title: Defining the learning curve for robotic-assisted esophagogastrectomy.
abstract: BACKGROUND
  The expansion of robotic-assisted surgery is occurring quickly, though little is generally known about the "learning curve" for the technology with utilization for complex esophageal procedures. The purpose of this study is to define the learning curve for robotic-assisted esophagogastrectomy with respect to operative time, conversion rates, and patient safety.
  
  
  METHODS
  We have prospectively followed all patients undergoing robotic-assisted esophagogastrectomy and compared operations performed at our institutions by a single surgeon in successive cohorts of 10 patients. Our measures of proficiency included: operative times, conversion rates, and complications. Statistical analyses were undertaken utilizing Spearman regression analysis and Mann-Whitney U test. Significance was accepted with 95 % confidence.
  
  
  RESULTS
  Fifty-two patients (41 male: 11 female) of mean age 66.2 ± 8.8 years underwent robotic-assisted esophagogastrectomies for malignant esophageal disease. Neoadjuvant chemoradiation was administered to 30 (61 %) patients. A significant reduction in operative times (p <0.005) following completion of 20 procedures was identified (514 ± 106 vs. 397 ± 71.9). No conversions to open thoracotomy were required. Complication rates were low and not significantly different between any 10-patient cohort; however, no complications occurred in the final 10-patient cohort. There were no in-hospital mortalities.
  
  
  CONCLUSIONS
  For surgeons proficient in performing minimally-invasive esophagogastrectomies, the learning curve for a robotic-assisted procedure appears to begin near proficiency after 20 cases. Operative complications and conversions were infrequent and unchanged across successive 10-patient cohorts.
authors.affiliation: Department of Surgery, University of South Florida, Tampa, FL, USA.
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Hernandez
authors.forename: Francesca
authors.initials: F
authors.lastname: Dimou
authors.forename: Jill
authors.initials: J
authors.lastname: Weber
authors.forename: Khaldoun
authors.initials: K
authors.lastname: Almhanna
authors.forename: Sarah
authors.initials: S
authors.lastname: Hoffe
authors.forename: Ravi
authors.initials: R
authors.lastname: Shridhar
authors.forename: Richard
authors.initials: R
authors.lastname: Karl
authors.forename: Kenneth
authors.initials: K
authors.lastname: Meredith
mesh_terms: D000368:Aged; D059186:Chemoradiotherapy, Adjuvant; D004938:Esophageal Neoplasms / Q000628:therapy*; D016629:Esophagectomy / Q000009:adverse effects / Q000193:education / Q000379:methods*; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects / Q000193:education / Q000379:methods*; D017052:Hospital Mortality; D006801:Humans; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D061646:Operative Time; D011446:Prospective Studies; D012371:Robotics / Q000193:education; D013908:Thoracotomy