Robotic Cholecystectomy is Safe and Effective for all Levels of Gallbladder Pathology in both the Elective and Emergent Setting in a Patient Population with a High Comorbidity Load: Outcomes from East Flatbush, New York Submission to the Journal of Robotic Surgery

Robotic Cholecystectomy is Safe and Effective for all Levels of Gallbladder Pathology in both the Elective and Emergent Setting in a Patient Population with a High Comorbidity Load: Outcomes from East Flatbush, New York Submission to the Journal of Robotic Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Robotic Cholecystectomy is Safe and Effective for all Levels of Gallbladder Pathology in both the Elective and Emergent Setting in a Patient Population with a High Comorbidity Load: Outcomes from East Flatbush, New York Submission to the Journal of Robotic Surgery Shannon Crehan, Mohamed Ali Ahmed, Nicholas Morin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6994381/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Aug, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted 11 You are reading this latest preprint version Abstract Background The value of using the Da Vinci robotic platform to perform a cholecystectomy is still under investigation, particularly within emergent settings. The aim of our study is to analyze the safety, efficacy, and clinical outcomes associated with robotic cholecystectomy among patients with a high comorbidity load, comparative health disparities, and varying degrees of gallbladder pathology. Objective To measure and compare 30-day postoperative complications seen in the robot-assisted cholecystectomy in a patient population with a high comorbidity load. Methods We conducted a single-institution, retrospective analysis of a total of 218 patients who underwent either an elective or emergent robotic cholecystectomy from January 2019 to January 2024. All cases were performed at a tertiary care hospital by four surgeons with varying levels of robotic experience, ranging from 25 years to 7 years of robotic experience. Baseline preoperative demographics, comorbidities, severity of gallbladder pathology, and 30-day clinical outcomes were recorded. Results Of the 218 patients, 94 were emergent and 124 were elective. All had varying degrees of gallbladder pathology. The emergent cases were significantly more likely to have severe pathological findings compared to the elective cases. The overall complication rate in our population was 7.3%. The most common complications were postoperative sickle cell crisis, hepatic abscess, and incisional seroma. No bile duct injuries were encountered, and minimal 30-day outcomes were encountered. Conclusions In both elective and emergent settings, robotic cholecystectomy is safe and effective in a patient population with a high comorbidity load, health disparities, and varying degrees of gallbladder pathology. Robotic cholecystectomy emergent robotic cholecystectomy cholecystitis surgical outcomes in safety net hospital high comorbidity burden health inequity Figures Figure 1 Figure 2 Figure 3 Introduction Robot-assisted cholecystectomy (RC) has demonstrated efficacy in treating cholecystitis for over two decades [ 1 ]. Ongoing evaluation of RC safety and effectiveness remains paramount to ensure best practices and optimization of patient care. Robotic surgery offers many advantages to patients and surgeons, such as augmented wrist flexibility allowing for a greater range of motion compared to traditional rigid laparoscopic instruments, superior precision, improved access to tight anatomical spaces, and the potential for smaller incisions that can lead to a shorter recovery period [ 2 ]. The feature of the three-dimensional camera along with the use of near-infrared fluorescent imaging with ICG (FireFly), further improves visualization of the gallbladder and the surrounding structures during cholecystectomy [ 3 ]. Our patient population in East Flatbush, Brooklyn, NY, is characterized by high rates of obesity, inadequate access to medical insurance, and significant comorbidities , making this community one of the most medically underserved in New York City (NYC) [ 4 ]. A high comorbidity burden in conjunction with a high body mass index (BMI), leads to a more difficult cholecystectomy with a higher rate of complications. The use of RC remains subject to scrutiny, underscoring the need for continued research to validate its safety and effectiveness for its application in cholecystectomy. We aim to assess the safety of RC in East Flatbush, a community burdened by multiple health disparities. Methods This study retrospectively analyzed 218 patients who underwent robotic cholecystectomy at Kings County Hospital Center in East Flatbush, Brooklyn, NY, from January 1st, 2019, to January 1st, 2024. Patients were included if they had undergone either elective or emergent robotic cholecystectomy during this period and excluded if their case was converted to open, open cholecystectomy, or laparoscopic cholecystectomy. Patients were initially categorized based on surgical urgency into elective (n = 124) and emergent (n = 94) groups. Additional subgroup analyses were performed based on patient demographics, clinical presentations, comorbidities, and intraoperative characteristics to evaluate their influence on complication rates, severity of complications, and length of hospital stay. Data Source and Study Population Data was extracted from EPIC electronic medical records. Various parameters were recorded: demographics and baseline characteristics (BMI, sex, age, race, insurance type, ASA), admission and operative data ( emergent admission (ED admission), ambulatory status, operation to discharge time, total length of stay), social history (alcohol use, smoking status, and drug use). The comorbidities recorded: Hypertension (HTN), hyperlipidemia (HLD), heart failure (HF), diabetes mellitus (Type I or II), obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), asthma, cerebrovascular accident (CVA), coronary artery disease (CAD), current cancer, anemia, sickle cell anemia (SCA), human immunodeficiency virus (HIV), sepsis, acute kidney injury (AKI), hepatitis C virus (HCV), pancreatitis, chronic kidney disease (CKD). Charlson Comorbidity Index (CCI) was calculated and recorded for each patient. Patient’s surgical and medical history, imaging ( ultrasound, CT, MRI, HIDA) and findings ( presence of common bile duct stones, and common bile duct size) were documented. Intraoperative findings were recorded from operative note: severity of inflammation, subtotal cholecystectomy, purulent cholecystitis, gangrenous cholecystitis, abscess, perforation, post-operative drain placement, and estimated blood loss. Special attention was paid to identifying any technical challenges, intraoperative adverse events, or findings that correlated with the severity of pathology or possible complications. Final pathology findings, 30-day complications, readmissions, and mortality data was extracted. Gallbladder pathology was stratified into severe and mild cohorts based on findings from operative notes and final pathology reports. Severe gallbladder pathology was defined by the following features: gangrenous changes, severe inflammation, hydropic distention, purulence, transmural necrosis, fibrosis, perforation, porcelain gallbladder, or subtotal cholecystectomy. Specific diagnoses included necrotizing cholecystitis, sarcomatoid or poorly differentiated carcinoma, abscess formation, severe chronic active cholecystitis with hemorrhage or ulceration, and cholelithiasis with biliary obstruction or porcelain changes were also included in the severe pathology cohort. Mild gallbladder pathology included cases with moderate chronic active cholecystitis, cholelithiasis, Rokitansky-Aschoff sinuses, or fibrosis without features and patients with previous cholecystectomy tubes. RC was performed using the Da Vinci Surgical System. Procedures were performed by attending surgeons with varying levels of robotic experience, ranging from highly experienced in robot-assisted procedures for 25 years and other surgeons with 7 years of experience. Patients with stable conditions were scheduled for elective surgeries, whereas patients presenting with acute conditions requiring immediate intervention underwent emergent surgeries. Outcomes Primary outcomes included 30-day postoperative complications. Secondary outcomes assess the correlation between patient comorbidities, gallbladder pathology severity, length of stay, readmissions, intraoperative and postoperative diagnosis, and health insurance access. Statistical Analysis Data analysis was performed using Python (v3.11), leveraging libraries including Pandas, Numpy, Scipy, Statsmodels, and Matplotlib [ 5 – 9 ]. Univariate comparisons between elective and emergent robotic cholecystectomy groups utilized the Chi-square or Fisher’s exact test for categorical variables and the independent t-test, based on data normality. A Monte Carlo simulation-enhanced chi-square test was applied for sparse categorical data to ensure robust p-value estimation. Regression analyses employed binary logistic regression to identify predictors of 30-day postoperative complications and ordinary least squares (OLS) linear regression to evaluate continuous outcomes, such as length of stay. Predictor variables included ASA classification, comorbidity burden, admission status, operative timing, imaging, and laboratory findings. Categorical variables were dummy-coded. Model performance was assessed through pseudo R² (McFadden’s), likelihood ratio tests, Wald statistics, p-values, variance inflation factors (VIF) for multicollinearity, and convergence status. Diagnostic plots were used to verify OLS regression assumptions. Models exhibiting instability or convergence issues were excluded from the final interpretation. Statistical significance was defined as a two-sided p-value < 0.05, consistent with standard biomedical research practice and default test behavior in Python-based statistical libraries [ 8 ]. Results Our study included 218 patients with gallbladder pathology. The mean age was 47.4 ± 16.9 years (range: 16–92 years). 81.7% were female and 18.3% were male. The mean BMI was 32.1 ± 6.8 kg/m² (range: 13.95–53.26). Table 1 Comparison of key demographic, clinical and insurance characteristics between the study cohort, the population of East Flatbush, and the overall NYC population. Data includes age, gender distribution, comorbid conditions, obesity rates, insurance status, and poverty level. Dashed entries (-) indicate data unavailability for the respective population. The patient population’s comorbidities, as illustrated in Table 1 , depict the most common comorbidities found, which were hypertension (n = 75), 34% of our patient population, DM 23% (n = 50), and HLD 23% (n = 51). Study Patient Population Population of East Flatbush Population of NYC Population n = 218 n = 154,575 n = 8,537,673 Age (mean years) 47 39.8 38 Gender, %(n) Female Male 81.7 (178) 18.3 (40) 68.6% 31.4% 52% 48% BMI, %(n) 58% (128), Mean 32.1 kg/m² 34% 24% HTN, %(n) 34% (75) 36% 28% DM, %(n) 23% (50) 15% 11% HLD, %(n) 51% (51) - - Asthma, %(n) 29% ((29) - - Anemia, %(n) 20% (20) - - OSA, %(n) 11% (11) - - SCA, %(n) 8% (8) - - CKD, %(n) 8% (8) - - Current Cancer, %(n) 7% (7) - - HIV %(n) 7% (7) - - New HIV Diagnosis (per 100,000 people) - 35.6 24 Insurance Type, % (n) No Insurance: 4.6% (10) 15% 12% Emergency Medicaid: 11.9% (26) - - Medicare 4.6% (10) Medicaid: 31.7% (69) - - NYC Care (low-income insurance): 4.6% (10) - - Other Private Insurance: 42.6% (93) - - Poverty - 19% 20% The overall 30-day postoperative complication rate in our study population was 7.3% (n = 16). The complication rate in the emergent cholecystectomy group (n = 94) was 8.51% (n = 8), and in the elective cholecystectomy group (n = 124) was 6.45% (n = 8). The two highest rates of complication in the study group were the severe pathology elective group (n = 11), which had a complication rate of 18% (n = 2), and the severe pathology emergent group (n = 35), which had a complication rate of 17% (n = 6). When breaking the groups into severe gallbladder pathology (n = 46) and mild gallbladder pathology (n = 172), the severe pathology group had a much higher rate of complication at 17.39% (n = 8) compared to the mild pathology group, 4.87% (n = 8). A statistically significant difference was found when comparing the severe and mild pathology groups to postoperative complications using chi-square with a value of 6.92 with a p-value of 0.0087 (Yates’ correction applied). Patients with severe pathology had higher odds of postoperative complications compared to those with mild pathology (odds ratio = 4.32, 95% CI: 1.52–12.23) Table 2 Postoperative complication rates compared to comorbidity burden per patient. Patients were stratified by the number of documented comorbidities, revealing a general trend toward higher complication rates with increasing comorbidity burden. Comorbidity Burden Per Patient (n) Total Patients (n) Complications (n) Complication (%) 0 86 4 4.7% 1 56 1 1.8% 2 33 6 18% 3 23 2 8.6% 4 14 2 14% 5 4 1 25% 6 0 0 0 7 1 0 0 8 1 0 0 We initially employed logistic regression to examine the relationship between increasing comorbidity burden and the likelihood of 30-day postoperative complications, treating comorbidity as a continuous variable. The model demonstrated a positive trend, with each additional comorbidity associated with higher odds of complications (odds ratio [OR] = 1.33; 95% CI: 1.00–1.78), though this narrowly missed conventional statistical significance (p = 0.052). To assess the robustness of these findings, we also conducted a Chi-square test with Monte Carlo simulation, which yielded a consistent p-value (p = 0.052), supporting the observed trend despite the sparse data. Given the possibility of a nonlinear relationship, we subsequently treated comorbidity burden as a categorical variable. This model initially failed to converge due to limited data at higher comorbidity levels (specifically, levels 7 and 8, each comprising a single patient without complications). To mitigate this issue, we collapsed comorbidity counts of 5 or more into a single aggregated category (≥ 5). Patients with two comorbidities had significantly greater odds of complications compared to those with no comorbidities (OR = 4.56; 95% CI: 1.20–17.36). Although other groups also showed elevated odds, such as an OR of 3.42 (95% CI: 0.56–20.72, p = 0.181) for patients with four comorbidities and an OR of 6.83 (95% CI: 0.57–81.25, p = 0.128) for those with five or more, these did not reach statistical significance. Table 3 Postoperative complications stratified by comorbidity. SCA and CVA were significantly associated with increased complications (p = 0.0146 and 0.0452, respectively). Comorbidity Complications (n) Postoperative Complication 0 4 RUQ pain with inspiration, chills, itching of skin, acute vision loss, superficial thrombophlebitis, incisional seroma SCA* 3 Sickle cell crisis (2), chest pain HTN 6 Hypertensive crisis, incisional hematoma, SOB, hepatic abscess, constipation and tremors CAD 1 Hypertensive crisis HLD 3 Suture loose and drainage of incision, constipation and tremors OSA 3 Hepatic Abscess, chest pain, sickle cell crisis Asthma 2 Hepatic Abscess DM 4 Postop chest pain, SOB, hepatic Abscess Anemia 2 Incisional hematoma, ileus HIV 1 Incisional hematoma CVA* 2 Ileus, constipation and tremors CKD 1 Constipation and tremors HF 1 Constipation and tremors Sepsis 1 Hepatic Abscess The most common complications discovered: sickle cell crisis postoperatively with acute chest syndrome (n = 2), hepatic abscess (n = 4), incisional hematoma (n = 3), pulmonary embolism (n = 1), and postoperative ileus (n = 1). We examined the association between sickle cell anemia (SCA) and postoperative complications using Fisher’s exact test due to small sample sizes. The analysis revealed a statistically significant association (OR = 9.09, 95% CI: 1.95–42.31; p = 0.0146), indicating that patients with SCA had significantly higher odds of developing complications compared to those without SCA . Fisher’s exact test was used to evaluate the association between a history of CVA and postoperative complications. The association was statistically significant ( p = 0.0452), with patients who had a history of CVA demonstrating significantly greater odds of postoperative complications compared to those without CVA (OR = 9.38; 95% CI: 1.45–60.84). Regarding hospital length of stay, most patients stayed between 2 and 3 days, though a smaller number remained hospitalized for more than two weeks. On average, emergent cases had a hospital stay that was approximately 4 days longer than elective admissions . This difference was statistically significant ( p < 0.001; 95% CI: 3.27–4.70), based on linear regression analysis. Linear regression analysis showed that severe gallbladder pathology was associated with a significantly longer hospital stay, adding an average of 2.8 days compared to patients with milder disease (p < 0.0001; 95% CI: 1.76–3.93). Discussion Due to East Flatbush’s medically underserved patient population, the question was raised to see if RC was safe in a population with low socioeconomic status, health inequity, and a high rate of comorbidities compared to the population of NYC. Health disparities among populations are known to lead to worse health outcomes [ 10 – 11 ]. In communities experiencing health disparities, such as East Flatbush, patients face significant barriers to accessing advanced medical technologies, including robotic surgery. While robotic surgery is available at Kings County Hospital, its availability remains insufficient to meet the demands of the East Flatbush population. This discrepancy becomes critical since it is known that robotic surgery has been shown to decrease burnout in surgeons. Surgeon burnout is decreased by the enhanced ergonomic nature of operating robotically compared to laparoscopy, which in turn can lead to better outcomes for patients and increase the longevity of surgeons' careers [ 12 ]. 1. Health Disparities Inadequate access to healthy food leads to increased prevalence of obesity, hypertension and type 2 diabetes mellitus. The study population in East Flatbush, Brooklyn, is a known USDA-designated food desert - an area with a large number of food vendors where most are bodegas instead of supermarkets [ 13 ]. Bodegas offer high-calorie and low-nutrient value foods, with a scarce amount of fruits and vegetables for sale. Additionally, the high number of fast-food stores in the area further compounds these challenges, as these venues typically offer low-cost but calorically dense meals with poor nutritional quality, reinforcing patterns of dietary inadequacy and food insecurity. Of the 10 patients in our study who were uninsured, one had particularly advanced gallbladder disease and was readmitted about a week after surgery with shortness of breath and swelling in both legs. This patient also had hypertension and diabetes, which likely contributed to the complication. It is well documented that lower socioeconomic status is linked to worse outcomes after surgery [ 14 ]. Patients without insurance may delay seeking care or face barriers to managing chronic conditions, both of which can increase surgical risk. When analyzing our data, we considered whether being uninsured might increase the likelihood of complications. Although we did see a complication in one of those patients, the overall association wasn’t statistically significant (p = 0.54). Even though there are health disparity exists in our population, the study’s complication rate for RC was just 7.3%. We find this to be encouraging and suggests that with attentive perioperative care, favorable outcomes are achievable even in populations that often face barriers to healthcare access. 2. Comorbidity Burden High comorbidity burden is frequently associated with more severe gallbladder pathology, which in turn can elevate the risk of surgical complications [ 15 ]. Difficult gallbladders are characterized by pronounced inflammation and distorted anatomy; they are commonly linked to higher incidences of bile duct injuries and intraoperative bleeding. Our patient sample demographics, represented in Table 1 , was compared to the population of East Flatbush and the rest of NYC. Our study population and the population of East Flatbush have much higher rates of hypertension, diabetes and high BMI when compared to NYC . We investigated whether there was a correlation between the specific type of comorbidity and postoperative complication. We found that SCA (p = 0.0146) and CVA (p = 0.0452) was statistically significant . It is well established that SCA leads to gallbladder pathology due to the increased rate of red blood cell hemolysis and the risk of surgical complications is increased in this patient population [ 16 ]. Patients with SCA are known to have a higher risk of gallbladder issues, particularly cholelithiasis, because of the ongoing breakdown of red blood cells and the buildup of pigment stones [ 17 ]. Two of our SCA patients had mild pathology, and experienced a sickle cell crisis in the postoperative period. One patient had severe pathology, which led to acute chest syndrome, further proving that early intervention in SCA patients is crucial to limit the complications seen. All of the sickle cell patients who had complications had cholelithiasis. Equally noteworthy was the statistical significance observed in patients with a history of CVA. CVA can be associated with gallbladder pathology due to the metabolic buildup of cholesterol in the gallbladder and vessel walls as well as an inflammatory state [ 18 ]. CVA appears to influence postoperative outcomes in less predictable ways. Our CVA cohort included two patients who experienced distinct postoperative courses. One developed postoperative ileus, while the other presented to the emergency department with constipation and tremors. Despite their shared comorbidity, there were no identifiable similarities in imaging findings, length of hospital stay, or gallbladder pathology severity. 3. Postoperative Complications: In this study, we investigated whether robotic surgery could be a safe option for patients who are generally considered higher risk—those with multiple health issues that often make surgery more complicated [ 19 ]. These patients, including many from underserved backgrounds, veterans, or those with limited access to healthcare, are frequently underrepresented in surgical research. More research is necessary to study outcomes of robotic surgery performance in these sicker populations. Given that higher comorbidity often leads to more complications, it’s reasonable to question whether a robotic approach is appropriate. Our findings suggest that, even in these complex cases, robotic cholecystectomy can be done safely . This is encouraging and points to the potential for broader access to robotic techniques, even for patients who may not traditionally be seen as ideal candidates. In our total patient population, which includes both elective and emergent patient groups, the use of RC depicts minimal complications at a low rate of 7.3% (n = 16). We observed a statistically significant increase in complication rates among patients with severe gallbladder pathology compared to those with mild pathology (p = 0.003 ). This finding reinforces the safety and effectiveness of robotic cholecystectomy (RC) in mild disease . In contrast, the higher complication rate seen in severe pathology cases highlights the need to further investigate contributing factors and explore potential refinements in perioperative management. Because the severity of pathology is typically confirmed through postoperative histopathology, identifying reliable preoperative indicators is critical. Certain imaging findings, such as gallbladder wall thickening, pericholecystic fluid, and abscess formation serve as early markers of disease severity. Incorporating these parameters into preoperative risk stratification models and refining robotic techniques for high-complexity cases may help optimize outcomes in patients with severe gallbladder disease. It’s worth noting that there were no bile duct injuries in this study. That’s encouraging, especially when compared with larger studies, which reported a 0.4% injury rate in RC cases [ 20 ]. While our patient population was smaller, the absence of this complication is still reassuring. Finally, none of the patients required reoperation after their robotic cholecystectomy (p = 1.000). Taken together, these results support the safety of this approach, even for patients with more complex health profiles. 4. Hospital Length of Stay Patients in the emergent RC cohort tended to stay in the hospital longer than those who had elective procedures. On average, emergent cases added about four extra days to the length of stay . This likely reflects how much more complex and urgent these cases can be. Even in these higher-risk situations, the robotic approach was still effective, suggesting it can be a useful tool even when cases are more complicated. We also looked at how the severity of the gallbladder disease affected recovery. Patients with severe pathology stayed in the hospital around 2.8 days longer than those with milder forms. This highlights the real impact disease burden can have on recovery time. We also looked at other health factors. For each one-point rise in the CCI , patients stayed 0.6 days longer in the hospital. While higher CCI scores were linked to longer stays, they didn’t show a strong connection to complication rates [ 21 ]. This may suggest that comorbidities slow recovery more than they impact immediate surgical outcomes. 5. Limitations The sample size was relatively small (n = 218) and came from a single institution, which limits how widely the results can be applied. The range of surgical experience among providers may also have influenced outcomes. About 80% of the patients in this study were female. This lines up with the fact that gallbladder disease is more common in women, but it does make it harder to know whether the results apply to male patients. There may be differences in how men present or recover that weren’t captured here. We also found a statistically significant difference in complication rates between patients with mild versus severe pathology. Since there were so few complication events overall in these patient cohorts, the study was underpowered. A post hoc analysis showed only 9% power, meaning it’s possible we missed meaningful patterns or overestimated the importance of findings that were statistically significant. With low event counts and mostly categorical variables, we also couldn’t run reliable multivariable models to control for other factors. Conclusions Our observed complication rate of 7.3% is notably lower than the nationally reported average of 15% [ 22 ]. This supports the safety of RC even in a population with a higher rate of obesity, hypertension, diabetes, and the uninsured compared to the NYC population (uninsured patients: 15% East Flatbush vs. 12% NYC). No significant correlation was found between the number of comorbidities and complication rates in our study population. However, a statistically significant association was found between severe gallbladder pathology and higher complication rates, independent of comorbidity burden or surgical urgency (elective compared to emergent.) The complication rate in patients with severe gallbladder pathology was found to be more than quadruple that of the mild pathology group complication rate (17.39 versus 4.87, respectively), highlighting the impact of disease severity on postoperative outcomes. Overall, the complication rate was low in our study population. This supports the safety of RC in a population with a high number of comorbidities, health inequalities, and varying degrees of gallbladder pathology. Further research is needed to evaluate the safety of RC in the acute care surgery setting, particularly emergent cholecystitis if diseased gallbladders (Tokyo Guidelines grade II and III) can be safely operated using the RC treatment method and compare these outcomes to the laparoscopic cholecystectomy outcomes. Additionally, further research should focus on identifying and removing barriers in populations with health disparities to improve access to advanced surgical treatments such as the robot-assisted cholecystectomy. Declarations Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests: The authors have no relevant financial or non-financial interests to disclose. Author Contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Shannon Crehan, Mohamed Ali Ahmed and Nicholas Morin. The first draft of the manuscript was written by Shannon Crehan, and Mohamed Ali Ahmed. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics Approval Human subjects: This research study was conducted retrospectively from data obtained for clinical purposes. We consulted extensively with the IRB of BRANY who determined that our study did not need ethical approval. Our study was defined as category 12- exempt. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Consent to Participate: Informed consent was obtained from all individual participants included in the study. References Zaman JA, Singh TP. (2018) The emerging role for robotics in cholecystectomy: the dawn of a new era? Hepatobiliary Surg Nutr. doi: 10.21037/hbsn.2017.03.01 . 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M., Guzzetta, A., & Huerta, S. (2021). Outcomes of robotic and laparoscopic cholecystectomy for benign gallbladder disease in Veteran patients. Journal of robotic surgery , 15 (6), 849–857. https://doi.org/10.1007/s11701-020-01183-3 Kalata S, Thumma JR, Norton EC, Dimick JB, Sheetz KH. (2023) Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy. JAMA Surg. doi: 10.1001/jamasurg.2023.4389 Alburakan, A. A., Abdullah Alshammari, S., Saud AlOtaibi, W., Hamad Almalki, J., Shalhoub, M. M., & Nouh, T. A. (2022). Charlson Comorbidity Index as a Predictor of Difficult Cholecystectomy in Patients With Acute Cholecystitis. Cureus , 14 (11), e31807. https://doi.org/10.7759/cureus.31807 Esteban Aguayo, Vishal Dobaria, Morcos Nakhla, Young-Ji Seo, Joseph Hadaya, Nam Yong Cho, Sohail Sareh, Yas Sanaiha, Peyman Benharash, (2020) National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy, Surgery, Volume 168, Issue 4,2020, Pages 625–630, ISSN 0039-6060, https://doi.org/10.1016/j.surg.2020.06.018 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Aug, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 14 Jul, 2025 Reviews received at journal 14 Jul, 2025 Reviewers agreed at journal 14 Jul, 2025 Reviewers agreed at journal 13 Jul, 2025 Reviewers agreed at journal 13 Jul, 2025 Reviews received at journal 13 Jul, 2025 Reviewers agreed at journal 13 Jul, 2025 Reviewers invited by journal 13 Jul, 2025 Editor assigned by journal 28 Jun, 2025 Submission checks completed at journal 28 Jun, 2025 First submitted to journal 27 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6994381","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":485353481,"identity":"5ee9d5bd-f278-4114-a9fd-e9152e6b3505","order_by":0,"name":"Shannon Crehan","email":"data:image/png;base64,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","orcid":"","institution":"Icahn School of Medicine at Mount Sinai Hospital","correspondingAuthor":true,"prefix":"","firstName":"Shannon","middleName":"","lastName":"Crehan","suffix":""},{"id":485353482,"identity":"aea17493-f77c-43ea-8f02-3b5de5ef952c","order_by":1,"name":"Mohamed Ali Ahmed","email":"","orcid":"","institution":"Kings County Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Ali","lastName":"Ahmed","suffix":""},{"id":485353483,"identity":"b397d97a-2819-491b-8351-4cac03dbc6b6","order_by":2,"name":"Nicholas Morin","email":"","orcid":"","institution":"Kings County Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Nicholas","middleName":"","lastName":"Morin","suffix":""}],"badges":[],"createdAt":"2025-06-27 21:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6994381/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6994381/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11701-025-02620-x","type":"published","date":"2025-08-02T16:06:01+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87265792,"identity":"a9bd6ac5-3c2c-4135-a24d-7589fb42902e","added_by":"auto","created_at":"2025-07-22 07:58:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":144835,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of complication rates in patients with gallbladder disease, grouped by how severe or mild the gallbladder pathology and whether their surgery was done emergently or electively.\u003c/strong\u003e Each bar shows the percentage of patients who had a postoperative complication. Complications were more common in the groups with severe gallbladder pathology, regardless of elective or emergent admission.\u003cem\u003eThe severity of the gallbladder pathology was found to correlate with a higher rate of complication. (p=0.0087).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6994381/v1/5f289226536c5a0d00c876fa.png"},{"id":87265793,"identity":"4ec71ad6-e4dd-4a85-894f-ff172c7557f1","added_by":"auto","created_at":"2025-07-22 07:58:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":162822,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHospital length of stay (LOS) among patients admitted for emergent surgical cases (n = 94).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6994381/v1/26b0028dd3208f53ecc1054d.png"},{"id":87265789,"identity":"53270ea1-0009-4357-bd14-6239d3d58c49","added_by":"auto","created_at":"2025-07-22 07:58:30","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":30825,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHospital length of stay among patients with severe gallbladder pathology (n = 46).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6994381/v1/895f0c21732ee6aeaa8d61d0.png"},{"id":88268455,"identity":"42939919-f0f3-40b4-825c-0282e1b9650e","added_by":"auto","created_at":"2025-08-04 16:51:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1402637,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6994381/v1/3e71d331-ad84-4928-8c58-6d962135419e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Robotic Cholecystectomy is Safe and Effective for all Levels of Gallbladder Pathology in both the Elective and Emergent Setting in a Patient Population with a High Comorbidity Load: Outcomes from East Flatbush, New York Submission to the Journal of Robotic Surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRobot-assisted cholecystectomy (RC) has demonstrated efficacy in treating cholecystitis for over two decades [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Ongoing evaluation of RC safety and effectiveness remains paramount to ensure best practices and optimization of patient care. Robotic surgery offers many advantages to patients and surgeons, such as augmented wrist flexibility allowing for a greater range of motion compared to traditional rigid laparoscopic instruments, superior precision, improved access to tight anatomical spaces, and the potential for smaller incisions that can lead to a shorter recovery period [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The feature of the three-dimensional camera along with the use of near-infrared fluorescent imaging with ICG (FireFly), further improves visualization of the gallbladder and the surrounding structures during cholecystectomy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Our patient population in East Flatbush, Brooklyn, NY, is characterized by \u003cem\u003ehigh rates of obesity, inadequate access to medical insurance, and significant comorbidities\u003c/em\u003e, making this community one of the most medically underserved in New York City (NYC) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. A high comorbidity burden in conjunction with a high body mass index (BMI), leads to a more difficult cholecystectomy with a higher rate of complications. The use of RC remains subject to scrutiny, underscoring the need for continued research to validate its safety and effectiveness for its application in cholecystectomy. We aim to assess the safety of RC in East Flatbush, a community burdened by multiple health disparities.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study retrospectively analyzed 218 patients who underwent robotic cholecystectomy at Kings County Hospital Center in East Flatbush, Brooklyn, NY, from January 1st, 2019, to January 1st, 2024. Patients were included if they had undergone either elective or emergent robotic cholecystectomy during this period and excluded if their case was converted to open, open cholecystectomy, or laparoscopic cholecystectomy. Patients were initially categorized based on surgical urgency into elective (n\u0026thinsp;=\u0026thinsp;124) and emergent (n\u0026thinsp;=\u0026thinsp;94) groups. Additional subgroup analyses were performed based on patient demographics, clinical presentations, comorbidities, and intraoperative characteristics to evaluate their influence on complication rates, severity of complications, and length of hospital stay.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData Source and Study Population\u003c/h2\u003e\u003cp\u003eData was extracted from EPIC electronic medical records. Various parameters were recorded: demographics and baseline characteristics (BMI, sex, age, race, insurance type, ASA), admission and operative data \u003cb\u003e(\u003c/b\u003eemergent admission (ED admission), ambulatory status, operation to discharge time, total length of stay), social history (alcohol use, smoking status, and drug use). The comorbidities recorded: Hypertension (HTN), hyperlipidemia (HLD), heart failure (HF), diabetes mellitus (Type I or II), obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), asthma, cerebrovascular accident (CVA), coronary artery disease (CAD), current cancer, anemia, sickle cell anemia (SCA), human immunodeficiency virus (HIV), sepsis, acute kidney injury (AKI), hepatitis C virus (HCV), pancreatitis, chronic kidney disease (CKD). Charlson Comorbidity Index (CCI) was calculated and recorded for each patient. Patient\u0026rsquo;s surgical and medical history, imaging \u003cb\u003e(\u003c/b\u003eultrasound, CT, MRI, HIDA) and findings \u003cb\u003e(\u003c/b\u003epresence of common bile duct stones, and common bile duct size) were documented. Intraoperative findings were recorded from operative note: severity of inflammation, subtotal cholecystectomy, purulent cholecystitis, gangrenous cholecystitis, abscess, perforation, post-operative drain placement, and estimated blood loss. Special attention was paid to identifying any technical challenges, intraoperative adverse events, or findings that correlated with the severity of pathology or possible complications. Final pathology findings, 30-day complications, readmissions, and mortality data was extracted.\u003c/p\u003e\u003cp\u003eGallbladder pathology was stratified into severe and mild cohorts based on findings from operative notes and final pathology reports. Severe gallbladder pathology was defined by the following features: gangrenous changes, severe inflammation, hydropic distention, purulence, transmural necrosis, fibrosis, perforation, porcelain gallbladder, or subtotal cholecystectomy. Specific diagnoses included necrotizing cholecystitis, sarcomatoid or poorly differentiated carcinoma, abscess formation, severe chronic active cholecystitis with hemorrhage or ulceration, and cholelithiasis with biliary obstruction or porcelain changes were also included in the severe pathology cohort. Mild gallbladder pathology included cases with moderate chronic active cholecystitis, cholelithiasis, Rokitansky-Aschoff sinuses, or fibrosis without features and patients with previous cholecystectomy tubes.\u003c/p\u003e\u003cp\u003eRC was performed using the Da Vinci Surgical System. Procedures were performed by attending surgeons with varying levels of robotic experience, ranging from highly experienced in robot-assisted procedures for 25 years and other surgeons with 7 years of experience. Patients with stable conditions were scheduled for elective surgeries, whereas patients presenting with acute conditions requiring immediate intervention underwent emergent surgeries.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003ePrimary outcomes included 30-day postoperative complications. Secondary outcomes assess the correlation between patient comorbidities, gallbladder pathology severity, length of stay, readmissions, intraoperative and postoperative diagnosis, and health insurance access.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData analysis was performed using Python (v3.11), leveraging libraries including Pandas, Numpy, Scipy, Statsmodels, and Matplotlib [\u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Univariate comparisons between elective and emergent robotic cholecystectomy groups utilized the Chi-square or Fisher\u0026rsquo;s exact test for categorical variables and the independent t-test, based on data normality. A Monte Carlo simulation-enhanced chi-square test was applied for sparse categorical data to ensure robust p-value estimation. Regression analyses employed binary logistic regression to identify predictors of 30-day postoperative complications and ordinary least squares (OLS) linear regression to evaluate continuous outcomes, such as length of stay. Predictor variables included ASA classification, comorbidity burden, admission status, operative timing, imaging, and laboratory findings. Categorical variables were dummy-coded. Model performance was assessed through pseudo R\u0026sup2; (McFadden\u0026rsquo;s), likelihood ratio tests, Wald statistics, p-values, variance inflation factors (VIF) for multicollinearity, and convergence status. Diagnostic plots were used to verify OLS regression assumptions. Models exhibiting instability or convergence issues were excluded from the final interpretation. Statistical significance was defined as a two-sided p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05, consistent with standard biomedical research practice and default test behavior in Python-based statistical libraries [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOur study included 218 patients with gallbladder pathology. The mean age was 47.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.9 years (range: 16\u0026ndash;92 years). 81.7% were female and 18.3% were male. The mean BMI was 32.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8 kg/m\u0026sup2; (range: 13.95\u0026ndash;53.26).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eComparison of key demographic, clinical and insurance characteristics between the study cohort, the population of East Flatbush, and the overall NYC population.\u003c/b\u003e Data includes age, gender distribution, comorbid conditions, obesity rates, insurance status, and poverty level. Dashed entries (-) indicate data unavailability for the respective population. The patient population\u0026rsquo;s comorbidities, as illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, depict the most common comorbidities found, which were \u003cem\u003ehypertension (n\u0026thinsp;=\u0026thinsp;75), 34% of our patient population, DM 23% (n\u0026thinsp;=\u0026thinsp;50), and HLD 23% (n\u0026thinsp;=\u0026thinsp;51).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudy Patient Population\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePopulation of East Flatbush\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePopulation of NYC\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePopulation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;218\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;154,575\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;8,537,673\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (mean years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender, %(n)\u003c/p\u003e\u003cp\u003eFemale\u003c/p\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e81.7 (178)\u003c/p\u003e\u003cp\u003e18.3 (40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68.6%\u003c/p\u003e\u003cp\u003e31.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e52%\u003c/p\u003e\u003cp\u003e48%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI, %(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58% (128), Mean 32.1 kg/m\u0026sup2;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHTN, %(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34% (75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDM, %(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23% (50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHLD, %(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51% (51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsthma, %(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29% ((29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnemia, %(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20% (20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOSA, %(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11% (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSCA, %(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8% (8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCKD, %(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8% (8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurrent Cancer, %(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7% (7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHIV %(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7% (7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNew HIV Diagnosis (per 100,000 people)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eInsurance Type, % (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo Insurance: 4.6% (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmergency Medicaid: 11.9% (26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedicare 4.6% (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedicaid: 31.7% (69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNYC Care (low-income insurance): 4.6% (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther Private Insurance: 42.6% (93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePoverty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe overall 30-day postoperative complication rate in our study population was 7.3% (n\u0026thinsp;=\u0026thinsp;16). The complication rate in the emergent cholecystectomy group (n\u0026thinsp;=\u0026thinsp;94) was 8.51% (n\u0026thinsp;=\u0026thinsp;8), and in the elective cholecystectomy group (n\u0026thinsp;=\u0026thinsp;124) was 6.45% (n\u0026thinsp;=\u0026thinsp;8). The two highest rates of complication in the study group were the severe pathology elective group (n\u0026thinsp;=\u0026thinsp;11), which had a complication rate of 18% (n\u0026thinsp;=\u0026thinsp;2), and the severe pathology emergent group (n\u0026thinsp;=\u0026thinsp;35), which had a complication rate of 17% (n\u0026thinsp;=\u0026thinsp;6). When breaking the groups into severe gallbladder pathology (n\u0026thinsp;=\u0026thinsp;46) and mild gallbladder pathology (n\u0026thinsp;=\u0026thinsp;172), the severe pathology group had a much higher rate of complication at 17.39% (n\u0026thinsp;=\u0026thinsp;8) compared to the mild pathology group, 4.87% (n\u0026thinsp;=\u0026thinsp;8).\u003c/p\u003e\u003cp\u003eA statistically significant difference was found when comparing the severe and mild pathology groups to postoperative complications using chi-square with a value of 6.92 with a p-value of 0.0087 (Yates\u0026rsquo; correction applied). \u003cem\u003ePatients with severe pathology had higher odds of postoperative complications compared to those with mild pathology (odds ratio\u0026thinsp;=\u0026thinsp;4.32, 95% CI: 1.52\u0026ndash;12.23)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003ePostoperative complication rates compared to comorbidity burden per patient.\u003c/b\u003e Patients were stratified by the number of documented comorbidities, revealing a general trend toward higher complication rates with increasing comorbidity burden.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComorbidity Burden Per Patient (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal Patients (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComplications (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eComplication (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e86\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e4.7%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e56\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e1.8%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e33\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e18%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e23\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e8.6%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e14\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e14%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e25%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e8\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWe initially employed logistic regression to examine the relationship between increasing comorbidity burden and the likelihood of 30-day postoperative complications, treating comorbidity as a continuous variable. The model demonstrated a positive trend, with each additional comorbidity associated with higher odds of complications (odds ratio [OR]\u0026thinsp;=\u0026thinsp;1.33; 95% CI: 1.00\u0026ndash;1.78), though this narrowly missed conventional statistical significance (p\u0026thinsp;=\u0026thinsp;0.052). To assess the robustness of these findings, we also conducted a Chi-square test with Monte Carlo simulation, which yielded a consistent p-value (p\u0026thinsp;=\u0026thinsp;0.052), supporting the observed trend despite the sparse data.\u003c/p\u003e\u003cp\u003eGiven the possibility of a nonlinear relationship, we subsequently treated comorbidity burden as a categorical variable. This model initially failed to converge due to limited data at higher comorbidity levels (specifically, levels 7 and 8, each comprising a single patient without complications). To mitigate this issue, we collapsed comorbidity counts of 5 or more into a single aggregated category (\u0026ge;\u0026thinsp;5). \u003cem\u003ePatients with two comorbidities had significantly greater odds of complications compared to those with no comorbidities\u003c/em\u003e (OR\u0026thinsp;=\u0026thinsp;4.56; 95% CI: 1.20\u0026ndash;17.36). Although other groups also showed elevated odds, such as an OR of 3.42 (95% CI: 0.56\u0026ndash;20.72, p\u0026thinsp;=\u0026thinsp;0.181) for patients with four comorbidities and an OR of 6.83 (95% CI: 0.57\u0026ndash;81.25, p\u0026thinsp;=\u0026thinsp;0.128) for those with five or more, these did not reach statistical significance.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003ePostoperative complications stratified by comorbidity.\u003c/b\u003e SCA and CVA were significantly associated with increased complications (p\u0026thinsp;=\u0026thinsp;0.0146 and 0.0452, respectively).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComorbidity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComplications (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePostoperative Complication\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRUQ pain with inspiration, chills, itching of skin, acute vision loss, superficial thrombophlebitis, incisional seroma\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSCA*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSickle cell crisis (2), chest pain\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHTN\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHypertensive crisis, incisional hematoma, SOB, hepatic abscess, constipation and tremors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCAD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHypertensive crisis\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHLD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSuture loose and drainage of incision, constipation and tremors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOSA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHepatic Abscess, chest pain, sickle cell crisis\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAsthma\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHepatic Abscess\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDM\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePostop chest pain, SOB, hepatic Abscess\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnemia\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIncisional hematoma, ileus\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHIV\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIncisional hematoma\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCVA*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIleus, constipation and tremors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCKD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConstipation and tremors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHF\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConstipation and tremors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSepsis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHepatic Abscess\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe most common complications discovered: sickle cell crisis postoperatively with acute chest syndrome (n\u0026thinsp;=\u0026thinsp;2), hepatic abscess (n\u0026thinsp;=\u0026thinsp;4), incisional hematoma (n\u0026thinsp;=\u0026thinsp;3), pulmonary embolism (n\u0026thinsp;=\u0026thinsp;1), and postoperative ileus (n\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e\u003cp\u003eWe examined the association between sickle cell anemia (SCA) and postoperative complications using Fisher\u0026rsquo;s exact test due to small sample sizes. The analysis revealed a statistically significant association (OR\u0026thinsp;=\u0026thinsp;9.09, 95% CI: 1.95\u0026ndash;42.31; p\u0026thinsp;=\u0026thinsp;0.0146), indicating that \u003cem\u003epatients with SCA had significantly higher odds of developing complications compared to those without SCA\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eFisher\u0026rsquo;s exact test was used to evaluate the association between a history of CVA and postoperative complications. The association was statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0452), with \u003cem\u003epatients who had a history of CVA demonstrating significantly greater odds of postoperative complications\u003c/em\u003e compared to those without CVA (OR\u0026thinsp;=\u0026thinsp;9.38; 95% CI: 1.45\u0026ndash;60.84).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eRegarding hospital length of stay, most patients stayed between 2 and 3 days, though a smaller number remained hospitalized for more than two weeks. On average, \u003cem\u003eemergent cases had a hospital stay that was approximately 4 days longer than elective admissions\u003c/em\u003e. This difference was statistically significant (\u003cb\u003ep\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; 95% CI: 3.27\u0026ndash;4.70), based on linear regression analysis.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eLinear regression analysis showed that \u003cem\u003esevere gallbladder pathology was associated with a significantly longer hospital stay, adding an average of 2.8 days\u003c/em\u003e compared to patients with milder disease (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001; 95% CI: 1.76\u0026ndash;3.93).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDue to East Flatbush\u0026rsquo;s medically underserved patient population, the question was raised to see if RC was safe in a population with low socioeconomic status, health inequity, and a high rate of comorbidities compared to the population of NYC. Health disparities among populations are known to lead to worse health outcomes [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]. In communities experiencing health disparities, such as East Flatbush, patients face significant barriers to accessing advanced medical technologies, including robotic surgery. While robotic surgery is available at Kings County Hospital, its availability remains insufficient to meet the demands of the East Flatbush population. This discrepancy becomes critical since it is known that robotic surgery has been shown to decrease burnout in surgeons. Surgeon burnout is decreased by the enhanced ergonomic nature of operating robotically compared to laparoscopy, which in turn can lead to better outcomes for patients and increase the longevity of surgeons\u0026apos; careers [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e1. Health Disparities\u003c/h2\u003e\n \u003cp\u003eInadequate access to healthy food leads to increased prevalence of obesity, hypertension and type 2 diabetes mellitus. \u003cem\u003eThe study population in East Flatbush, Brooklyn, is a known USDA-designated food desert\u003c/em\u003e- an area with a large number of food vendors where most are bodegas instead of supermarkets [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]. Bodegas offer high-calorie and low-nutrient value foods, with a scarce amount of fruits and vegetables for sale. Additionally, the high number of fast-food stores in the area further compounds these challenges, as these venues typically offer low-cost but calorically dense meals with poor nutritional quality, reinforcing patterns of dietary inadequacy and food insecurity.\u003c/p\u003e\n \u003cp\u003eOf the 10 patients in our study who were uninsured, one had particularly advanced gallbladder disease and was readmitted about a week after surgery with shortness of breath and swelling in both legs. This patient also had hypertension and diabetes, which likely contributed to the complication. It is well documented that lower socioeconomic status is linked to worse outcomes after surgery [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]. Patients without insurance may delay seeking care or face barriers to managing chronic conditions, both of which can increase surgical risk. When analyzing our data, we considered whether being uninsured might increase the likelihood of complications. Although we did see a complication in one of those patients, the overall association wasn\u0026rsquo;t statistically significant (p\u0026thinsp;=\u0026thinsp;0.54). \u003cem\u003eEven though there are health disparity exists in our population, the study\u0026rsquo;s complication rate for RC was just 7.3%.\u003c/em\u003e We find this to be encouraging and suggests that with attentive perioperative care, favorable outcomes are achievable even in populations that often face barriers to healthcare access.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003e2. Comorbidity Burden\u003c/h3\u003e\n\u003cp\u003eHigh comorbidity burden is frequently associated with more severe gallbladder pathology, which in turn can elevate the risk of surgical complications [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. Difficult gallbladders are characterized by pronounced inflammation and distorted anatomy; they are commonly linked to higher incidences of bile duct injuries and intraoperative bleeding.\u003c/p\u003e\n\u003cp\u003eOur patient sample demographics, represented in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, was compared to the population of East Flatbush and the rest of NYC. \u003cem\u003eOur study population and the population of East Flatbush have much higher rates of hypertension, diabetes and high BMI when compared to NYC\u003c/em\u003e. We investigated whether there was a correlation between the specific type of comorbidity and postoperative complication. We found that \u003cem\u003eSCA (p\u0026thinsp;=\u0026thinsp;0.0146) and CVA (p\u0026thinsp;=\u0026thinsp;0.0452) was statistically significant\u003c/em\u003e. It is well established that SCA leads to gallbladder pathology due to the increased rate of red blood cell hemolysis and the risk of surgical complications is increased in this patient population [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. Patients with SCA are known to have a higher risk of gallbladder issues, particularly cholelithiasis, because of the ongoing breakdown of red blood cells and the buildup of pigment stones [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. Two of our SCA patients had mild pathology, and experienced a sickle cell crisis in the postoperative period. One patient had severe pathology, which led to acute chest syndrome, further proving that early intervention in SCA patients is crucial to limit the complications seen. All of the sickle cell patients who had complications had cholelithiasis.\u003c/p\u003e\n\u003cp\u003eEqually noteworthy was the statistical significance observed in patients with a history of CVA. CVA can be associated with gallbladder pathology due to the metabolic buildup of cholesterol in the gallbladder and vessel walls as well as an inflammatory state [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. CVA appears to influence postoperative outcomes in less predictable ways. Our CVA cohort included two patients who experienced distinct postoperative courses. One developed postoperative ileus, while the other presented to the emergency department with constipation and tremors. Despite their shared comorbidity, there were no identifiable similarities in imaging findings, length of hospital stay, or gallbladder pathology severity.\u003c/p\u003e\n\u003ch3\u003e3. Postoperative Complications:\u003c/h3\u003e\n\u003cp\u003eIn this study, we investigated whether robotic surgery could be a safe option for patients who are generally considered higher risk\u0026mdash;those with multiple health issues that often make surgery more complicated [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. These patients, including many from underserved backgrounds, veterans, or those with limited access to healthcare, are frequently underrepresented in surgical research. More research is necessary to study outcomes of robotic surgery performance in these sicker populations. Given that higher comorbidity often leads to more complications, it\u0026rsquo;s reasonable to question whether a robotic approach is appropriate. \u003cem\u003eOur findings suggest that, even in these complex cases, robotic cholecystectomy can be done safely\u003c/em\u003e. This is encouraging and points to the potential for broader access to robotic techniques, even for patients who may not traditionally be seen as ideal candidates.\u003c/p\u003e\n\u003cp\u003eIn our total patient population, which includes both elective and emergent patient groups, the use of RC depicts minimal complications at a low rate of 7.3% (n\u0026thinsp;=\u0026thinsp;16). We observed a statistically significant increase in complication rates among patients with severe gallbladder pathology compared to those with mild pathology \u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.003\u003c/em\u003e). This finding reinforces the \u003cem\u003esafety and effectiveness of robotic cholecystectomy (RC) in mild disease\u003c/em\u003e. In contrast, the higher complication rate seen in severe pathology cases highlights the need to further investigate contributing factors and explore potential refinements in perioperative management. Because the severity of pathology is typically confirmed through postoperative histopathology, identifying reliable preoperative indicators is critical. Certain imaging findings, such as gallbladder wall thickening, pericholecystic fluid, and abscess formation serve as early markers of disease severity. Incorporating these parameters into preoperative risk stratification models and refining robotic techniques for high-complexity cases may help optimize outcomes in patients with severe gallbladder disease.\u003c/p\u003e\n\u003cp\u003eIt\u0026rsquo;s worth noting that there were \u003cem\u003eno bile duct injuries in this study.\u003c/em\u003e That\u0026rsquo;s encouraging, especially when compared with larger studies, which reported a 0.4% injury rate in RC cases [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. While our patient population was smaller, the absence of this complication is still reassuring. Finally, none of the patients required reoperation after their robotic cholecystectomy (p\u0026thinsp;=\u0026thinsp;1.000). Taken together, these results support the safety of this approach, even for patients with more complex health profiles.\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e4. Hospital Length of Stay\u003c/h2\u003e\n \u003cp\u003ePatients in the emergent RC cohort tended to stay in the hospital longer than those who had elective procedures. On average, \u003cem\u003eemergent cases\u003c/em\u003e added about \u003cem\u003efour extra days to the length of stay\u003c/em\u003e. This likely reflects how much more complex and urgent these cases can be. Even in these higher-risk situations, the robotic approach was still effective, suggesting it can be a useful tool even when cases are more complicated. We also looked at how the severity of the gallbladder disease affected recovery. Patients with \u003cem\u003esevere pathology\u003c/em\u003e stayed in the hospital around \u003cem\u003e2.8 days longer\u003c/em\u003e than those with milder forms. This highlights the real impact disease burden can have on recovery time.\u003c/p\u003e\n \u003cp\u003eWe also looked at other health factors. \u003cem\u003eFor each one-point rise in the CCI\u003c/em\u003e, patients stayed \u003cem\u003e0.6 days longer\u003c/em\u003e in the hospital. While higher CCI scores were linked to longer stays, they didn\u0026rsquo;t show a strong connection to complication rates [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. This may suggest that comorbidities slow recovery more than they impact immediate surgical outcomes.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e5. Limitations\u003c/h2\u003e\n \u003cp\u003eThe sample size was relatively small (n\u0026thinsp;=\u0026thinsp;218) and came from a single institution, which limits how widely the results can be applied. The range of surgical experience among providers may also have influenced outcomes. About 80% of the patients in this study were female. This lines up with the fact that gallbladder disease is more common in women, but it does make it harder to know whether the results apply to male patients. There may be differences in how men present or recover that weren\u0026rsquo;t captured here.\u003c/p\u003e\n \u003cp\u003eWe also found a statistically significant difference in complication rates between patients with mild versus severe pathology. Since there were so few complication events overall in these patient cohorts, the study was underpowered. A post hoc analysis showed only 9% power, meaning it\u0026rsquo;s possible we missed meaningful patterns or overestimated the importance of findings that were statistically significant. With low event counts and mostly categorical variables, we also couldn\u0026rsquo;t run reliable multivariable models to control for other factors.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur observed complication rate of 7.3% is notably lower than the nationally reported average of 15% [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This supports the \u003cem\u003esafety of RC even in a population with a higher rate of obesity, hypertension, diabetes, and the uninsured\u003c/em\u003e compared to the NYC population (uninsured patients: 15% East Flatbush vs. 12% NYC).\u003c/p\u003e\u003cp\u003eNo significant correlation was found between the number of comorbidities and complication rates in our study population. However, a statistically significant association was found between severe gallbladder pathology and higher complication rates, independent of comorbidity burden or surgical urgency (elective compared to emergent.) The complication rate in patients with severe gallbladder pathology was found to be more than quadruple that of the mild pathology group complication rate (17.39 versus 4.87, respectively), highlighting the impact of disease severity on postoperative outcomes.\u003c/p\u003e\u003cp\u003eOverall, the complication rate was low in our study population. \u003cem\u003eThis supports the safety of RC in a population with a high number of comorbidities, health inequalities, and varying degrees of gallbladder pathology.\u003c/em\u003e Further research is needed to evaluate the safety of RC in the acute care surgery setting, particularly emergent cholecystitis if diseased gallbladders (Tokyo Guidelines grade II and III) can be safely operated using the RC treatment method and compare these outcomes to the laparoscopic cholecystectomy outcomes. Additionally, further research should focus on identifying and removing barriers in populations with health disparities to improve access to advanced surgical treatments such as the robot-assisted cholecystectomy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Shannon Crehan, Mohamed Ali Ahmed and Nicholas Morin. The first draft of the manuscript was written by Shannon Crehan, and Mohamed Ali Ahmed. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHuman subjects: This research study was conducted retrospectively from data obtained for clinical purposes. We consulted extensively with the IRB of BRANY who determined that our study did not need ethical approval. Our study was defined as category 12- exempt.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnimal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent to Participate:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZaman JA, Singh TP. (2018) The emerging role for robotics in cholecystectomy: the dawn of a new era? Hepatobiliary Surg Nutr. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21037/hbsn.2017.03.01\u003c/span\u003e\u003cspan address=\"10.21037/hbsn.2017.03.01\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 29531940; PMCID: PMC5835599.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen HA, Hutelin Z, Moushey AM, Diab NS, Mehta SK, Corey B. 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Outcomes of robotic and laparoscopic cholecystectomy for benign gallbladder disease in Veteran patients. \u003cem\u003eJournal of robotic surgery\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(6), 849\u0026ndash;857. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11701-020-01183-3\u003c/span\u003e\u003cspan address=\"10.1007/s11701-020-01183-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKalata S, Thumma JR, Norton EC, Dimick JB, Sheetz KH. (2023) Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy. \u003cem\u003eJAMA Surg.\u003c/em\u003e doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamasurg.2023.4389\u003c/span\u003e\u003cspan address=\"10.1001/jamasurg.2023.4389\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlburakan, A. A., Abdullah Alshammari, S., Saud AlOtaibi, W., Hamad Almalki, J., Shalhoub, M. M., \u0026amp; Nouh, T. A. (2022). Charlson Comorbidity Index as a Predictor of Difficult Cholecystectomy in Patients With Acute Cholecystitis. \u003cem\u003eCureus\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(11), e31807. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7759/cureus.31807\u003c/span\u003e\u003cspan address=\"10.7759/cureus.31807\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEsteban Aguayo, Vishal Dobaria, Morcos Nakhla, Young-Ji Seo, Joseph Hadaya, Nam Yong Cho, Sohail Sareh, Yas Sanaiha, Peyman Benharash, (2020) National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy, Surgery, Volume 168, Issue 4,2020, Pages 625\u0026ndash;630, ISSN 0039-6060, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.surg.2020.06.018\u003c/span\u003e\u003cspan address=\"10.1016/j.surg.2020.06.018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Robotic cholecystectomy, emergent robotic cholecystectomy, cholecystitis, surgical outcomes in safety net hospital, high comorbidity burden, health inequity","lastPublishedDoi":"10.21203/rs.3.rs-6994381/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6994381/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe value of using the Da Vinci robotic platform to perform a cholecystectomy is still under investigation, particularly within emergent settings. The aim of our study is to analyze the safety, efficacy, and clinical outcomes associated with robotic cholecystectomy among patients with a high comorbidity load, comparative health disparities, and varying degrees of gallbladder pathology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo measure and compare 30-day postoperative complications seen in the robot-assisted cholecystectomy in a patient population with a high comorbidity load.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a single-institution, retrospective analysis of a total of 218 patients who underwent either an elective or emergent robotic cholecystectomy from January 2019 to January 2024. All cases were performed at a tertiary care hospital by four surgeons with varying levels of robotic experience, ranging from 25 years to 7 years of robotic experience. Baseline preoperative demographics, comorbidities, severity of gallbladder pathology, and 30-day clinical outcomes were recorded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 218 patients, 94 were emergent and 124 were elective. All had varying degrees of gallbladder pathology. The emergent cases were significantly more likely to have severe pathological findings compared to the elective cases. The overall complication rate in our population was 7.3%. The most common complications were postoperative sickle cell crisis, hepatic abscess, and incisional seroma. No bile duct injuries were encountered, and minimal 30-day outcomes were encountered.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn both elective and emergent settings, robotic cholecystectomy is safe and effective in a patient population with a high comorbidity load, health disparities, and varying degrees of gallbladder pathology.\u003c/p\u003e","manuscriptTitle":"Robotic Cholecystectomy is Safe and Effective for all Levels of Gallbladder Pathology in both the Elective and Emergent Setting in a Patient Population with a High Comorbidity Load: Outcomes from East Flatbush, New York Submission to the Journal of Robotic Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-22 07:58:25","doi":"10.21203/rs.3.rs-6994381/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-14T19:17:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-14T15:59:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"13649335415406663545421952811733978214","date":"2025-07-14T15:47:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"94630025480956155240954552972395264150","date":"2025-07-13T23:30:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190334774176093815890010487708865830234","date":"2025-07-13T13:47:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-13T09:07:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123048100829779878253290091292982267915","date":"2025-07-13T08:11:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-13T08:06:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-28T14:59:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-28T10:44:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2025-06-27T20:58:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"e6d6aa93-ff34-498d-a970-abbc16b79b18","owner":[],"postedDate":"July 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-04T16:45:20+00:00","versionOfRecord":{"articleIdentity":"rs-6994381","link":"https://doi.org/10.1007/s11701-025-02620-x","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2025-08-02 16:06:01","publishedOnDateReadable":"August 2nd, 2025"},"versionCreatedAt":"2025-07-22 07:58:25","video":"","vorDoi":"10.1007/s11701-025-02620-x","vorDoiUrl":"https://doi.org/10.1007/s11701-025-02620-x","workflowStages":[]},"version":"v1","identity":"rs-6994381","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6994381","identity":"rs-6994381","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}