Haemorrhage following transoral robotic surgery in head and neck cancer

As the utilisation of transoral robotic surgery (TORS) continues to rise, there is a growing need to evaluate the risks of perioperative complications. Post-TORS haemorrhage represents the most severe complication associated with TORS, however currently there is no consensus for managing these patients. This review assessed the extent of post-TORS haemorrhage in head and neck cancer (HNC) patients and evaluated current approaches for achieving haemostasis following post-TORS haemorrhage. A comprehensive search of Medline, Embase & Web of Science was conducted, to identify articles published from the databases' inception to January 2025. Severity, incidence & management strategies employed in these studies were examined, in addition to risk factors associated with post-TORS haemorrhage. 28 studies met our inclusion criteria. The pooled average bleeding incidence for HNC patients following TORS was 7.24%, with the median day for initial bleeding episode occurring post-operative day 6. Classification of post-TORS haemorrhage severity was documented for 28.5% of reported bleeds, highlighting the need to adopt a classification system. Management strategies for achieving haemostasis varied significantly between institutions, and granularity with respect to airway management was poorly reported. Currently, consensus regarding an appropriate stepwise approach to managing post-TORS haemorrhage remains contested, as highlighted by the varied nature of haemostatic management techniques employed across a range of institutions in the included literature. As data becomes more readily available a standardised approach to classification of haemorrhage severity will be possible and consensus on haemostatic techniques can be made, which will support the creation of best practice guidelines.