VIMS Journal: December 2016

Case Report

Abdominal Incision Scar EndometriosisFollowing Cesarean Section: Case Report

Dr. Asif Ahmed , Dr. Barnali Basu, Dr. Arunava Das , Dr. Krishnendu Gupta , Dr. Bijit Chowdhury

Abstract :
Endometriosis is described as the presence offunctioning endometrial tissue outside the uterinecavity. Scar endometriosis is a rare disease, andis difficult to diagnose. The symptoms arenonspecific, typically involving abdominal wallpain at the incision site specially at the time ofmenstruation. It commonly follows obstetricalandgynaecological surgeries. The diagnosis isfrequently made only after excision of thediseased tissue, followed by histologicalexamination. This is a case series study ofabdominal wall endometriosis following cesareansection.

Introductions:
Endometriosis was first described by Rokitanskyin 1860 and was defined as the presence andproliferation of the endometrium outside theuterine cavity. Affecting an estimated 89 millionwomen of reproductive age worldwide,endometriosis occurs in 5% to 10% of all women,often resulting in debilitating pain and infertility.Although most frequently found in the pelvis,reports citing extrapelvic endometrial locationsrange from the lungs to the extremities. In aseries, the prevalence of surgically provenendometriosis in scars was 1.6%. [1,2] The mostcommon site is at a cesarean section scar. Butthere are case reports of involvement of the rectusabdominis muscle in a virgin abdomen. [3,4]

Endometriosis, in patients with scars, is morecommon in the abdominal skin and subcutaneous tissue compared to muscle and fascia.Endometriosis involving only the rectus muscleand sheath is very rare. [5] The simultaneousoccurrence of pelvic endometriosis with scarendometriosis has been found to be infrequent.Scar endometriosis is rare and difficult todiagnose, often confused with other surgicalconditions.

Case Report :
Case 01 : Mrs. PC, 29-year-old woman wasseen in consultation for a painful abdominalscar since 6 months. She was an otherwisehealthy woman with no significant medicalhistory. Her surgical history included anuncomplicated cesarean section five years ago.She complained of increasing pain andtenderness at the Pfannenstiel incisional siteduring her menstruation days, with no historyof discharge.

Physical examination revealed a well-healedcesarean scar, with two lumps over the previousscar, one on right side (2 x 2cm) and anotherone extending from midline to left side (4 x 6cm). Swelling was firm, tender and fixed withunderlying rectus sheath.

The scar was completely excised with clearmargins. The rectus sheath was apposed with2-0 prolene, followed by prolene mesh over thegap. Postoperative period was uneventful.Histopathology showed fibroadipose tissueswith interspersed glands and stroma ofendometriosis.

apposition of prolene mesh and fixation with rectus sheath

cut section of the specimen showing the cavity of endometrioma

specimen of the whole endometriotic tissue with clear margin

Case 02 :
Mrs. MG, 28 yrs old lady presented with a painfullump on the right lateral aspect of a Pfannensteilincision five years after an uneventful caesareansection. The lump was associated with cyclicalpain with no history of discharge. Abdominalexamination revealed a lump about 3 x 3 cm,firm, non mobile and tender, attached withunderlying rectus sheath.
Wide excision with clear margins wereperformed. Postoperative period was uneventful.Histopathology confirmed diagnosis ofendometriosis of abdominal wall scar.

Case 03 :
Mrs. SM, 29 yrs old woman presented at ourOPD with gradual development of swelling overleft lower abdomen, with cyclical pain andtenderness during and just after her menstruation.She had a history of uneventful caesarean sectionseven years back.
Examination revealed a lump about 3 x 2.5 cmjust above the left lateral aspect of Pfannensteilincision, which was firm tender and attachedwith underlying rectus sheath.
Wide excision with clear margins wereperformed. Postoperative period was uneventful.Histopathology confirmed diagnosis ofendometriosis of abdominal wall scar.

Discussion :
Scar endometriosis is a rare entity reported inthe gynaecological literature, and presents inwomen who have undergone a previousabdominal or pelvic operation [6] . The incidencehas been estimated to be only 0.03% to 0.15%of all cases of endometriosis. Many theories asto the cause of scar endometriosis have beenpostulated; however, the most generally accepted theory is the iatrogenic transplantation ofendometrial implants to the wound edge duringan abdominal or pelvic surgery.

The diagnosis of scar endometriosis may bechallenging. Cyclical changes in the intensity ofpain and size of the endometrial implants duringmenstruation are usually characteristic of classicalendometriosis. However, in the largest reportedseries [7] to date, only 20% of the patients exhibitedthese symptoms. Patients usually complain oftenderness to palpation and a raised, unsightlyhypertrophic scar.

Management includes both surgical excision andhormonal suppression. Oral contraceptives,progestational and androgenic agents have beentried. It is believed that hormonal suppression isonly partially effective and surgical excision ofthe scar is the definitive treatment.

Scar endometriosis is a rare and often elusivediagnosis that can lead to both patient andphysician frustration. One should maintain a highlevel of suspicion in any woman presenting with pain at an incisional site, most commonlyfollowing pelvic surgery. A thorough historyand physical examination should always beperformed, and every surgeon should considerthis entity in their differential diagnosis.

Malignant Risk :
Malignant change of endometriosis in a cesareanscar is rare [8] . Long-standing recurrent scarendometriosis could undergo malignant changesand clinicians should be aware. Only 21.3% ofcases of malignant transformation ofendometriosis occur at extragonadal pelvic sitesand 4% of cases in scars after laparotomy.

Follow Up and Prevention :
Follow up of endometriosis patients is importantbecause of the chances of recurrence, whichmay require re-excision. In cases of continualrecurrence, possibility of malignancy should beruled out. Hence, good technique and propercare during cesarean section may help inpreventing endometriosis.

References
  1. Roberge RJ, Kantor WJ, Scorza L. Rectus abdominisendometrioma. Am J Emerg Med 1999. 17(7):675-67710.1016/S0735-6757(99)90157-2.

  2. Apostolidis S, Michalopoulos A, Papavramidis TS,Papadopoulos VN, Paramythiotis D, Harlaftis N. InguinalEndometriosis: Three cases and literature review. SouthMed J 2009;102:206-7.

  3. Nominato NS, Prates LF, Lauar I, Morais J, Geber S.Caesarean section greatly increases risk of scarendometriosis. Eur J Obstet Gynecol 2010; 152:83-5.

  4. Hashim H, Shami S. Abdominal Wall Endometriosis inGeneral Surgery. The Internet Journal of Surgery.2002; 3.

  5. Celik M, Bülbüloglu E, Büyükbese MA, Cetinkaya A.Abdominal Wall Endometrioma: Localizing in RectusAbdominus Sheath. Turk J Med Sci 2004;34:341-343.

  6. Khoo JJ. Scar endometriosis presenting as an acuteabdomen: A case report. Aust NZ Obstet Gynaecol.2003; 43:164-5.

  7. Ding CD, Hsu S. Scar endometriosis at the site ofcesarean section. Taiwanese J Obstet Gynecol. 2006;3:247-9.

  8. Sergent F, Baron M, Le Cornec JB, Scotté M, Mace P,Marpeau L. Malignant transformation of abdominalwall endometriosis: a new case report. J Gynecol ObstetBiol Reprod (Paris) 2006; 35(2):186-190.

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