Optimizing robotic utilization: the role of preoperative grading scales in prioritizing robotic surgery for minimally invasive cholecystectomy

The debate over laparoscopic versus robotic surgery in acute care is intensifying as the adoption of robotic platforms grows among surgeons. Central to the discussion are comparisons of cost-effectiveness and outcomes, particularly regarding major complications and operative times.1–5

The Robotic versus Laparoscopic Emergency and Acute Care Surgery: Redefining Novelty (RLEARN) study group (Klein et al) conducted a retrospective review of their institution’s experience with laparoscopic cholecystectomy (LC) versus robotic cholecystectomy (RC).6 The study focused on assessing whether the operative complexity of the pathology influenced outcomes. To evaluate this, the authors retrospectively calculated the World Journal of Emergency Surgery (WJES) score and Parkland Grading Score (PGS) based on their interpretation of operative dictations. The analysis included 260 patients and found that RC had shorter operative times in relatively complex cases, with a similar conversion rate to open surgery compared with LC.

We commend the authors for employing validated metrics to identify where the robotic approach may be most effectively implemented in a teaching hospital. The study underscores the value of validated metrics in differentiating the severity of pathology to better understand the potential benefits of robotic technology in reducing operative times. Specifically, the findings showed that RC was associated with reduced operative times in patients with moderate to severe cholecystitis (WJES grades B and C; PGS grade 2).

In their discussion, the authors hypothesize that for grade A cholecystitis, where no difference in operative times was observed between RC and LC, the advanced technical capabilities of the robotic platform may not be necessary. Conversely, for grade D cholecystitis, where cases are inherently highly complex, neither approach demonstrated a clear advantage in operative time. We agree with the authors that robotic surgery may offer the most significant benefit in moderately challenging cases, where its technical capabilities could significantly reduce operative times.

While the RLEARN study provides valuable insights and adds much-needed data to this field, future research should focus on prospective designs that use preoperative grading scales. A significant limitation of the current study is its retrospective nature. Interpretations of intraoperative findings through non-uniform operative dictations may be speculative without photographic evidence or real-time observations.

We recommend that future studies comparing laparoscopic and robotic approaches prioritize preoperative grading scales such as the Severe Acute Cholecystitis Score to predict high-grade cholecystitis preoperatively and assist in surgical decision-making.7 Thus, acute care surgeons can develop protocols to determine when robotic surgery is appropriate, cost-effective and potentially superior to traditional laparoscopic techniques.