rather than reassuring.
- Both reviews agree that robotic cholecystectomy reduces conversion to open surgery — odds ratios of 0.35 and 0.44 respectively — and that it costs substantially more, at roughly 5,000 to 6,000 US dollars per case against 2,000 to 3,000.
- A propensity-matched Korean single-centre study of 340 pairs found single-port robotic cholecystectomy comparable in safety to conventional laparoscopic surgery, with a shorter operative time of 40.0 against 45.0 minutes.

## Full article

Robotic cholecystectomy has moved from novelty to routine option without ever passing the test that would establish it is better. Its share of all gallbladder removals rose from under 1 percent to between 3 and 26 percent depending on the region by 2024, while laparoscopic surgery still accounts for 85 to 95 percent of the global total.

In the space of about six weeks either side of the new year, two systematic reviews attempted to say whether the machine is safer. They reached opposite conclusions on the outcome that matters most.

### The disagreement, stated plainly

**Bile duct injury, robotic versus laparoscopic cholecystectomy**

| Review | Patients | Finding |
| --- | --- | --- |
| Qadri et al., December 2025 | 1,770,300 across 25 studies | Odds ratio 1.42 (0.43–4.66), not significant |
| Coco & Leanza, January 2026 | 412,000+ across 38 studies | 0.72% vs 0.23%, relative risk 3.12 (2.34–3.91) |

The first concluded that robotic cholecystectomy is a safe and effective alternative with equivalent complication profiles. The second concluded that it is associated with an increased rate of bile duct injury and that its safety profile needs clarifying. Same procedure, same question, overlapping literature, and headlines that point in opposite directions.

### Why both can be right

The resolution is in the interval rather than the estimate. The larger review's confidence interval for bile duct injury runs from 0.43 to 4.66. That range is wide enough to contain a substantial protective effect, no effect at all, and the tripled risk the second review reported. A result like that does not say the two procedures are equally safe. It says the analysis could not tell.

**0.43 to 4.66** — the confidence interval around the larger meta-analysis's null finding for bile duct injury — a range that includes the tripled risk the other review reported  
_Source: Qadri M et al., Journal of Robotic Surgery, 2025_

This is the ordinary shape of evidence about a rare event. Bile duct injury happens in well under 1 percent of operations, so even 1.77 million patients yield few enough events that the pooled estimate wobbles. Reporting the odds ratio without the interval converts an inconclusive result into a reassuring one, which is how a review that could not answer the question gets cited as having answered it.

> **The second review's own caution**  
> The authors who found tripled risk wrote that it should be interpreted with caution because of potential confounders including early learning-curve effects and coding variability in administrative data. Robotic cases are disproportionately early-adoption cases performed while surgeons were still learning, and administrative databases record what was coded rather than what happened.

### What both reviews agree on

- Conversion to open surgery is less likely with the robot: odds ratios of 0.35 (0.31–0.41) and 0.44 (0.32–0.61).
- Length of stay is essentially the same, at 1.4 to 2.7 days in the newer review and a pooled difference of 0.02 days in the older one.
- Overall and postoperative complication rates are not meaningfully different, at odds ratios of 0.96 and 0.99 in the older review.
- The robot costs more: roughly 5,000 to 6,000 US dollars per case against 2,000 to 3,000, and 2,088 euro against 1,726 in European centres.

Operative time is the one practical measure that splits by geography. Western centres in the newer review took longer with the robot, 75 minutes against 60; some Asian institutions reported the reverse, 22 minutes against 33. The older review's pooled figure was 12.65 minutes longer for the robotic approach.

### The Korean evidence is small and careful

A team at Korea University College of Medicine compared single-port robotic cholecystectomy against conventional laparoscopic surgery in patients operated on between November 2020 and April 2023. From 1,184 patients they matched 340 pairs on age, sex, body mass index, ASA score, stones, polyps, acute cholecystitis, diabetes, hypertension, preoperative ERCP and — unusually and importantly — the operating surgeon.

Operative time was significantly shorter in the robotic group, 40.0 minutes against 45.0. Their conclusion is deliberately modest: comparable safety and feasibility, with prospective studies needed before broader claims.

Korea also has a domestically developed surgical robot, the Revo-i. The published gallbladder experience with it, from Yonsei University College of Medicine, is a case series of nine patients, all completed without complication or conversion. That is a feasibility report and its authors describe it as one.

### What would actually settle this

1. Both reviews draw heavily on national administrative databases, where an operative approach and a complication are both codes rather than observations, and where the robotic cohort is weighted toward the years when the technique was new.
2. Patients are not randomised to a robot. Where the newer review found a technical advantage — obesity, complex anatomy — is also where surgeons choose the robot, so selection runs in both directions and is not removed by pooling.
3. The Korean comparison is one centre and 340 matched pairs, which is enough to detect a difference in operative time and nowhere near enough to detect a difference in bile duct injury.
4. A trial large enough to resolve a difference between 0.23 and 0.72 percent would need tens of thousands of randomised patients. Nobody has run it, and the cost difference means nobody is obviously motivated to.

> **What a patient can take from this**  
> The honest position is that robotic cholecystectomy converts to open surgery less often, costs two to three times more, and has not been shown either safer or more dangerous for the bile duct because the studies capable of showing it have not been done. Anyone citing either review as settling that question is citing a confidence interval they did not read.

## Sources

- Qadri M, Habib E, Ghawas AA, Aftab M, Jamshed A, Adnan M, et al. Clinical outcomes of laparoscopic versus robotic cholecystectomy approaches: a systematic review and GRADE assessment meta-analysis. Journal of Robotic Surgery 2025;20(1):61. doi:10.1007/s11701-025-03022-9. PMID:41354898. https://doi.org/10.1007/s11701-025-03022-9
- Coco D, Leanza S. Comparative effectiveness, safety, and cost of laparoscopic versus robotic minimally invasive cholecystectomy: a systematic review and meta-analysis. Journal of Robotic Surgery 2026;20(1):177. doi:10.1007/s11701-025-02863-8. PMID:41540300. https://doi.org/10.1007/s11701-025-02863-8
- Choi YJ, Shin YL, Jeon SM, Yu S, Jo HS, Kim DS, Yu YD. Safety and feasibility of robotic single-port (SP) cholecystectomy compared to conventional laparoscopic cholecystectomy: a propensity score matching analysis. Surgical Endoscopy 2026;40(7):5626-5633. doi:10.1007/s00464-026-12723-7. PMID:42301445. https://doi.org/10.1007/s00464-026-12723-7
- Park SH, Kang CM. Reduced port robotic cholecystectomy using the Revo-i single-site plus ONE port approach: a case series with video. Journal of Minimally Invasive Surgery 2026;29(1):54-58. doi:10.7602/jmis.2026.29.1.54. PMID:41847792. https://doi.org/10.7602/jmis.2026.29.1.54

## Citation

David Seo (2026). "Two meta-analyses published weeks apart disagree about whether robotic gallbladder surgery injures more bile ducts. Read the confidence intervals". Medical Insights Korea. https://medicalinsightskorea.com/news/robotic-cholecystectomy-evidence-disagreement

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