Da Vinci-assisted versus laparoscopic sleeve gastrectomy for obesity: a GRADE-assessed systematic review and meta-analysis of prospective comparative studies with prespecified subgroup analysis by baseline BMI severity.

Robot-assisted sleeve gastrectomy has emerged as an alternative to conventional laparoscopy for managing severe obesity; however, its comparative effectiveness across the obesity spectrum remains unknown. We synthesized prospective comparative evidence comparing da Vinci–assisted and laparoscopic sleeve gastrectomy, incorporating prespecified body mass index strata and GRADE certainty ratings. The protocol (eligibility criteria, outcomes, subgroup definitions, and analysis plan) was finalized before database searching; however, administrative registration in PROSPERO (CRD420251274054) was completed on December 27, 2025, one day after the final database search (December 26, 2025). We searched PubMed, Embase, Web of Science, Cochrane CENTRAL, Scopus, ClinicalTrials.gov, and WHO ICTRP from inception to December 2025 for prospective comparative studies that enrolled adults undergoing primary sleeve gastrectomy and compared the robotic and laparoscopic approaches. Two reviewers independently screened the studies, extracted data, and assessed the risk of bias using the ROBINS-I tool. The primary outcomes included operative time, complications, and twelve-month body mass index. Random-effects meta-analyses were performed with pre-specified body mass index-stratified subgroups and sensitivity analyses. The GRADE methodology was used to assess the certainty of evidence. Five prospective studies enrolling 222 robotic and 246 laparoscopic patients were analyzed. Robotic surgery was associated with significantly longer operative time than laparoscopy (mean difference 12.89 min, 95% confidence interval 4.46–21.33; p = 0.003; I² = 78%), yet demonstrated comparable overall complications (odds ratio 0.86, 95% confidence interval 0.25–2.90; p = 0.80), anastomotic leak (odds ratio 1.20, 95% confidence interval 0.34–4.26; p = 0.78), bleeding (odds ratio 1.15, 95% confidence interval 0.12–11.22; p = 0.90), and length of stay (mean difference 0.13 days, 95% confidence interval − 0.47 to 0.73; p = 0.67). Robotic surgery achieved a significantly lower twelve-month body mass index compared than laparoscopy (mean difference − 1.85 kg per meter squared, 95% confidence interval − 3.38 to − 0.31; p = 0.02; I² = 0%). Body mass index-stratified subgroup analyses revealed numerically smaller operative time differences in patients with a higher body mass index, although the interaction was not statistically significant. GRADE certainty was very low for all outcomes owing to the serious risk of bias, inconsistency, and imprecision. Robot-assisted sleeve gastrectomy confers modest operative time prolongation with comparable perioperative safety and small twelve-month body mass index improvement compared with laparoscopy, although evidence certainty remains very low. These findings support cautious adoption at experienced centers, particularly for super-obese patients, while highlighting the urgent need for definitive randomized trials to establish the comparative effectiveness and optimal patient-selection criteria.