title: Learning curve for transoral robotic surgery: a 4-year analysis.
abstract: OBJECTIVE
  As new institutions incorporate transoral robotic surgery (TORS) into their everyday practice, it is helpful to have a timeline reference of expected goals to follow as their experience increases. This article evaluates a single tertiary care academic institution's experience with TORS for head and neck tumors and reports its 4-year learning curve.
  
  
  OBJECTIVE
  To evaluate a single institution's experience with TORS over a 4-year period and report treatment trends and clinical outcomes.
  
  
  METHODS
  Prospective case study.
  
  
  METHODS
  A single tertiary care academic institution.
  
  
  METHODS
  A total of 168 patients underwent TORS for tumors of the head and neck at University of Alabama at Birmingham between March 2007 and September 2011. The total group was subdivided into 4 consecutive groups (42 patients each). Patients were monitored throughout their hospital stay and up to 4.5 years postoperatively (mean follow-up duration, 14 months).
  
  
  METHODS
  Transoral robotic surgery.
  
  
  METHODS
  Data points were collected and compared over time, including feasibility, operative time, tumor type, stage, subsite, length of intubation, need for tracheostomy, feeding tube use, hospital stay, margin status, neck dissection performed, and postoperative complications.
  
  
  RESULTS
  Significant decreases in operative time, length of intubation, and hospital stay were seen as TORS experience increased. Overall, the mean operative time decreased by 47% (group 4, 86 minutes; group 1, 183 minutes). Total mean intubation time decreased by 87% (group 1, 12.9 hours; group 4, 1.7 hours) and mean hospital stay decreased from 3.0 days to 1.4 days. There was not a significant difference between groups in number of cases unable to be performed robotically (7-9 per group), tumor stage (majority T1/T2), tumor subsite (majority oropharynx), positive margin status (2-5 per group), number of salvage cases performed (7-9 per group), and number of tracheostomies (2-4 per group) or feeding tubes (22-25 per group) required.
  
  
  CONCLUSIONS
  This is the first multiyear prospective study to document a single institution's TORS experience over time and demonstrate particular areas of expected improvement as case number increases.
authors.affiliation: Head and Neck Surgery Center of Florida, Florida Hospital Celebration Health, Celebration, FL 34747, USA.
authors.forename: Hilliary N
authors.initials: HN
authors.lastname: White
authors.forename: John
authors.initials: J
authors.lastname: Frederick
authors.forename: Terence
authors.initials: T
authors.lastname: Zimmerman
authors.forename: William R
authors.initials: WR
authors.lastname: Carroll
authors.forename: J Scott
authors.initials: JS
authors.lastname: Magnuson
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000407:Alabama / Q000453:epidemiology; D004210:Dissection; D005260:Female; D005500:Follow-Up Studies; D005774:Gastrostomy / Q000706:statistics & numerical data; D006258:Head and Neck Neoplasms / Q000601:surgery*; D006801:Humans; D007442:Intubation, Intratracheal / Q000706:statistics & numerical data; D059032:Learning Curve; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D061646:Operative Time; D019647:Oral Surgical Procedures / Q000193:education*; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D012371:Robotics / Q000193:education*; D013997:Time Factors; D014139:Tracheostomy / Q000706:statistics & numerical data