{"paper_id":"0e93f78d-bda7-49f5-8979-d76d8190a046","body_text":"~ 30 ~ \nInternational Journal of Case Reports in Surgery 2024; 6(1): 30-34 \n \n \nE-ISSN: 2708-1508 \nP-ISSN: 2708-1494 \nIJCRS 2024; 6(1): 30-34 \nwww.casereportsofsurgery.com  \nReceived: 21-10-2023 \nAccepted: 30-12-2023 \n \nM Benkhaldoun \nResident in Plastic Surgery, Department \nof National Burn Center and Plastic and \nReconstructive Surgery, Ibn Rochd \nCasablanca University Hospital Faculty \nof Medicine and Pharmacy of Casablanca \nHASSAN II University, Morocco \nCasablanca \n \nI Sahel \nResident in Obstetrics and Gynecology \nsurgery, Department of Obstetrics and \nGynecology, Abderrahim El Harouchi \nHospital, Ibn Rochd Casablanca \nUniversity Hospital Faculty of Medicine \nand Pharmacy of Casablanca HASSAN \nII University, Morocco Casablanca \n \nH Benaguida \nObstetrics and Gynecology Surgeon, \nDepartment OF Obstetrics and \nGynecology, Abderrahim El Harouchi \nHospital, Ibn Rochd Casablanca \nUniversity Hospital Faculty of Medicine \nand Pharmacy of Casablanca HASSAN \nII University, Morocco Casablanca \n \nS Karti \nPlastic Surgeon, Department of National \nBurn Center and Plastic and \nReconstructive Surgery, Ibn Rochd \nCasablanca University Hospital Faculty \nof Medicine and Pharmacy of Casablanca \nHASSAN II University, Morocco \nCasablanca \n \nA El Youssfi \nPlastic Surgeon, Department of National \nBurn Center and Plastic and \nReconstructive surgery, Ibn Rochd \nCasablanca University Hospital Faculty \nof Medicine and Pharmacy of Casablanca \nHASSAN II University, Morocco \nCasablanca \n \nS Sabur \nPlastic Surgeon, Department of National \nburn Center and Plastic and \nreconstructive surgery, Ibn Rochd \nCasablanca University Hospital Faculty \nof Medicine and Pharmacy of Casablanca \nHASSAN II University, Morocco \nCasablanca \n \nA El Harti \nPlastic Surgeon, Department of National \nBurn Center and Plastic and \nReconstructive Surgery, Ibn Rochd \nCasablanca University Hospital Faculty \nof Medicine and Pharmacy of Casablanca \nHASSAN II University, Morocco \nCasablanca \n \nM Diouri \nPlastic Surgeon and Chief of the \nDepartment, Department of National \nBurn Center and Plastic and \nReconstructive Surgery, Ibn Rochd \nCasablanca University Hospital Faculty \nof Medicine and Pharmacy of Casablanca \nHASSAN II University, Morocco \nCasablanca \n \nCorresponding Author: \nM Benkhaldoun \nResident in Plastic Surgery, Department \nof National Burn Center and Plastic and \nReconstructive Surgery, Ibn Rochd \nCasablanca University Hospital Faculty \nof Medicine and Pharmacy of Casablanca \nHASSAN II University, Morocco \nCasablanca \n \nParietal endometriosis on cesarean scar: Study of a \ncase \n \nM Benkhaldoun, I Sahel, H Benaguida, S Karti, A El Youssfi, S Sabur, A \nEl Harti and M Diouri \n \nDOI: https://doi.org/10.22271/27081494.2024.v6.i1a.97 \n \nAbstract \nObjective: Parietal endometriosis is a rare pathology. It can occur on all scars, most often during \nsurgical procedures with hysterotomy. It affects 0.03 to 0.4% of cesarean scars. \nPatients and Method: we report the case of abdominal wall endometriosis treated in the plastic \nsurgery department of the Ibn Rochd hospital center in Casablanca. \nResults: The age of our patient is 32 years old. She has two previous cesarean sections with \nPfannenstiel type laparotomies. The interval between the intervention and the appearance of symptoms \nis three years. She presented a clinical pi cture made up of pain punctuated by the menstrual cycle. The \ntreatment was surgical type of excision. The lesion invades the rectus abdominis muscle. The size of \nthe lesion is 3 cm. There were no complications or recurrence. \nDiscussion and Conclusion: Local endometrial cell transplantation is the most likely \npathophysiological mechanism to explain parietal endometriosis. The typical clinical picture combines \nswelling and pain punctuated by the menstrual cycle, but it is not always complete. Medical imaging \nmakes little contribution. Surgical treatment must be broad enough to avoid any recurrence. No means \nof prevention has proven its effectiveness. \n \nKeywords: Parietal endometriosis, endometriosis, surgical treatment, cesarean section scar, endometrioma \n \nIntroduction \nEndometriosis affects 8 to 15% of women in genital activity  [1, 2]. It is defined by the \nexistence of endometrial tissue outside the uterine cavity. The endopelvic form of this \npathology is the most common. But it can affect almost all organs exce pt the spleen. Among \nthe most frequent extrapelvic locations we must mention: the lung, the gallbladder, the small \nintestine and the colon, the kidneys, the rectovaginal septum, and the abdominal wall (recipis \nabdominis sheath, inguinal hernias). and umbil icals). This pathology is also found on \nabdominopelvic scars: episiotomies, uterine surgery scars, cesarean section scars, the path of \nan amniocentesis needle  [3, 4] and a trocar port  [5, 6], more rarely on an appendectomy scar. \nParietal endometriosis repr esents 1 to 2% of cases of extragenital endometriosis  [7]. The \nincidence of parietal endometriosis after cesarean section varies according to studies from \n0.03 to 0.4%  [1, 7, 8]. It can more rarely appear without any surgical history  [9]. The term \nparietal endometrioma is used to designate pelvic or extra-pelvic endometriosis in significant \nquantities and forming a mass. \nWe present a case of parietal endometriosis on cesarean section scar treated by the team of \nthe plastic surgery department of the Ibn Rochd hospital center in Casablanca. \n \nPatient and methodical \nWe report a case of parietal endometriosis. Pathological proof of the endometriotic lesion \nwas made. For our patient, we noted her age, the existence of a history of cesarean section or \npelvic surgery, the interval between the intervention and the first symptoms, the existence of \na history of endometriosis, the location and the size of the lesion, type of symptoms, carrying \nout additional tests; a non -specific ultrasound showing an oval formation, wit h irregular \ncontours, hypoechoic, heterogeneous, vascularized on color Doppler measuring \n32.6mm*30*23mm (Fig4); completed by an objectified MRI; an oval tissue formation, well \nlimited with irregular contours in heterogeneous isosignal T 1 and T 2 with zones in T 1 \nhypersignal after fat saturation, in peripheral hypersignal in diffusion without clear \nrestriction of diffusion, enhanced heterogeneously and especially in the periphery after \ninjection (Fig5); the type of treatment, the performance of a laparoscopy,  the existence of \npelvic endometriosis lesions and finally the presence or absence of a recurrence. \n\nInternational Journal of Case Reports in Surgery http://www.casereportsofsurgery.com \n \n~ 31 ~ \nResults \nOur patient with parietal endometriosis lesions on a scar was \ntreated in our department. His age is 32 years old. She had \nno history of genito -pelvic endometriosis. On the other \nhand, she has a surgical history. These are two cesarean \nsections with Pfannenstiel type laparotomy. \nThe interval between the surgical procedure and the \nappearance of the first symptoms is three years. Our patient \npresented a mass next to the scar (Fig 1) with cyclical pain \nassociated with an increase in volume of the mass. \nAdditional examinations were carried out using ultrasound \nand a scanner. Surgical treatment such as excision was \ncarried out. The  lesion infiltrates the ap oneurosis and the \nrectus abdominis muscle (Fig 2). The lesion found is 3 cm \n(Fig3). A simple suture of the parietal aponeurosis was \nsufficient to close the wall. No complications or recurrences \nwere noted. \n \n \n \nFig 1: Location and size of the tumor \n \n \n \nFig 2: Appearance and depth of the tumor \n \n \n \nFig 3: The tumor after total excision \nDiscussion \nEndometriosis is defined by the location of endometrial \ntissue outside the uterine cavity. Pelvic injuries are the most \ncommon. Endometrioma defines a significant amo unt of \nectopic endometrial tissue. Endometriomas  Parietals are \nrare. Several locations are possible. The most common are \nabdominal scars. These scars are often those of cesarean \nsections. In our case, our patient had two cesarean sections \nbefore the first symptoms appeared. It seems that this is \noften a complication of Pfannestiel type laparotomies  [10]. In \nour case, the laparotomy performed was of this type. \nParietal endometrioma complicates 0.03 to 0.4% of cesarean \nsections [1, 7, 8]. Steck and Helwig  [11] report 56 cases of \nparietal endometriosis on abdominal scar including 25 \ncesarean sections or 44.5%. In 1991 Rani  [12] reports 27 \ncases of parietal endometriosis. In 1995 Koger  [13] reported \n24 cases of parietal endometriosis. The other series include \na little less than ten patients  [1-14-16]. The lesion may appear \nearly after the surgical procedure or later. In the literature \nthe interval between the intervention and the appearance of \nthe first symptoms can ra nge from six months to 37 years \n[17]. The gap observed for our patient is 3 years. Classically, \naffected patients are all of childbearing age, as in our case. \nBut cases of probable reactivation of lesions under hormone \nreplacement therapy or in the presence of a secreting adrenal \nor ovarian tumor hav e been described  [2-18]. Finally, \nendometriomas on cesarean section scars would be more \nfrequent for cesarean sections carried out early, that is to say \nin the second trimester of pregnancy [12]. \n \nPathophysiology \nThe pathophysiology of this type of lesion is poorly \nunderstood. To explain endometriosis lesions several \ntheories have been proposed. The first theory was the reflux \ntheory. Endometrial cells implanting ectopically arise from \nthe reflux of menstrual blood through the tubes. For the \nsecond, the metaplastic theory, cells of the epithelium \nCoelomics under the influence of various stimuli undergo \nmetaplasia into endometrial cells. Finally, the metastatic \ntheory would explain certain extra-genital lesions by venous \nor lymphatic dissemination. For parietal endometriomas, the \nmost probable mechanism is the local transplantation of \nendometrial cells which will develop in a particular context. \nEndometrial cells have a high potential to develop in non -\nepithelialized areas [2]. Their development is also favored by \nsecondary inflammation induced by immunological factors. \nThe metaplastic theory has also been proposed to explain \nparietal endometriomas. Endometrioma arises from \npluripotential primitive mesenchymal cells which undergo \nspecific metaplastic differenti ation [1]. Finally, some \nauthors[19]think that the lesions could be explained by \nanatomical modifications. The uterus would adhere to the \nparietal peritoneum and with each episode  of menstruation \nthe blood flowing back through the tubes would follow the \nperitoneal folds and the adhesions to impregnate the scars. \n \nPathology \nMacroscopic appearance \nParietal endometriosis classically presents in the form of a \ncystic tumor. These are small tumors whose diameter is on \naverage 2 or 3 cm and can range from  microscopic form at \n12 cm in diameter  [28]. On section, the lesion has a fibrous \nappearance but the center of the lesion may contain a \nnecrotic area with the appearance of old blood. \n\nInternational Journal of Case Reports in Surgery http://www.casereportsofsurgery.com \n \n~ 32 ~ \nMicroscopic appearance \nMicroscopic examination reveals a columnar glandular \nepithelium of variable size, often cystic type associated with \na cytogenic chorion and lymphocytic inflammation. The \npercentage of these two elements varies with changes in \nhormonal impregnation. In the proliferative phase, the \nstromal cell population is unifor m, associated with \nproliferation of the glandular epithelium. During the \nsecretory phase, at the level of the chorion two cell \npopulations differentiate: large cells and small clear cells \nresembling respectively pre -decidual cells and endometrial \ngranulocytes. This appearance is typical of endometriosis \nbut can sometimes be confused with adenocarcinoma or \nadenocarcinoma metastasis. \n \nLocation \nThe lesion invades the underlying tissues next to the scars. \nBut certain parietal lesions appear outside of any surgi cal \ncontext [9-20]. For some authors, the umbilicus is likened to a \nscar, which would explain the affinity of endometrial cells \nfor this location [15]. The lesion often invades the abdominal \nmuscles and their sheath. It can invade all parietal \nstructures. The muscles most affected are the rectus \nabdominis muscle, the external oblique muscle and the \ntransverse muscle. Inguinal lesions related to the round \nligament are also described. \n \nClinical \nGenerally the tumor is small in volume, approximately 2 cm \nin dia meter. Classically the lesion is described as a mass \nappearing next to a scar which increases in size and \nbecomes painful cyclically, concomitantly with \nmenstruation. The cyclical nature of the pain is an important \nelement of orientation but it is far from  being essential to \nsuggest the diagnosis. Finally, when the lesion is very \nsuperficial it is possible to cyclically observe a change in \ncolor of the lesion which becomes bluish and can even \nfistulate into the skin in the form of a bloody discharge. \nPalpation of the lesion should make it possible to assess its \nsize and location in depth, the lesion frequently invading the \nabdominal muscles and their sheath. The main differential \ndiagnoses of a mass associated with an abdominal scar are: \nhernias, granulomas on threads, abscesses, hematomas, \nneuromas, epidermoid cysts and finally, more rarely, \nmalignant tumors (sarcoma, metastases of carcinomas) [1, 21, \n22]. In the case of a typical picture, the diagnosis can be easy \nto evoke. But, sometimes it is more difficu lt. In 37% of \ncases [1] the diagnosis is an anatomopathological discovery. \n \nAdditional tests \nRadiologie \nThe images obtained by ultrasound or using scanner in \nscarred endometriosis are not very specific. These are either \nimages having the appearance of a fl uid collection which \nwas the case in our patient (Fig 4) or tissue images without \nspecific character [3-23]. This solid or cystic appearance could \nalso change during the cycle depending on hormonal \nimpregnation. The CT scan can be useful to characterize th e \ninvasion of the lesion in depth,  MRI can also help with \ndiagnosis. In T 1 sequence, the lesion will be in hypersignal \nif intralesional bleeding is present  [24, 25] . These additional \nexaminations can also help eliminate a differential diagnosis \nsuch as an inguinal hernia. There is also no correlation \nbetween the fact that the lesion is suspected or not and the \nrequest for examination. Faced with a typical clinical \npicture, apart from the diagnosis of deep localization of the \nlesion, additional examinations provide little information \nand have few indications. \n \n \n \nFig 4: Ultrasound of the tumor \n \n \n \nFig 5: abdominopelvic MRI \n \nBiology \nSerum CA125 level may be increased in correlation with \nepithelial cell proliferation in endometriosis lesion [2]. \n \nMicro biopsy \nAccording to some authors  [21], an aspiration biopsy using a \nfine needle can make it possible to make the diagnosis or \nconfirm it before considering any surgical treatment. Our \nexperience leads us to prefer lumpectomy and single -stage \ntreatment. \n \nTreatment \nAttempts at medical treatment by medical castration have \nbeen made but the standard treatment remains surgical \n\nInternational Journal of Case Reports in Surgery http://www.casereportsofsurgery.com \n \n~ 33 ~ \nexcision of the lesion, especially since rare cases of \nendometrioid carcinomas on scars have been described  [26] \nand that recurrence under medica l treatment is ineducable. \nIn our case, our patient benefited from surgical treatment \nwhich was effective. Several studies [1-7] report a high rate of \nrecidivism. The reported risks of recurrence, however, vary \nfrom one study to another, from 0 to 15%  [1-16]. It therefore \nseems important to us to carry out a wide excision from the \noutset, even if it means using a parietal prosthesis to close \nthe aponeurotic defect  [7] which will also be done in the \nevent of a repeat offense. \nIn our case, we did not need to use a prosthesis and we did \nnot note any recurrence but the follow -up for our patient \nwas limited to two months. Some authors  [22] believe that it \nis necessary to prevent recurrences to have a healthy margin \nof 5 mm around the excision site and to avoid an y breakage \nof the lesion during the procedure. \nThe main complication of treatment is the secondary \nappearance of a hematoma. Recurrences seem frequent. \nParietal endometriosis is only associated in 24 to 26% of \ncases with pelvic lesions  [8, 12, 27]. The ben efit of systematic \nexploration by laparoscopy is limited by the prevalence of \nassociated lesions and by the risks involved in carrying out \nan examination whose therapeutic contribution is not \nobvious. Some authors suggest as a pathophysiological \nmechanism the migration of endometrial cells through a \ndefective cesarean section scar  [7]. Experimental \nendometriosis can also be achieved by invaginating the \nendometrium in a cesarean scar  [7-15]. It therefore seems \nimportant to us during the closure of a hysterot omy to \nensure the quality of the closure and to put back in place any \ninvagination of the endometrium, especially since the \ncesarean section is carried out early in the pregnancy. Some \nauthors [16] carry out a pressurized physiological saline wash \nof the s car during cesarean sections. There is currently no \nmeans of prevention that has proven its effectiveness. \n \nConclusion \nEndometriomas on cesarean section scars represent a \nsignificant portion of parietal endometriosis lesions. Very \nfrequently the patient has no history of pelvic endometriosis. \nThe symptoms can be typical with pain punctuated by the \nmenstrual cycle but it is necessary to know how to make the \ndiagnosis in the presence of a painful parietal tumor or not \nin the case of a history of gynecological  surgery. Additional \nexaminations are not very specific. They may possibly make \nit possible to locate the lesion in depth or eliminate a \ndifferential diagnosis. The excision of the lesions must be \nlarge enough to avoid any recurrence. As the associated \ngenito-pelvic lesions are most of the time asymptomatic, it \ndoes not seem necessary to systematically perform an \nexploratory laparoscopy. Finally, no means of prevention \nhas proven to be effective. However, given the \npathophysiological hypotheses, it seems important to ensure \nthe quality of hysterotomy closure during cesarean sections. \n \nReferences \n1. Patterson GK, Winburn GB. Abdominal wall \nendometriomas: report of eight cases. Am Surg. \n1999;65(1):36-9. \n2. Elabsi M, Lahlou MK, Rouas L, Essadel H, Benamer S, \nMohammadine A, et al . Scarring endometriosis of the \nabdominal wall. Ann Chir. 2002;127(1):65-7. \n3. Hughes ML, Bartholomew D, Paluzzi M. Abdominal \nwall endometriosis after amniocentesis. A report box. J \nReprod Med. 1997;42(8):597-9. \n4. Kaunitz A, Di Sant'Agnese PA. Needl e tract \nendometriosis: an unusual complication of \namniocentesis. Obstet Gynecol. 1979;54(6):753-5. \n5. Healy JT, Wilkinson NW, Sawyer M. Abdominal wall \nendometrioma in a laparoscopic trocar tract: a case \nreport. Am Surg. 1995;61(11):962-3. \n6. Thylan S. Re: abdomi nal wall endometrioma in a \nlaparoscopic trocar tract: a case report. Am Surg. \n1996;62(7):617. \n7. Lamblin G, Mathevet P, Buenerd A. Parietal \nendometriosis on abdominal scar, about three \nobservations. J Gynecol Obstet Biol Reprod (Paris). \n1999;28(3):271-4. \n8. Chatterjee SK. Scar endometriosis: a clinicopathologic \nstudy of 17 cases. Obstet Gynecol. 1980;56(1):81-4. \n9. Tomas E, Martin A, Garfia C, Sanchez Gomez F, \nMorillas JD, Castellano Tortajada G, et al. Abdominal \nwall endometriosis in absence of previous surgery. J \nUltrasound Med. 1999;18(5):373-4. \n10. Daye SS, Barone JE, Lincer RM, Blabey RC, Smego \nDR. Pfannenstiel syndrome. Am Surg. 1993;59(7):459 -\n60. \n11. Steck WD, Helwig EB. Cutaneous Endometriosis. \nJAMA. 1965;191(3):167-70. \n12. Rani PR, Soundararaghavan S, Rajaram P. \nEndometriosis in abdominal scars -review of 27 cases. \nInt J Gynaecol Obstet. 1991;36(3):215-8. \n13. Koger KE, Shatney CH, Hodge K, McClenathan JH. \nSurgical scar endometrioma. Surg Gynecol Obstet. \n1993;177(3):243-6. \n14. Seydel AS, Sickel JZ, Warner ED, Sax HC. Extrapelvic \nendometriosis: diagnosis and treatment. Am J Surg. \n1996;171(3):239. \n15. Caligaris P, Masselot R, Ducassou MJ, Le Treut Y, \nBricot R. Endometriosis of the abdominal wall. J \nGynecol Obstet Biol Reprod (Paris). 1981;10(4):465 -\n71. \n16. Wasfie T, Gomez E, Seon S, Zado B. Abdominal wall \nendometrioma after cesarean section: a preventable \ncomplication. Int Surg. 2002;87(3):175-7. \n17. Kennedy SH, Brodribb J, Godfrey AM, Barlow DH. \nPreoperative treatment of an abdominal wall \nendometrioma with nafarelin acetate. Case report. Br J \nObstet Gynaecol. 1988;95(5):521-3. \n18. Choi SW, Lee HN, Kang SJ, Kim HO. A case of \ncutaneous endometriosis developed in postmenopausal \nwoman receiving hormonal replacement. J Am Acad \nDermatol. 1999;41(2 Pt 1):327-9. \n19. Beizig S. Parietal endometriosis on cesarean s ection \nscar. J Chir (Paris). 1992;129(6-7):327-9. \n20. Ideyi SC, Schein M, Niazi M, Gerst PH. Spontaneous \nendometriosis of the abdominal wall. Dig Surg. \n2003;20(3):246-8. \n21. Simsir A, Thorner K, Waisman J, Cangiarella J. \nEndometriosis in abdominal scars: a report of three \ncases diagnosed by fine -needle aspiration biopsy. Am \nSurg. 2001;67(10):984-6. \n22. Matthes G, Zabel DD, Nastala CL, Shestak KC. \nEndometrioma of the abdominal wall following \ncombined abdominoplasty and hysterectomy: case \n\nInternational Journal of Case Reports in Surgery http://www.casereportsofsurgery.com \n \n~ 34 ~ \nreport and review of the literat ure. Ann Plast Surg. \n1998;40(6):672-5. \n23. Amato M, Levitt R. Abdominal wall endometrioma: CT \nfindings. J Comput Assist Tomogr. 1984;8(6):1213-4. \n24. Yu CY, Perez -Reyes M, Brown JJ, Borrello JA. MR \nappearance of umbilical endometriosis. J Comput \nAssist Tomogr. 1994;18(2):269-71. \n25. Turpin F, Daclin PY, Karam R, Meny R, Salanon AP, \nParamelle PJ, et al. A case of localization of muscular \nendometriosis and Nuck's canal. J Radiol. \n2001;82(8):933-5. \n26. Kotwall CA, Kirkbride P, Zerafa AE, Murray D. \nEndometrial cancer and abdom inal wound recurrence. \nGynecol Oncol. 1994;53(3):357-60. \n27. Wolf Y, Haddad R, Werbin N, Skornick Y, Kaplan O. \nEndometriosis in abdominal scars: a pitfall diagnosis. \nAm Surg. 1996;62(12):1042-4. \n28. Bumpers HL, Butler KL, Best IM. Endometrioma of \nthe abdominal wal l. Am J Obstet Gynecol. \n2002;187(6):1709-10. \n \nHow to Cite This Article \nBenkhaldoun M, Sahel I, Benaguida H, Karti S, Youssfi AE, Sabur S, \net al . Parietal endometriosis on cesarean scar: Study of a case . \nInternational Journal of Case Reports in Surgery. 2024;6(1):30-34. \n \n \nCreative Commons (CC) License \nThis is an open access journal, and articles are distributed under the \nterms of the Creative Commons Attribution -Non Commercial-Share \nAlike 4.0 International (CC BY -NC-SA 4.0) License, which allows \nothers to remix, tweak, and build upon the work non -commercially, \nas long as appropriate credit is given and the new creations are \nlicensed under the identical terms.","source_license":"CC0","license_restricted":false}