Abdominal wall endometriosis (AWE): Two case reports and literature review

INTRODUCTION AND IMPORTANCE

Endometriosis is one of the most frequent gynecologic disorders, clinically confirmed or suspected in one of nine women by the age of 44 years. Its location of occurrence can be classified into intra and extra pelvic. Abdominal wall endometriosis (AWE) is one of its rare location, with frequency of 0.04 to 5.5 %. Furthermore there are only a few cases of AWE in Indonesia that have been reported.

CASE PRESENTATION

Here we present two Indonesian patients at a General Hospital in Tangerang, Indonesia. The first patient, 26 years old, complained of an umbilical mass 2 years after caesarean section. The second patient, 36 years old, complained of an umbilical mass since 8 months, with no history of prior surgery. Both patients had pre-operative ultrasonography (US) and underwent wide local excision. Histopathology examination with presence of endometrial glandular components and endometrial-like stroma confirmed the diagnosis of AWE.

CLINICAL DISCUSSION

AWE is defined as any endometrial tissue found superficial to the peritoneum, locating most commonly at umbilical, inguinal area, and anterior abdominal wall. Pre-operative diagnostic tools include abdominal ultrasonography (US) or abdominopelvic computed tomography (CT) scan. Since treatment with medications is usually not effective, surgical treatment is recommended, along with confirmation by histopathological examination.

CONCLUSION

Diagnosis of AWE should be suspected in all women with symptoms of an abdominal mass and cyclic pain, especially if the patient had history of surgery at the abdominal region. AWE is quite rare, but its symptoms can affect quality of life. Hence, a multi-disciplinary approach is necessary, with the strongly recommended treatment of wide local excision to prevent recurrence and malignant transformation.

Recurrent perineal scar endometriosis: A case report

Introduction

Endometriosis is a chronic disease with the presence of endometrium-like tissue containing endometrial glands and stroma outside the uterus. The incidence of episiotomy scar endometriosis after vaginal delivery is 0.06-0.7%.

Case presentation

A 28-year-old parous woman with two previous vaginal deliveries with episiotomy presented to the outpatient department with severe pain and swelling in the perineal region over the past year, leading to difficulty in sitting, coitus and routine essential activities like defecation. She had undergone local perineal nodule excision surgery twice, which confirmed her perineal scar endometriosis diagnosis one year earlier at another hospital with no improvement in symptoms. Physical examination revealed a firm, tender, deeply embedded palpable nodule measuring approximately 3 - 4 cm in the left posterolateral aspect of the distal vagina. Wide local excision of the nodule with a clear margin of 1 cm was performed. The nodule extended up to the left ischial tuberosity and apex up to the pudendal vessels complex.

Discussion

The classic diagnostic triad of perineal endometriosis were present in this patient. Surgical intervention with wide local excision with a clear margin of approximately 1 cm of healthy tissue reduces the chance of recurrence.

Conclusion

Awareness of this condition among medical practitioners will lead to early diagnosis and excision. Timely intervention in the form of excision with free margins is the definitive treatment and provides complete pain relief and good quality of life for endometriosis patients.

The ultrasonography, colour Doppler ultrasonography and sonoelastography findings of scar endometriosis in comparison with menstrual phases

We aimed to evaluate ultrasonography (US), colour Doppler US (CDUS) and sonoelastography (SEL) findings of histopathologically proven abdominal wall scar endometriosis in comparison with menstrual phases. A total of 24 female patients with scar endometriosis were included. Lesion size, volume, echogenicity, solid/cystic or complex appearance, contour and location on US, vascularisation on CDUS, and elasticity on SEL were recorded in both menstrual and ovulatory phases. Hypoechoic heterogeneous lesions with increased peripheral echogenicity were observed in all lesions. The mean ± standard deviation (SD) volume of the lesions in the menstrual and ovulatory phases of the lesions was 4.36 ± 3.01 cm³ and 4.63 ± 7.61 cm³ (p = .316). The mean ± SD resistive index values on CDUS in the menstrual and ovulatory phases were 0.96 ± 0.09 and 0.97 ± 0.07, respectively (p = .667). The SEL examination demonstrated a hard coding pattern in all cases with no statistically significant difference between menstrual and ovulatory phases (p = .176). We found no significant difference in terms of US, CDUS and SEL findings of scar endometriosis in comparison with menstrual phases which suggests there is no need to evaluate the patient in a specific menstrual phase.Impact StatementWhat is already known on this subject? Scar endometriosis is the endometriosis located at the abdominal wall around the scar area with a very rare incidence. The typical sonographic findings of scar endometriosis are a hypoechoic solid mass with irregular contours. High resistive index on colour Doppler ultrasonography (CDUS) and hard coding pattern on sonoelastography (SEL) are seen in the lesion.What do the results of this study add? This is the first study that evaluates sonographic features of scar endometriosis lesions in the menstrual phase. We found that scar endometriosis lesions did not have a significant difference in terms of B-mode US, CDUS and SEL in menstrual and ovulatory phases.What are the implications of these findings for clinical practice and/or further research? Our findings suggest that there is no need to evaluate the patient in a specific menstrual phase.

Caesarean Scar Endometriosis May Require Abdominoplasty

Endometriosis is defined as an ectopic presence of endometrium-like tissue outside uterine cavity, which most commonly involves intraperitoneal organs. However, one of the less frequent forms of the disease is abdominal wall endometriosis usually developing in surgical scars following obstetric and gynaecological surgeries involving uterine cavity entering, that is, caesarean section, myomectomy or hysterectomy. In this case report we present a case of a patient with extensive caesarean scar endometriosis, who required complex surgical management. Successful surgical treatment involved not only radical tumour resection and application of mesh in postoperative hernia prevention but also adequate wound closure ensuring satisfactory cosmetic results, which was most challenging. The abdominal wall defect could not be sutured by traditional technique, thus polypropylene mesh was used and partial abdominoplasty was performed. The wound healed without complication and 24-month follow-up showed no evidence of local recurrence and satisfactory cosmetic result. In case of extensive endometrial abdominal wall tumours surgical treatment may involve application of advanced plastic surgery techniques, like abdominoplasty or skin/musculocutaneous flaps transposition.

Laparoscopic umbilical trocar port site endometriosis: A case report

BACKGROUND

Abdominal wall endometriosis can occur secondary to gynecological and obstetric pelvic laparotomy; however, this is a rare clinical event. There are few cases of endometriosis involving the incision site of a laparoscopic surgery, especially for those of the endometrial nodule at the umbilical trocar port site where the camera is placed.

CASE SUMMARY

We describe the case of a 37-year-old woman who presented with a 2-year history of a tough swelling below the umbilicus, which presented periodical pain during menstruation. The patient had undergone laparoscopic ovarian cystectomy 4 years prior, and we theorized that the umbilical nodule was a complication of that laparoscopic surgery. Histological analysis confirmed the diagnosis of abdominal umbilical scar endometriosis secondary to previous laparoscopic surgery. Surgical removal of the nodule followed by three cycles of leuprorelin was curative.

CONCLUSION

Abdominal mass and pain in women of childbearing age with a previous history of pelvic surgery should support consideration of endometriosis at the surgical site.

Cutaneous endometriosis: Presentation of 33 cases and literature review

OBJECTIVE

Cutaneous endometriosis is a rare condition that usually affects the abdominal wall in women with a history of open abdominal surgery. It has a characteristic clinical picture of a mass and pain associated with menstruation. The diagnosis is difficult on being an uncommon and little known condition. Once there is suspicion, a correct anamnesis and examination is usually sufficient. The treatment is normally surgery.

STUDY DESIGN

The study included all women identified with a diagnosis of cutaneous endometriosis over a period of 20 years. The variables collected and analysed included, age, surgical history, gynaecology history, symptoms, time period between surgery and consultation, specialist consulted, location, size, tests performed, treatment, and recurrence.

RESULTS

A total of 33 women were identified, with a mean age of 35.4 ± 2.33 years. A surgical history was found in 31 (93%) of 33 women. The main symptom was abdominal mass (96%), followed by period pain (51%), and non-period pain (42%). The initial diagnosis was correct in 15 (45%) of 33 women, and after performing further tests it was correct in 23 (69%) of 33 women. The main additional test was fine needle aspiration (FNA) in 24 (72%) of 33 patients. Surgery was performed on 30 (90%) of 33 women, with 8 (24%) women requiring a prosthesis. There was a recurrence of cutaneous endometriosis in 3 (9%) women.

CONCLUSION

Although it is a rare disease, its association with gynaecological surgery, and in particular caesarean section, means that there should be more awareness of this condition. Its diagnosis may be complicated due to lack of knowledge, when a proper examination and anamnesis can give us the key.

Symptomatology and Surgical Perspective of Scar Endometriosis: A Case Series of 16 Women

AIM

The prevalence of scar endometriosis is increasing with the increasing caesarean deliveries and laparoscopic procedures done for pelvic endometriosis. To analyse the symptomatology and surgical perspective of scar endometriosis.

MATERIALS AND METHODS

Retrospective review of 16 women who underwent surgery for scar endometriosis in the period of 4 years in Amrita institute of medical sciences.

RESULTS

Mean age of the patients is 35.19 years. Mean interval from the index surgery to the presentation is 4.56 years. Mean size of the swelling is 2.84 cm. In 68.8% of the patients, caesarean section was the inciting surgery. 18.7% had port site endometriosis. Cyclical pain and swelling at the scar site was present in 93.8% of the women. 18.9% had concurrent pelvic endometriosis. All women had involvement of the subcutaneous tissue followed by 11 women with the involvement of rectus sheath. There was no recurrence of the lesion in the operated patients in the mean follow-up period of 11.91 months.

CONCLUSION

In all women presenting with cyclical scar site pain and swelling, scar endometriosis should be considered. It commonly follows caesarean section and laparoscopic surgeries done for endometriosis. Wide local excision with or without reconstruction is the method of choice for this condition. Role of tumescent solution during surgery and postoperative medical management to reduce recurrence needs further prospective studies.

Scar endometriosis: Diagnosis by fine needle aspiration

Endometriosis is defined as the presence of a functioning endometrium outside the uterus. Abdominal wall endometriosis is a rare entity. Most of the abdominal wall endometriosis occurs in or around surgical scars following caesarean section or hysterectomy. We report a case of scar endometriosis following caesarean section and diagnosed by fine needle aspiration cytology (FNAC). Excision biopsy confirmed the FNAC diagnosis of scar endometriosis.

Surgical Treatment of Scar Endometriosis Following Cesarean Section, a Series of 12 Cases

It is difficult to conduct studies with larger series in rarely observed diseases. We report our experience in managing cesarean scar endometriosis (CSE) and emphasize the diagnosis and treatment options. The objective of our study is to review the clinical characteristics of CSE and to evaluate our surgical outcomes. We have collected and documented a case series of 12 patients who underwent surgical wide en bloc excision with surrounding clear margins for CSE. Patients' demographic features, symptoms, and clinical and operative findings were evaluated. The mean age was 34.6 years. Cyclical pain was documented in seven patients, while three patients presented with noncyclical pain. Menstrually-related enlargement of the nodule was observed in four patients, and only one patient had a complaint of dark brown leakage. The mean operation time was 26 min. The endometriotic lesions ranged from a diameter of 2 to 8 cm in size. Patients recovered completely, and no recurrence was observed. To prevent iatrogenic transplantation, additional attention is needed during surgery that exposes endometrial tissue. Complete wide excision of CSE is both diagnostic and therapeutic. To avoid unnecessary referrals, awareness of its typical clinical manifestations remains the mainstay for intervention. The most important issues to be considered during surgery is nonspreading endometriosis while manipulation.

Scar endometriosis - a rare cause for a painful scar: A case report and review of the literature

Endometriosis is described as the presence of functioning endometrial tissue outside the uterine cavity. Scar endometriosis is a rare disease, and is difficult to diagnose. The symptoms are nonspecific, typically involving abdominal wall pain at the incision site at the time of menstruation. It commonly follows obstetrical and gynecological surgeries. The diagnosis is frequently made only after excision of the diseased tissue. A case report of a patient with a troublesome scar after a caesarian section is presented. Surgical excision led to the diagnosis of scar endometriosis. The pathogenesis, diagnosis and treatment of this somewhat rare condition are discussed.