{"paper_id":"0c424052-73c3-43e8-9117-62208d304506","body_text":"WWW.KJOG.ORG290\nA CASE OF TROCAR SITE IMPLANTATION OF \nENDOMETRIOSIS THREE YEARS AFTER LAPAROSCOPIC \nHYSTERECTOMY\nHo-Hyoung Lee, MD, Soyi Lim, MD, Jin-Woo Shin, MD, Chan-Yong Park, MD\nDepartment of Obstetrics and Gynecology, Gil Medical School, Gachon University of Medicine and Science, Incheon, Korea\nWe present the case of a 42-year-old woman who had undergone laparoscopic hysterectomy for uterine myoma three years prior \nto diagnosis with trocar site endometriosis. The patient was observed to suffer endometrial implant exclusively at the suprapub ic \ntrocar site. This case demonstrated that trocar site endometriosis can occur, even in a patient without a uterus and without \nprevious endometriosis. The etiopathogenesis of this condition was likely attributed to the dissemination of endometrial tissue  \nduring laparoscopic surgery, resulting in subsequent microscopic endometriosis cell implantation in the trocar site.\nKeywords: Endometriosis; Laparoscopy; Implantation\nReceived: 2011.12.19.   Revised: 2012.3.1.  Accepted: 2012.3.19.\nCorresponding author: Soyi Lim, MD\nDepartment of Obstetrics and Gynecology, Gil Medical School, \nGachon University of Medicine and Science, 1198 Guwol-dong, \nNamdong-gu, Incheon 405-760, Korea \nTel: +82-32-460-3254  Fax: +82-32-460-3290 \nE-email: soyilim@gmail.com\nTh is is an Open Access article distributed under the terms of the Creative Commons \nAttribution Non-Commercial License (http://creativecommons.org/licenses/\nby-nc/3.0/) which permits unrestricted non-commercial use, distribution, and \nreproduction in any medium, provided the original work is properly cited.\nCopyright © 2012. Korean Society of Obstetrics and Gynecology \nEndometriosis is a condition whereby functional endometrial tis-\nsue is present outside the uterine cavity. The disease commonly af-\nfects the pelvis with the most common locations being the ovaries, \nurine ligaments, rectovaginal septum and peritoneum. Unusual \nendometriosis outside the pelvis has been reported to include the \nbladder, intestines, appendix, hernia sacs, lungs, kidneys and other \nextremities. It well known that endometriosis may migrate and \nimplant in various anatomic locations including surgical scars [1]. \nHerein, we report the rare case of a patient who had undergone a \nlaparoscopic hysterectomy for uterine myoma three years prior to \na diagnosis of trocar site endometriosis.\nCase Report\nA 42 year old woman presented an approximately 3 cm sized \nmass in the suprapubic region at the site of trocar insertion, ac-\ncompanied by cyclic pain which had commenced eight months \nprior to her visit. The patient had undergone two Cesarean sec-\ntions, ten and twelve years prior to her visit, as well as a lapa-\nroscopic subtotal hysterectomy which was applied at a private \nclinic in order to treat a large uterine myoma three years prior to \nher visit. According to the private clinic, she did not report pelvic \npain, dysmenorrhea or dyspareunia prior to the hysterectomy. And \nbesides the uterine myoma, no other abnormal operative fi  ndings \nwere observed during the hysterectomy. Our physical examination \nrevealed an approximately 5 cm sized, non-tender mass, accom-\npanied with slight swelling, located in the suprapubic region just \nbeneath the suprapubic trocar site scar. Ultrasonography revealed \na 5.5 × 2.2 cm, oval-shaped, hypoechoic mass in the abdominal \nwall of the suprapubic region. No abnormal findings were ob-\nserved in the pelvis or ovaries (Fig. 1). Routine clinical laboratory \ntest results were all within normal limits except for CA-125, which \nwas slightly above normal range at 45.4 IU/mL. Based on these \nfindings and symptoms, granulomas due to surgical wounds or \nCASE REPORT\nKorean J Obstet Gynecol 2012;55(4):290-292\nhttp://dx.doi.org/10.5468/KJOG.2012.55.4.290\npISSN 2233-5188\n · eISSN 2233-5196\n\nWWW.KJOG.ORG 291\nHo-Hyoung Lee, et al. Trocar site implantation of endometriosis\nendometriosis was suspected. Surgical exploration was conducted \nwith the patient under general anesthesia. A sharp dissection was \ncarried down to the palpable mass, which was firmly attached \nto the fascia. Intraoperatively, an approximately 5 cm sized hard \nmass was found between the subcutaneous tissue and the fascia. \nThe mass was completely removed and the defect primarily closed. \nHistopathological examination revealed hyperplastic cicatic fi  bro-\nsis with regions of scattered stromal tubular and cystic glandular \nendometrial tissues (Fig. 2). The patient’s postoperative course was \nuneventful. She was treated with gonadotropin releasing hormone \nagonist with add-back therapy for 6 months with no resulting \ncomplications. Her serum CA-125 level returned to a normal range \nafter one month. After 19 months, she reported no abdominal \npain or other specifi  c complaints.\nDiscussion\nSurgical scar endometriosis is a rare condition and is always iat-\nrogenic. It can be observed after Cesarean section [2,3] and after \nepisiotomy at the perineal site [4]. Surgical scar endometriosis at \nthe trocar site has been described to be associated with the use of \nlaparoscopic surgery as a method for treatment [5,6]. In our case, \na symptomatic lesion was observed to develop three years after \nher laparoscopic hysterectomy, yet there was no endometriosis \nlesion noted at that time. As our knowledge, there is no case with \nscar endometriosis developed after hysterectomy for myoma such \nas our patient. This raises the question of how endometriosis im-\nplantation could occur three years after a laparoscopic hysterecto-\nmy in a patient without any previous evidence of an endometriotic \nlesion? \nThe etiopathogenetic mechanism by which endometriosis develops \nat a surgical wound site is evidently linked to endometrial tissue \ndissemination during the course of gynecological surgery. Subse-\nquent to surgery, and under the stimulus of therapeutic estrogen, \nsuch tissues tend to grow until becoming symptomatic [1]. The \ninfl  uence of surgical tumor manipulation and the resultant shed-\nding of tumor cells has been observed [7]. It has also been sug-\ngested that localized tissue ischemia renders that tissue conduc-\ntive to implantation [6]. Several authors have hypothesized that \nthe practice of insuffl  ating CO\n2 into the peritoneal cavity causes \ncell aerosolization and may promote tumor cell shedding [5-8]. A \nhigher probability of tumor growth on the peritoneum has been \nassociated with gas laparoscopy as opposed to gasless laparos-\ncopy procedures [7,8]. In the case of our patient, we suggest that \nmicroscopic endometriosis or otherwise undetected endometrial \ntissue, disseminated to the trocar site during laparoscopic surgery. \nBecause microscopic endometriosis tissue or endometrial cell \nimplantation likely occurred within the laparoscopy trocar site, \nsecondary to manipulation or instrument interference, our case \nsupports the hypothesis that the pneumoperitoneum influences \nthe mechanism of free intraperitoneal cell implantation within the \nabdominal cavity. \nIn conclusion, endometriosis in the trocar site is not a common \ncomplication but may occur in a patient without a uterus due to \nhysterectomy, even in a patient without previous endometriosis. \nThis can occur because microscopic endometriosis may implant at \nthe trocar site during hysterectomy. In light of the fact that the use \nFig. 1. Transabdominal sonography reveals a hypoechoic mass in the su-\nprapubic region.\nFig. 2. Endometrial stroma and gland structure of fibroadipose tissue \n(H&E, ×40).\n\nWWW.KJOG.ORG292\nKJOG  Vol. 55, No. 4, 2012\nof the laparoscopic procedure in the treatment of numerous gyne-\ncological pelvic conditions is increasingly common, surgeons who \nperform laparoscopy must utilize procedural caution to protect the \ntrocar site and surgical wound in order to prevent the dissemina-\ntion of endometrial cells.\nReferences\n  1. Koger KE, Shatney CH, Hodge K, McClenathan JH. Surgical \nscar endometrioma. Surg Gynecol Obstet 1993;177:243-6.\n  2. Firilas A, Soi A, Max M. Abdominal incision endometriomas. \nAm Surg 1994;60:259-61.\n  3. Luisi S, Gabbanini M, Sollazzi S, Calonaci F , Razzi S, Petraglia \nF . Surgical scar endometriosis after Cesarean section: a case \nreport. Gynecol Endocrinol 2006;22:284-5.\n  4. Gordon PH, Schottler JL, Balcos EG, Goldberg SM. Peri-\nanal endometrioma: report of five cases. Dis Colon Rectum \n1976;19:260-5.\n  5. Wakefi  eld SE, Hellen EA. Endometrioma of the trocar site after \nlaparoscopy. Eur J Surg 1996;162:523-4.\n  6. Martínez-Serna T, Stalter KD, Filipi CJ, Tomonaga T. An unusual \ncase of endometrial trocar site implantation. Surg Endosc \n1998;12:992-4.\n  7. Murthy SM, Goldschmidt RA, Rao LN, Ammirati M, Buchmann T, \nScanlon EF . The infl  uence of surgical trauma on experimental \nmetastasis. Cancer 1989;64:2035-44.\n  8. Hubens G, Pauwels M, Hubens A, Vermeulen P , Van Marck E, \nEyskens E. The infl  uence of a pneumoperitoneum on the peri-\ntoneal implantation of free intraperitoneal colon cancer cells. \nSurg Endosc 1996;10:809-12.\n복강경하 자궁절제술 시행 3년 후 트로카 삽입부위에서 발생한 자궁내막증 1예 \n가천의과학대학교 길병원 산부인과  \n이호형, 임소이, 신진우, 박찬용   \n  저자들은 3년 전에 복강경하 자궁절제술을 시행한 42세 여성에서 트로카 삽입부위에 발생한 자궁내막증 증례를 보고하는 바이다. 본 \n증례는 트로카 삽입부위의 자궁내막증이 자궁절제술을 시행받아 이미 자궁이 없는 환자에서도 발생할 수 있음을 시사하며, 특히 이전에 \n자궁내막증이 없었고 자궁근종으로 수술을 받은 경우였어도 발생하였다는 점이 특이할 만하다. 본 증례에서 발생한 병변의 발생 기전으\n로는 복강경수술 당시 자궁내막조직이 퍼져나갔거나, 육안으로 식별 어려운 자궁내막증 세포가 트로카 삽입부위에 착상한 것으로 생각\n된다.\n중심단어: 자궁내막증, 복강경, 착상","source_license":"CC0","license_restricted":false}