Should Transcervical Arterial Ligation Be Performed During Transoral Robotic Surgery?

TRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.com.

Background

Over the past 20 years, transoral robotic surgery (TORS) has cemented itself in the treatment paradigm for human papillomavirus (HPV)-mediated oropharyngeal squamous cell carcinoma (OPC). TORS was first approved by the U.S. Food and Drug Administration for the management of T1–T2 tumors of the oropharynx in 2009 and then again in 2019 with the debut of the da Vinci SP Surgical system (Intuitive Surgical Inc., Sunnyvale, Calif.). TORS allows for precise removal of OPC with adequate surgical margins, while preserving critical structures needed for speech and swallowing. Final pathology learned from TORS and neck dissection allows for safe reduction or elimination of post-operative adjuvant therapy.

The feared surgical complication of TORS is oropharyngeal hemorrhage. External carotid artery (ECA) branches (e.g., facial, lingual arteries) are routinely encountered during deep dissection. Post-operative bleeding can range from minor bleeding managed conservatively to life-threatening hemorrhage resulting in complications such as hypoxia, airway compromise, hemodynamic instability, and cardiopulmonary arrest. Published bleeding rates in TORS patients range from 5.4% to 13.2%. Major/severe bleeding occurs in 1.8% to 6.0% of TORS patients. To mitigate the risk of post-operative oropharyngeal bleeding, many TORS surgeons have advocated for transcervical arterial ligation (TCAL) of the ECA and its associated branches.

Given the use of TORS in the increasingly more common early-stage HPV-mediated OPC patient, a review of recent data regarding TCAL and a formal recommendation on whether it should be routinely performed is warranted.

Best Practice

Given the significant potential benefit with limited risk of complications, TCAL should be performed concurrently with TORS to decrease the risk of severe post-operative bleeding. Future studies should examine the optimal TCAL approach (selective ECA branches versus total ligation of the ECA).