Bilateral Umbilical Artery Avulsion During Robot-Assisted Pelvic Lymphadenectomy for Endometrial Cancer: A Case Report Emphasizing Safe Hemostatic Management

Robot-assisted surgery has been rapidly adopted worldwide because of its advantages, including reduced blood loss, enhanced dexterity, and lower perioperative morbidity.However, the lack of haptic feedback remains an inherent limitation of robotic systems and may contribute to unintended vascular injury.When unexpected bleeding occurs, achieving hemostasis while avoiding secondary injury to adjacent organs and vessels becomes a critical challenge.A 54-year-old woman with a body mass index of 35 kg/m² underwent robot-assisted total hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy for clinical stage IA endometrial cancer.During development of the right paravesical space, traction applied by the robotic arm caused avulsion of the right umbilical artery at its origin, resulting in arterial bleeding from the right internal iliac artery.Temporary hemostasis was achieved with bipolar coagulation.After completion of the right pelvic lymphadenectomy, two large vascular clips were applied to reinforce hemostasis.Subsequently, removal of the traction suture used to elevate the bilateral umbilical arteries toward the abdominal wall for exposure of the bilateral paravesical spaces caused a similar avulsion of the left umbilical artery at its origin after completion of the left pelvic lymphadenectomy.Hemostasis was achieved with bipolar coagulation followed by the application of two large clips.The postoperative course was uneventful.Because our institutional surgical protocol involves developing the pararectal spaces before the paravesical spaces, the ureters had already been identified before the vascular injury occurred.This facilitated safe hemostatic management while minimizing the risk of ureteral injury.Although vascular clips provided effective hemostasis, their application through the assistant port was technically challenging because of the limited insertion angle in the deep pelvis.This case highlights the importance of appropriate surgical sequencing and preparedness for vascular emergencies while suggesting that articulating robotic clip appliers may facilitate safer and more efficient hemostasis.