Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Importance: Postoperative hemorrhage after transoral robot-assisted surgery (TORS) can be a life-threatening complication. Surgeons routinely ligate external carotid branches transcervically for bleeding risk mitigation. Another critical component of TORS should be the transoral management of surgical bed vessels at risk for postoperative rupture.
Objective: To illustrate principles of transoral ligation of distal external carotid branches to mitigate bleeding risk from anterograde and retrograde arterial blood flow.
Design: Retrospective cohort study
Setting: Single academic head and neck cancer program.
Participants: Patients who received TORS for the treatment of oropharyngeal cancer between May 2022 and September 2024.
Exposures: With preoperative imaging we assessed the anatomical location of external carotid arterial branches that we expected to be in close proximity to our TORS resection bed. Intraoperatively, exposed vessels were ligated as proximally and distally as possible through the transoral approach. Additionally, careful dissection was extended deep to the wound surface for additional vessels judged to be at risk for postoperative exposure and bleeding. These were also ligated as far proximally and distally as accessible. During the same procedure, neck dissections were performed, and the facial, lingual, and submental arteries were ligated transcervically as far distally and proximally as accessible.
Main Outcomes and Measures: Bleeding rates, surgical margins, and pharyngocutaneous fistula rates after TORS.
Results: The records of 25 patients who received TORS resection with transoral surgical bed ligation were reviewed. All patients underwent the approach to bleeding risk mitigation as described above, by one attending surgeon. One patient of 25 (4%) had a postoperative pharyngocutaneous fistula complicated by neck infection that resolved with systemic antibiotics. Negative margins were achieved in 24 of 25 (96%) patients. Postoperative bleeding occurred in one patient of 25 (4%) 30 days after surgery that did not require hospitalization and resolved spontaneously.
Conclusions and Relevance: In combination with transcervical ligation, transoral ligation of external carotid branches during TORS is safe and may add substantial postoperative bleeding risk mitigation for a high-risk surgery. A high comfort level with transoral vessel management may also maximize the probability of achieving negative margins with deeper dissection.