{"paper_id":"1686cbc9-bd78-4e65-9b6f-c3feb8d5a307","body_text":"Review began\n 02/07/2024 \nReview ended\n 02/28/2024 \nPublished\n 03/03/2024\n© Copyright \n2024\nKalfoutzou et al. This is an open access\narticle distributed under the terms of the\nCreative Commons Attribution License CC-\nBY 4.0., which permits unrestricted use,\ndistribution, and reproduction in any\nmedium, provided the original author and\nsource are credited.\nRectus Abdominis Endometriosis Following\nCesarean Section: A Case Report\nAreti Kalfoutzou \n, \nAsimina Restemi \n, \nAdam Mylonakis \n, \nKonstantinos Papadimitropoulos \n,\nDimitrios Matsaridis \n, \nAndria Peraki \n, \nMargaritis Tsantopoulos \n, \nNikolaos Chaleplidis \n1.\n Department of Medical Oncology, 251 Air Force General Hospital, Athens, GRC \n2.\n Department of Pathology, 251 Air\nForce General Hospital, Athens, GRC \n3.\n Department of Surgery, Laikon General Hospital, National and Kapodistrian\nUniversity of Athens, Athens, GRC \n4.\n Department of Surgery, 251 Air Force General Hospital, Athens, GRC \n5.\nDepartment of Radiology, 251 Air Force General Hospital, Athens, GRC \n6.\n Department of Gynecology, Elena Venizelou\nGeneral Maternal Hospital, Athens, GRC\nCorresponding author: \nAreti Kalfoutzou, \naretik92@gmail.com\nAbstract\nEndometriosis involves the growth of endometrial-like tissue outside the uterine cavity, with its\nmanifestation in the rectus abdominis muscle being exceptionally rare and primarily observed in women\nwith a history of abdominal surgeries. In this report, we present the case of a 42-year-old female with a\nmedical history of two cesarean sections who presented with cyclical abdominal pain and a palpable mass in\nthe right lower quadrant. An MRI scan of the pelvis revealed a lesion on the right lower quadrant of the\nabdominal wall, proximate to the previous Pfannenstiel incision. A percutaneous US-guided biopsy of the\nabdominal lesion was performed, and histopathology demonstrated the presence of endometrial glands and\nstroma, confirming the diagnosis of rectus abdominis endometriosis. She was submitted to a local wide\nexcision with adequate margins of normal surrounding tissue and has remained free of recurrence for two\nyears.\nCategories:\n Pathology, Obstetrics/Gynecology\nKeywords:\n cesarean section, surgical margins, surgical excision, caesarian section, rectus abdominis muscle,\nendometriosis\nIntroduction\nEndometriosis, characterized by the presence of endometrial tissue outside the uterus, is a complex\ngynecological condition affecting approximately 5%-10% of women globally \n[1,2]\n. Ectopic endometrial\ntissue, while most commonly found within the pelvic cavity (on the ovaries, fallopian tubes, and peritoneum)\ncan, in rarer instances, be present in extrapelvic locations such as the abdominal wall, lung, or even the\nbrain. \n[1,3]\n. Notably, the prevalence of abdominal wall endometriosis is reported to be between 0.03% and\n1% among women who have undergone cesarean sections or other types of abdominal surgery \n[4]\n. Despite its\nrarity, the impact of abdominal wall endometriosis on patients can be profound, often resulting in\nsignificant pain and discomfort, which may be cyclical in nature, coinciding with the menstrual cycle. The\ndiagnosis of rectus abdominis endometriosis poses significant challenges, as its symptoms can overlap with\nthose of other abdominal pathologies, necessitating a thorough differential diagnosis process and often\nrequiring a multidisciplinary approach. This report presents the case of a 42-year-old woman presenting\nwith cyclical abdominal pain and a palpable abdominal wall mass who was diagnosed with rectus abdominis\nendometriosis. The case aims to highlight the distinct clinicopathological characteristics and to increase\nclinical awareness and diagnostic suspicion of endometriosis in this uncommon location, particularly in\nwomen with a history of abdominal surgeries.\nCase Presentation\nA 42-year-old woman was referred to our department due to a history of abdominal pain that intensified\nduring menstruation over the past four years. Her medical history included two cesarean sections, performed\n12 and 10 years ago, and the surgical excision of an in situ melanoma in the genital region seven years ago.\nShe had no reported history of pelvic endometriosis. A physical examination of the abdomen revealed a\nfirm, painless, palpable mass in the lower right quadrant. Laboratory values, including tumor marker cancer\nantigen 125 (CA-125), were within normal limits (17.4, normal range: 0-35 U/mL). \nA transvaginal ultrasound showed no abnormal findings. However, an abdominal ultrasound identified a\nfocal hypoechoic lesion within the rectus abdominis muscle. Further evaluation by MRI scan of the pelvis\nrevealed a lesion measuring 20 mm in its largest dimension, located on the right lateral aspect of the lower-\nanterior abdominal wall, in proximity to the Pfannenstiel incision. On T1-weighted fat-saturated images,\nthe lesion exhibited avid contrast enhancement, whereas on T2-weighted images, its signal was slightly\nhyperintense compared to the left rectus abdominis muscle (Figure \n1\n). Notably, the posterior edge of the\nlesion was closely adjacent to loops of the small intestine without intruding upon them.\n1\n2\n3\n4\n5\n6\n2\n2\n \n Open Access Case\nReport\n \nDOI:\n 10.7759/cureus.55462\nHow to cite this article\nKalfoutzou A, Restemi A, Mylonakis A, et al. (March 03, 2024) Rectus Abdominis Endometriosis Following Cesarean Section: A Case Report.\nCureus 16(3): e55462. \nDOI 10.7759/cureus.55462\n\nFIGURE\n 1: An MRI scan of the abdomen with intravenous contrast\nPanel A: T1 post-contrast fat-saturated weighted image depicts a lesion with avid enhancement in the right rectus\nabdominis muscle (white arrow). Panel B: A T2-weighted image reveals a lesion with higher signal intensity in the\nright rectus abdominis muscle compared to the left (white arrow).\nA percutaneous US-guided biopsy of the palpable lesion was performed. Histopathological examination\nrevealed the presence of endometrial-type glands and stroma embedded within the muscular tissue (Figure\n2\n). Additionally, foci of hemosiderin-laden foci, fibrosis, and atrophy were observed in the adjacent muscular\ntissue. Immunohistochemical staining showed that the glandular cells were positive for cytokeratin 7 (CK7)\nand paired-box gene 8 (PAX8), while the stromal cells exhibited positive staining for CD10 (Figure \n3\n).\nCollectively, these findings were suggestive of ectopic endometrial tissue strictly confined within the rectus\nabdominis muscle without extension to adjacent tissues.\nFIGURE\n 2: Panel A: Histopathological examination (hematoxylin-eosin\nstain, 20x magnification) exhibits endometrial glands (white arrow) and\nstroma (black arrow) embedded within muscle fibers (visible on the left\nside of the image). Panel B: In the immunohistochemical analysis (20x\nmagnification), positive PAX8 staining is observed in both the glandular\ncomponent and the surrounding stroma.\nPAX8: paired-box gene 8\n2024 Kalfoutzou et al. Cureus 16(3): e55462. DOI 10.7759/cureus.55462\n2\n of \n6\n\nFIGURE\n 3: Immunohistochemical staining, 20x magnification\nPanel A: The glandular component exhibits positive staining for CK7. Panel B: The stromal component shows\npositive staining for CD10.\nCK7: cytokeratin 7\nSubsequently, the patient underwent local excision of the lesion en bloc with part of the surrounding rectus\nabdominis muscle without entering the peritoneal cavity. Macroscopic examination of the surgical specimen\nrevealed a whitish lesion measuring 25 mm in size. The lesion was removed with a minimum margin of 12\nmm of surrounding normal tissue on all sides. The lesion demonstrated characteristic features of\nendometriosis, including endometrial glands and stroma, accompanied by both recent and old hemorrhagic\nactivity. Hemosiderin-laden macrophages, as well as focal atrophy, were observed in the surrounding muscle\ntissue. Immunohistochemical analysis showed positive staining for CK7 in the glandular cells and positive\nstaining for CD10 in the stromal cells. Both glandular and stromal cells expressed PAX8, estrogen, and\nprogesterone receptors, confirming the diagnosis of rectus abdominis endometriosis. \nThe postoperative course was uneventful, and the patient was discharged the following day. She has been\nunder consistent gynecological follow-up for two years since the surgery, including monitoring with CA-125\nmeasurements, abdominal MRI scans, and gynecological ultrasounds, with no evidence of disease\nrecurrence. The patient is scheduled for biannual follow-up visits for a total of five years.\nDiscussion\nEndometriosis is defined by the presence of functional ectopic endometrial tissue outside the uterine cavity\n[5,6]\n. This condition primarily affects women of childbearing age, with a peak incidence around the age of\n35, and is a major cause of infertility among women in this age group \n[5]\n. Endometriosis can manifest within\nthe pelvic cavity, affecting the ovaries, fallopian tubes, Douglas pouch, cervix, vagina, bladder, rectum, and\nperitoneal surface, or extend to extrapelvic organs such as the skin, kidneys, lungs, extremities, liver,\nstomach, or brain \n[2,4,6-8]\n. An exceedingly rare form is rectus abdominis endometriosis, where the\nendometrial tissue lies within the rectus abdominis muscle \n[3,4]\n. This particular type of endometriosis\npredominantly affects women who have undergone prior abdominal surgical procedures, such as cesarean\nsections, with the onset usually ranging from three months to 10 years after the surgery \n[4,8,9]\n. The\nprevalence of rectus abdominis endometriosis, especially following a cesarean section, is reported to range\nfrom 0.03% to 0.45% \n[8]\n. Approximately 25% of these cases have a history of pelvic endometriosis \n[6,10,11]\n.\nOur patient presented symptoms six years after a cesarean section, and there was no history of pelvic\nendometriosis.\nVarious theories have been suggested to explain the etiology of endometriosis. The transplantation theory,\nwidely recognized, hypothesizes that endometriosis develops from the retrograde transport of viable\nendometrial tissue during menstruation \n[6,7,9,12,13]\n. The coelomic metaplasia theory proposes that\nendometriosis stems from the transformation of peritoneal cells \n[6,9,12,13]\n. The induction theory,\nalternatively, suggests that the spread of shed endometrial tissue leads to endometriosis \n[7,10,12]\n. Moreover,\nthe embryonic rest theory proposes that endometriosis is triggered by the activation of Müllerian origin cells\n[10]\n. Notably, abdominal wall endometriosis has been linked to iatrogenic dissemination following surgical\nprocedures in the abdomen \n[7]\n. Furthermore, the potential for lymphatic and vascular spread has been\nconsidered in the pathogenesis of extrapelvic endometriosis \n[7,10,12-14]\n. \nThe clinical presentation of rectus abdominis endometriosis varies widely, ranging from asymptomatic to\nsevere, incapacitating acute abdominal pain \n[11,15]\n. The most common symptoms include abdominal pain\nthat intensifies during menstruation, dysmenorrhea, irregular menses, dyspareunia, or infertility \n[2,8]\n. Non-\ncyclical abdominal pain can also be a symptom of this condition in one-third of patients \n[14]\n. A palpable\nnodule may be detected during a clinical examination, typically located adjacent to a surgical scar \n[16]\n. In\n2024 Kalfoutzou et al. Cureus 16(3): e55462. DOI 10.7759/cureus.55462\n3\n of \n6\n\nrare instances, a diagnosis is made incidentally during a surgical procedure performed for a different\nmedical issue \n[17]\n. \nLaboratory tests typically do not yield diagnostic results, although CA-125 levels are frequently found to be\nmildly elevated \n[2,3]\n. Ongoing studies are evaluating the potential of markers like C-reactive protein (CRP),\nanti-Müllerian hormone (AMH), follistatin, CA 19-9, CA 15-3, and vascular endothelial growth factor\n(VEGF), among others, as indicators for the detection of endometriosis; yet, to date, none have shown\nconsiderable specificity \n[3,11]\n. In our case, all laboratory tests, including CA-125, were within normal ranges.\nImaging modalities, including ultrasonography, CT scans, and MRI scans, can aid in distinguishing rectus\nabdominis endometriosis from adjacent tissues \n[15]\n. Common ultrasonographic findings include well-\ndefined, hypoechoic masses that may be solid, cystic, or have mixed components and frequently exhibit high\nvascularity on Doppler imaging \n[2,6,9,16]\n. On a CT scan, the lesions generally appear isointense to muscle\ntissue and exhibit heterogeneous, significant contrast enhancement \n[16]\n. An MRI scan of the abdomen and\npelvis is the preferred imaging modality, often showing cystic structures that display high signal intensity on\nT1-weighted images and variable intensities on T2-weighted images, depending on the amount of glandular\ntissue and the age of hemorrhagic products (9,15,16). However, it is important to note that there are no\nimaging findings pathognomonic for diagnosing rectus abdominis endometriosis \n[1,2,6,16]\n.\nDifferential diagnosis includes a variety of benign and malignant lesions of the abdominal wall, such as\nsuture granuloma, lymphadenopathy, abscess, inguinal or incisional hernia, lipoma, hematoma,\nsubcutaneous and sebaceous cysts, primary or metastatic cancer, lymphoma, sarcoma, and desmoid tumor\n[2,10-12,17-19]\n. \nA definitive diagnosis is established through histopathological analysis of tissue samples, typically acquired\nvia a US-guided biopsy \n[6,16,18]\n. In certain instances, the diagnosis is established postoperatively following\nan excisional biopsy \n[18]\n. Histopathological examination typically shows the presence of endometrial glands\nand stroma embedded in the skeletal muscle fibers of the rectus abdominis muscle \n[10,14]\n. The glands are\nencased by columnar epithelial cells, while the stroma consists of small, spindle-shaped cells with minimal\ncytoplasm \n[9]\n. Occasional foci of hemosiderin-laden macrophages can also be observed within the striated\nmuscle \n[20]\n. Immunohistochemistry typically indicates positive staining for estrogen and progesterone\nreceptors in both stromal and glandular cells, as well as positive staining for PAX8 and CK7 in glandular\ncells and positive CD10 staining in endometrial stroma \n[6,21]\n.\nThe primary treatment for this condition is wide local excision, which necessitates the removal of at least 10\nmm of normal tissue surrounding the lesion to reduce the risk of recurrence \n[2,7,9,17]\n. In rare instances,\nasymptomatic cases may be monitored without immediate intervention \n[15]\n. Historically, pharmacological\ntreatments such as oral contraceptives, gonadotropin-releasing hormone (GnRH) analogs, progesterone, or\ndanazol have been used with limited effectiveness as primary treatments \n[3,7,9,16]\n. However, these agents\nmay serve as an alternative for patients who cannot undergo surgery or as adjuvant therapy to mitigate the\nrisk of recurrence \n[7,9,16]\n. There has been a report of successful treatment of rectus abdominis\nendometriosis using sclerotherapy with ultrasound-guided ethanol injection \n[18]\n. Additionally, high-\nintensity focused ultrasound (HIFU) ablation has been experimented with and has shown promising results\n[22]\n. In our case, surgical intervention was decided due to the patient’s escalating abdominal pain, which led\nto the complete resolution of symptoms. \nThe prognosis is typically favorable, with a recurrence rate of up to 4.3% \n[9,11]\n. Instances of malignant\ntransformation have been documented, occurring in roughly 0.3% to 1% of cases \n[9,11]\n. Regular\ngynecological follow-up is crucial to detect any potential recurrence of endometriosis in the local area. This\ninvolves clinical assessment, CA-125 measurements, as well as consistent gynecological ultrasounds and\nabdominal imaging \n[10,11]\n. \nTo the best of our knowledge, this is the 25th case of endometriosis strictly confined within the rectus\nabdominis muscle reported in the literature since 1984 \n[3,6,7,23-26]\n. The patient's history of cesarean\nsections, the cyclical nature of her pain in sync with menstrual cycles, and the detection of a palpable nodule\nduring clinical examination are hallmark features of rectus abdominis endometriosis. This case underscores\nthe importance of considering rectus abdominis endometriosis in differential diagnosis, particularly in\npatients with similar clinical profiles, to ensure timely and appropriate management.\nConclusions\nThe diagnosis of rectus abdominis endometriosis requires a high index of suspicion, especially in women\nwith a history of abdominal surgeries presenting with cyclical abdominal pain. Surgical excision, ensuring\nwide margins of normal tissue, emerges as the cornerstone of treatment, offering the most definitive means\nof symptom relief and minimizing the risk of recurrence. Ongoing and thorough follow-up of patients is\nimperative in ensuring early recurrence detection and in maintaining and potentially enhancing the\npatient's overall quality of life.\n2024 Kalfoutzou et al. Cureus 16(3): e55462. DOI 10.7759/cureus.55462\n4\n of \n6\n\nAdditional Information\nAuthor Contributions\nAll authors have reviewed the final version to be published and agreed to be accountable for all aspects of the\nwork.\nConcept and design:\n  \nAdam Mylonakis, Areti Kalfoutzou, Nikolaos Chaleplidis\nAcquisition, analysis, or interpretation of data:\n  \nAdam Mylonakis, Areti Kalfoutzou, Asimina Restemi,\nDimitrios Matsaridis, Andria Peraki, Konstantinos Papadimitropoulos, Margaritis Tsantopoulos\nDrafting of the manuscript:\n  \nAdam Mylonakis, Areti Kalfoutzou, Asimina Restemi, Andria Peraki,\nKonstantinos Papadimitropoulos, Nikolaos Chaleplidis\nSupervision:\n  \nAdam Mylonakis, Areti Kalfoutzou, Dimitrios Matsaridis, Nikolaos Chaleplidis, Margaritis\nTsantopoulos\nCritical review of the manuscript for important intellectual content:\n  \nAreti Kalfoutzou, Dimitrios\nMatsaridis, Nikolaos Chaleplidis, Margaritis Tsantopoulos\nDisclosures\nHuman subjects:\n Consent was obtained or waived by all participants in this study. Institutional Review\nBoard, 251 Air Force General Hospital issued approval 155/20-11-2023. \nConflicts of interest:\n In compliance\nwith the ICMJE uniform disclosure form, all authors declare the following: \nPayment/services info:\n All\nauthors have declared that no financial support was received from any organization for the submitted work.\nFinancial relationships:\n All authors have declared that they have no financial relationships at present or\nwithin the previous three years with any organizations that might have an interest in the submitted work.\nOther relationships:\n All authors have declared that there are no other relationships or activities that could\nappear to have influenced the submitted work.\nReferences\n1\n. \nCalò PG, Ambu R, Medas F, Longheu A, Pisano G, Nicolosi A: \nRectus abdominis muscle endometriosis report\nof two cases and review of the literature\n. Ann Ital Chir. 2012,\n2\n. \nCozzolino M, Magnolfi S, Corioni S, Moncini D, Mattei A: \nAbdominal wall endometriosis on the right port\nsite after laparoscopy: case report and literature review\n. Ochsner J. 2015, 15:251-5.\n3\n. \nGiannella L, La Marca A, Ternelli G, Menozzi G: \nRectus abdominis muscle endometriosis: case report and\nreview of the literature\n. J Obstet Gynaecol Res. 2010, 36:902-6. \n10.1111/j.1447-0756.2010.01236.x\n4\n. \nSucandy I, Indeck MC: \nAbdominal wall endometriosis: a gynecologic condition commonly presented to\ngeneral surgeons\n. Am Surg. 2013, 79:E69-70.\n5\n. \nVitral GS, Salgado HC, Rangel JM: \nUse of radioguided surgery in abdominal wall endometriosis: an\ninnovative approach\n. World J Nucl Med. 2018, 17:204-6. \n10.4103/wjnm.WJNM_47_17\n6\n. \nKaraman H, Bulut F, Özaşlamacı A: \nEndometriosis externa within the rectus abdominis muscle\n. Ulus Cerrahi\nDerg. 2014, 30:165-8. \n10.5152/UCD.2014.2035\n7\n. \nEvruke IM, Babaturk A, Akbas G: \nA rare occurrence of endometriosis externa individually within the rectus\nabdominis muscle\n. Cureus. 2023, 15:e33662. \n10.7759/cureus.33662\n8\n. \nDordević M, Jovanović B, Mitrović S, Dordević G, Radovanović D, Sazdanović P: \nRectus abdominis muscle\nendometriosis after cesarean section--case report\n. Acta Clin Croat. 2009, 48:439-43.\n9\n. \nWasserman P, Kurra C, Taylor K, Wells B, Sharma A, Leon A: \nCatamenial rectus abdominis pain associated\nwith scar endometriosis status-post low transverse cesarean section\n. Cureus. 2018, 10:e3778.\n10.7759/cureus.3778\n10\n. \nKocakusak A, Arpinar E, Arikan S, Demirbag N, Tarlaci A, Kabaca C: \nAbdominal wall endometriosis: a\ndiagnostic dilemma for surgeons\n. Med Princ Pract. 2005, 14:434-7. \n10.1159/000088118\n11\n. \nIoannis TK, Sofia P: \nAbdominal wall endometriosis after cesarean section\n. HJOG. 2017, 16:25-30.\n12\n. \nSlaiki S, Jamor J: \nEndometriosis of the rectus abdominis muscles: a rare case of dual location\n. J Surg Case\nRep. 2020, 2020:rjaa360. \n10.1093/jscr/rjaa360\n13\n. \nMarci R, Lo Monte G, Soave I, Bianchi A, Patella A, Wenger JM: \nRectus abdominis muscle endometriotic\nmass in a woman affected by multiple sclerosis\n. J Obstet Gynaecol Res. 2013, 39:462-5. \n10.1111/j.1447-\n0756.2012.01933.x\n14\n. \nIbrahim MG, Delarue E, Abesadze E, Haas M, Sehouli J, Chiantera V, Mechsner S: \nAbdominal wall\nendometriosis: myofibroblasts as a possible evidence of metaplasia: a case report\n. Gynecol Obstet Invest.\n2017, 82:96-101. \n10.1159/000452101\n15\n. \nCoeman V, Sciot R, Van Breuseghem I: \nCase report. Rectus abdominis endometriosis: a report of two cases\n.\nBr J Radiol. 2005, 78:68-71. \n10.1259/bjr/28183033\n16\n. \nRoberge RJ, Kantor WJ, Scorza L: \nRectus abdominis endometrioma\n. Am J Emerg Med. 1999, 17:675-7.\n10.1016/s0735-6757(99)90157-2\n17\n. \nGranese R, Cucinella G, Barresi V, Navarra G, Candiani M, Triolo O: \nIsolated endometriosis on the rectus\nabdominis muscle in women without a history of abdominal surgery: a rare and intriguing finding\n. J Minim\nInvasive Gynecol. 2009, 16:798-801. \n10.1016/j.jmig.2009.08.005\n18\n. \nBozkurt M, Çil AS, Bozkurt DK: \nIntramuscular abdominal wall endometriosis treated by ultrasound-guided\n2024 Kalfoutzou et al. Cureus 16(3): e55462. DOI 10.7759/cureus.55462\n5\n of \n6\n\nethanol injection\n. Clin Med Res. 2014, 12:160-5. \n10.3121/cmr.2013.1183\n19\n. \nGourgiotis S, Veloudis G, Pallas N, Lagos P, Salemis NS, Villias C: \nAbdominal wall endometriosis: report of\ntwo cases\n. Rom J Morphol Embryol. 2008, 49:553-5.\n20\n. \nCoccia ME, Rizzello F, Nannini S, Cozzolino M, Capezzuoli T, Castiglione F: \nUltrasound-guided excision of\nrectus abdominis muscle endometriosis\n. J Obstet Gynaecol Res. 2015, 41:149-52. \n10.1111/jog.12502\n21\n. \nArakawa T, Fukuda S, Hirata T, et al.: \nPAX8: a highly sensitive marker for the glands in extragenital\nendometriosis\n. Reprod Sci. 2020, 27:1580-6. \n10.1007/s43032-020-00186-7\n22\n. \nYang Q, Zhang X: \nEfficacy and safety of high-intensity focused ultrasound ablation for rectus abdominis\nendometriosis: a 7-year follow-up clinical study\n. Quant Imaging Med Surg. 2023, 13:1417-25.\n10.21037/qims-22-695\n23\n. \nSaliba C, Jaafoury H, El Hajj M, Nicolas G, Haidar Ahmad H: \nAbdominal wall endometriosis: a case report\n.\nCureus. 2019, 11:e4061. \n10.7759/cureus.4061\n24\n. \nThanasa A, Thanasa E, Kamaretsos E, Gerokostas EE, Thanasas I: \nExtrapelvic endometriosis located\nindividually in the rectus abdominis muscle: a rare cause of chronic pelvic pain (a case report)\n. Pan Afr Med\nJ. 2022, 42:242. \n10.11604/pamj.2022.42.242.36325\n25\n. \nMishin I, Mishina A, Zaharia S, Zastavnitsky G: \nRectus abdominis endometrioma after caesarean section\n.\nCase Rep Surg. 2016, 2016:4312753. \n10.1155/2016/4312753\n26\n. \nGoker A, Sarsmaz K, Pekindil G, Kandiloglu AR, Kuscu NK: \nRectus abdominis muscle endometriosis\n. J Coll\nPhysicians Surg Pak. 2014, 24:944-6.\n2024 Kalfoutzou et al. Cureus 16(3): e55462. DOI 10.7759/cureus.55462\n6\n of \n6","source_license":"CC0","license_restricted":false}