title: Robotic Thymectomy: Learning Curve and Associated Perioperative Outcomes.
abstract: BACKGROUND
  Recently, robotic-assisted thymectomy (RAT) has emerged as an alternative to either, an open transsternal approach or to a video-assisted thoracoscopic approach, for both thymic tumors and benign lesions. We have reviewed our early experience with RAT to assess the associated learning curve as well as the short-term perioperative outcomes.
  
  
  METHODS
  A prospectively collected database was reviewed for patients who underwent RAT for all causes in the period 2012-2016. Robotic thymectomy cases were stratified and compared according to the number of cases performed by each surgeon (≤15 versus >15 cases). A propensity score matching was done to compare perioperative outcomes in patients undergoing robotic and transsternal resection of thymomas.
  
  
  RESULTS
  Seventy patients (47 females) with a median age of 52, underwent RAT. The median operative time was 102 min with 5 conversions to an open approach for local invasion (n = 3) or for complete pleural symphysis (n = 2). There were 2 rib fractures and 1 recurrent laryngeal nerve palsy. Median length of chest tube drainage and length of stay were 1 and 3 days, respectively. Operative time and estimated blood loss plateaued after surgeon's initial 15-20 cases, which may reflect the initial learning curve. A comparison between early and late robotic cases showed that with the growing experience, the operative time becomes shorter (94 versus 107 min, P = .018). Propensity score analysis between robotic and transsternal resection of thymoma (n = 22 in each group) showed no significant differences in operative time (P = .79), intraoperative complications (P = .99), or postoperative complications (P = .99).
  
  
  CONCLUSIONS
  Robotic thymectomy is feasible and safe, and is associated with comparable perioperative outcomes to the traditional transsternal approach in patients undergoing thymomectomy. An initial learning curve of 15-20 robotic thymectomy cases may be required by the surgeons to adequately perform this relatively novel technique.
authors.affiliation: Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital - Weill Cornell Medical College , New York, New York.
authors.forename: Mohamed K
authors.initials: MK
authors.lastname: Kamel
authors.affiliation: Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital - Weill Cornell Medical College , New York, New York.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Rahouma
authors.affiliation: Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital - Weill Cornell Medical College , New York, New York.
authors.forename: Brendon M
authors.initials: BM
authors.lastname: Stiles
authors.affiliation: Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital - Weill Cornell Medical College , New York, New York.
authors.forename: Abu
authors.initials: A
authors.lastname: Nasar
authors.affiliation: Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital - Weill Cornell Medical College , New York, New York.
authors.forename: Nasser K
authors.initials: NK
authors.lastname: Altorki
authors.affiliation: Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital - Weill Cornell Medical College , New York, New York.
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Port
mesh_terms: D005260:Female; D006801:Humans; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011183:Postoperative Complications; D057216:Propensity Score; D011446:Prospective Studies; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000193:education* / Q000379:methods; D013934:Thymectomy / Q000193:education* / Q000379:methods; D013945:Thymoma / Q000601:surgery*; D013953:Thymus Neoplasms / Q000601:surgery*
keywords: learning curve; robotic; thymectomy