Perioperative protocols are not well-developed for transoral robotic surgery (TORS), and the degree of variability in perioperative practices between institutions is unknown.
To understand current perioperative practices for TORS among academic medical centers.
Clinical fellows and fellowship directors participating in 49 American Head and Neck Society Advanced Training Council fellowships
Main Outcome(s) and Measure(s):
Operative decisions, medical and swallowing management, and disposition planning were assessed.
Thirty-eight responses were voluntarily collected (77.6%). Twenty-three centers (60.5%) performed greater than 25 cases annually with the remainder performing fewer. The DaVinci Si was the most commonly used platform (n=28, 73.7%). Most (n=23, 60.5%) centers limited resections to T1-T2 tumors, and the remainder considered operating on T3-T4 tumors. A majority of institutions advocated tailored resection to adequate margins (n=27, 71.1%) over fixed subunit-based resection (n=11, 28.9%). Most surgeons (n=29, 76.3%) performed neck dissection concurrent with primary tumor ablation, and 89.5% (n=34) routinely ligated branches of the external carotid artery. A minority of institutions (n=17, 45.9%) endorsed a standardized TORS care pathway. Antibiotic choices and duration varied, the most common choice being ampicillin/sulbactam (n= 21, 55.3%), and the most common duration being 24 hours or less (n=22, 57.9%). Opiates were the most commonly used pain medication (n=36, 94.7%), and multimodal analgesia was used at 36 centers (94.7%). Steroids were utilized at 31 centers (81.6%). Mechanical VTE prophylaxis was used at all centers, whereas pharmacologic prophylaxis was used at 29 centers (76.3%). Feeding tubes were placed proactively during surgery at 20 institutions (54.1%). Speech-language pathologists routinely performed post-operative swallow evaluations at 29 (78.4%) sites. The most common disposition was a floor bed (n=21, 55.3%), the median length of stay reported was two days (range 0-5, mean 2.45).
Conclusions and Relevance:
Practice patterns are variable among institutions performing TORS. While certain surgical practices were quite common, post-operative practices varied, and many institutions reported no standard TORS care pathway. Further understanding of the impact of individual practices on outcomes is necessary to develop evidence-based perioperative protocols for TORS.