Robot-Assisted Simple Hysterectomy Complicated by Postoperative Pelvic Hematoma Uncovering Platelet Dysfunction in Myelodysplastic Syndrome.

Postoperative hemorrhage following robot-assisted simple hysterectomy (RASH) is uncommon but can be life-threatening. While most cases are attributable to surgical factors, occult hematologic disorders may cause bleeding that is refractory to standard intraoperative hemostasis. A 48-year-old woman with a longstanding history of systemic lupus erythematosus (SLE) underwent RASH for a high-grade squamous intraepithelial lesion (HSIL/CIN3). Although mild intraoperative oozing was observed, there was no major vascular injury. Postoperatively, she developed a large pelvic hematoma with progressive hemoglobin decline, which ultimately led to delayed-onset contrast extravasation requiring transcatheter arterial embolization (TAE). Hematologic evaluation revealed giant platelets and impaired platelet aggregation, and bone marrow biopsy demonstrated megakaryocytic dysplasia, establishing a diagnosis of myelodysplastic syndrome (MDS). She had no preoperative cytopenias or bleeding history, and conventional coagulation testing failed to identify her hemostatic vulnerability. This case highlights the insidious nature of qualitative platelet dysfunction in MDS, which can precipitate significant perioperative hemorrhage even in the absence of thrombocytopenia. Multidisciplinary management involving gynecologic surgery, hematology, and interventional radiology was essential to achieve hemostasis and a favorable outcome. Clinicians should maintain a high index of suspicion for occult bleeding diatheses when confronted with unexplained perioperative hemorrhage following minimally invasive procedures.