Haemorrhage following transoral robotic surgery
D. Karassawa Zanoni
Department of Surgery, Head and Neck
Service, Memorial Sloan Kettering Cancer
Center, New York, NY, USA
I. Ganly, Department of Surgery Head and
Neck Service, Memorial Sloan Kettering
Cancer Center, New York, NY, USA.
NIH/NCI Cancer Center Support Grant,
Grant/Award Number: P30 CA008748
Background: To report our experience of postoperative haemorrhage in patients
following transoral robotic surgery (TORS).
Methods: Data were collected on patients having TORS. Postoperative haemor-
rhage within 30 days was graded using the Mayo Clinic grading system.
Results: Transoral robotic surgery operations were performed on 122 patients.
There were 23 bleeding events classified as minor to severe following 19 operations
(16%). Haemorrhage requiring a return to the operating room occurred after 7 oper-
ations (6%). The odds of an emergent haemorrhage were 5.19 times greater in
patients who had a staged neck dissection after TORS (P = .05). The odds of a post-
operative bleeding event were 2.6 times greater in patients receiving a larger resec-
tion (P = .107). There were no haemorrhage events in the 36 patients who received
a synchronous neck dissection with transcervical ligation of the external carotid
Conclusions: Surgical intervention for TORS haemorrhage occurred in 6% patients.
No haemorrhage occurred in patients who had ligation of the external carotid
Transoral robotic surgery (TORS) received approval from the FDA in
2009 and has been utilised for a number of different indications in
the upper aerodigestive tract (UADT),
particularly for the surgical
treatment of selected patients with cancer of the oropharynx. Tradi-
tional open surgical approaches with either mandibulotomy or lateral
pharyngotomy provide a good oncological standard against which
TORS can be compared.
TORS has the advantage of overcoming
line-of-sight restrictions, making it possible to access areas in the
UADT that was not previously accessible and can avoid the morbid-
ity of an open approach. TORS has been supported by a number of
recent publications reporting the short- and medium-term oncologi-
cal outcomes from single institutional studies
and a multi-institu-
tional study reporting a 3-year survival rate of 92.5% and a 3-year
recurrence-free rate of 88.8%.
There has also been promising func-
tional outcomes of TORS with appropriate adjuvant therapy.
Haemorrhage remains a potential risk after any surgery. Postop-
erative haemorrhage after TORS has been described and can be life
It is an area of current interest because of the increas-
ing adoption of TORS
and the active recruitment to current multi-
centre randomised controlled trials, such as ECOG 3311
In open surgical approaches, the
main feeder vessels to the primary resection are divided and ligated
and the defect repaired with a flap. In transoral robotic resections,
the primary defect is left open to heal by secondary intention.
The aim of this study was to describe our institutional experience
of postoperative haemorrhage after TORS. We aimed to report the
incidence of all haemorrhage episodes, episodes of major haemor-
rhage and identify predictive factors.
Memorial Sloan Kettering Cancer Center institutional review board
approval was granted for a retrospective study of all TORS
Presented at American Head and Neck academy meeting, Seattle, July 2016 as oral presen-
Accepted: 21 November 2017
© 2017 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/coa Clinical Otolaryngology. 2018;43:638–644.