Bile Duct Injury After Robotic Versus Laparoscopic Cholecystectomy: A Systematic Review of Comparative Studies, Including Acute Cholecystitis

Abstract

Background and Objectives: Bile duct injury (BDI) is the most serious complication of cholecystectomy. Whether robotic cholecystectomy (RC), now rapidly adopted, changes this risk compared with laparoscopic cholecystectomy (LC), including in acute cholecystitis, is disputed. Materials and Methods: Following PRISMA 2020, PubMed, Scopus and Web of Science were searched from inception to October 2026, with complementary and citation searching. Major BDI was the principal outcome; any coded BDI and conversion were secondary outcomes. Heterogeneous definitions and overlapping datasets required narrative synthesis. Results: Thirty-two observational studies published in 2017–2026 (11 database studies and 21 clinical series) were included. Medicare and New York State analyses of BDI requiring operative repair reported a higher risk after RC, whereas studies of coded BDI and clinical series with classified injuries reported similar or lower rates. In eight acute cholecystitis cohorts, BDI rates did not differ, but evidence for advanced inflammation was scarce. Conversion was lower with RC in most studies, although three database studies reported the opposite. Risk of bias was serious or critical in all studies. Conclusions: Current observational evidence neither demonstrates nor excludes a difference in major BDI between RC and LC. Prospective studies with standardised BDI classification, severity grading and surgeon-level adjustment are needed.