# Delayed Port-Site Hematoma Following Robot-Assisted Hysterectomy Using the Hinotori Surgical Robot System in an Anticoagulated Patient With Cardiovascular Comorbidities: A Case Report

## TL;DR

A 74-year-old woman on anticoagulation had a delayed port-site hematoma after robot-assisted hysterectomy, highlighting risks in managing anticoagulated patients.

## Contribution

This case report highlights the risk of delayed port-site hemorrhage in anticoagulated patients undergoing robotic surgery.

## Key findings

- The patient developed a 9-cm subcutaneous hematoma at the port site after anticoagulation was restarted.
- Bleeding was traced to a perforating branch of the inferior epigastric artery.
- Interrupting anticoagulation and using local compression achieved hemostasis.

## Abstract

Perioperative management of patients on anticoagulation therapy requires careful balancing of the thromboembolic and bleeding risks. Heparin bridging is considered for high-risk patients; however, it may increase the incidence of postoperative bleeding complications. We report the case of a 74-year-old woman with stage IA endometrial cancer and cardiovascular comorbidities, including atrial fibrillation and mitral stenosis, who was receiving warfarin therapy. She underwent robot-assisted laparoscopic hysterectomy using the Hinotori surgical robot system with heparin bridging. On postoperative day 5, after restarting both heparin and warfarin, the patient developed a 9-cm subcutaneous hematoma at the right lower abdominal port site. Contrast-enhanced computed tomography suggested bleeding from a perforating branch of the inferior epigastric artery. Anticoagulation was interrupted, and local compression achieved hemostasis. After cautious reinitiation of anticoagulation therapy, the patient was discharged on postoperative day 14 without recurrent bleeding. This case highlights the importance of careful interpretation of activated partial thromboplastin time during heparin bridging in patients receiving warfarin, as additive anticoagulant effects may lead to excessive anticoagulation. In addition, preoperative imaging assessment of abdominal wall vasculature and careful port placement are essential to prevent delayed port-site hemorrhage during robot-assisted surgery.