{"paper_id":"24c43220-7977-4494-a825-cb4ebc0f3083","body_text":"MEDICAL SCIENCE l CASE REPORT \nMedical Science, 26, ms395e2111 (2022)                                                                                                                                             1 of 4 \n \nScar endometriosis following \nlaparoscopic surgery: A rare \ncase report \n \nAkruti Shinde1, Kamlesh Chaudhari2, Deepti \nShrivastava2, Sunil Kumar2, Priti Verma3 \n \n \nABSTRACT \nEndometriosis is a major gynaecological disorder that affects 5% to 10% of \nfemale in their reproductive years. The ectopic implantation of functioning \nendometrium outside the uterus, with the pelvis being the most common site, \nis known as endometriosis. Scar endometriosis is difficult and rare to \ndistinguish from other surgical diseases. It can be found in 0.1 percent of \nwomen with a scar on their abdomen. These lesions usually follow \ngynaecological and obstetrical surgeries including laparotomy and \nlaparoscopic approaches of abdominal and pelvic cases. Following a \nlaparoscopic myomectomy, one patient developed scar endometriosis. This \nrare condition's diagnosis, pathogenesis and treatment are being discussed. \n \nKeywords: Endometriosis, Scar, Laparoscopic surgery \n \n \n1. INTRODUCTION \nGlobally, around 89 million women of reproductive age are affected by \nendometriosis. This roughly accounts for 7% to 10% of total female \npopulation. Endometriosis, which mainly occurs during the reproductive \nyears, is oestrogen dependant. It is associated with significant pain and \ninfertility. Endometrial tissue is at the incision site outside of the uterine \ncavity, after surgery is called as scar endometriosis. It's a rare type of \nendometriosis that can be occasionally mistaken for some other surgical or \ndermatological conditions. Abscess, suture granuloma, desmoid tumour, \nhematoma, sarcoma, and metastatic malignancy are all common misdiagnoses \nfor this condition.  \nExtra pelvic endometriosis is most commonly reported after \ngynaecological and obstetric proce dures such as episiotomy, hysterotomy, \ntubal ligations, hysterectomy and caesarean sections but there have been a few \ndocumented instances in the amniocentesis needle tract, laparoscopic trocar \ntract and after appendicectom y (Gupta et al., 2015) . Endometriosis caused by \nincisions or scars is extreme r are, affecting not more than 1% of individuals. \nScar endometriosis is found to occur in 0.3 -0.4 percent of Caesarean Section \npatients and 1 -2 percent of hysterotomy patients  (Purbadi et al., 2021) . \nAlthough extra-pelvic endometriosis is not uncommon, it has been confirmed \nin a several places, including the lungs, lower extremities, and most organs in \nMedical Science \n  pISSN 2321–7359; eISSN 2321–7367 \n \n \n \n \n \n \n \n \nTo Cite: \nShinde A, Chaudhari K, Shrivastava D, Kumar S, Verma P. Scar \nendometriosis following laparoscopic surgery: A rare case report. \nMedical Science, 2022, 26, ms395e2111.  \ndoi: https://doi.org/10.54905/disssi/v26i128/ms395e2111  \n \nAuthors’ Affiliation: \n1Resident, Department of Obstetrics & Gynaecology, Jawaharlal Nehru \nMedical College, Sawangi, Wardha, Maharashtra, India  \n2Professor, Department of Obstetrics & Gynaecology, Jawaharlal Nehru \nMedical College, Sawangi, Wardha, Maharashtra, India \n3Senior Resident, Department of Obstetrics & Gynaecology, Jawaharlal \nNehru Medical College, Sawangi, Wardha, Maharashtra, India \n \nPeer-Review History \nReceived: 09 February 2022 \nReviewed & Revised: 14/February/2022 to 02/October/2022 \nAccepted: 03 October 2022 \nPublished: 05 October 2022 \n \nPeer-review Method \nExternal peer-review was done through double-blind method. \n \nURL: https://www.discoveryjournals.org/medicalscience \n \n \n \nThis work is licensed under a Creative Commons Attribution 4.0 \nInternational License. \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n  \nCopyright © 2022 Discovery Scientific Society.  \n \nDISCOVERY \nSCIENTIFIC SOCIETY \n \n\nMEDICAL SCIENCE l CASE REPORT \nMedical Science, 26, ms395e2111 (2022)                                                                                                                                             2 of 4 \nbetween. The condition may result in unnecessary operation, mental and physical anguish with misdiagnosis to the patient.  \nThe current study examines the literature and reports on a case of scar endometriosis in order to identify physical symptoms \nand indications so as to facilitate earlier diagnosis and intervention (Vercellini et al., 2014). \n \n2. CASE REPORT \n34 years old nulligravida  with primary infertility came to gynaecology OPD with chief complaint of swelling in left iliac fossa over \nscar site since one year associated with low grade, dull aching pain at site of scar which increases during menstruation. Thi s pain \nused to get reli eved for sometime on taking painkillers. Patient is operated case of laparoscopic myomectomy done for multiple \nfibroid in civil hospital three years ago. General examination was done. On per abdomen examination swelling of 2 x 2 cm over  left \niliac fossa wi th tenderness was present (Figure 1). There was moderately pigmented area with firm in consistency on left side \nlaparoscopic scar site. There was no history of bronchial asthma, hypertension, diabetes mellitus, tuberculosis, thyroid disorder or \nany other chronic medical illness. Routine blood investigations were sent as shown in (Table 1). \n \nTable 1 Blood investigations as below \nSr. No. Investigation Measured Value ON ADMISSION \n1. CBC \nHb-10.8gm/dl,  \nMCV-96 fl,  \nPlatelet count- 128000/dl,  \nWBC Count- 14200/dl.   \n \n \n2. KFT \nCreatinine: 0.98mg/dl, \n S. Urea: 29mg/dl,  \nS. Sodium: 134mmol/l,  \nPotassium: 3.8mmol/l. \n \n3. LFT \nAspartate aminotransferase 25 u/l, \nalanine aminotransferase 31 u/l, \nAlkanlinePhophatase105 IU/l,  \nTotal Bilirubin: 1.07mg/dl \n \n \nUltrasonography of abdomen was advised. USG s/o well defined hypoechoic lesion in left lower abdomen over laparoscopic \nscar in subcutaneous plane. The lesion has irregular margin showing hypervascularity  on Doppler measuring 19.3 x 15.1 mm. \nmultiple intramural fibroid in bulky uterus with largest measuring 3.9 x 2.1 c m. A contrast enhanced computed tomography of \nabdomen was s/o bulky uterus with multiple fibroids distorting the uterine contour with minima l endometrial collection. \nHeterogeneously enhancing soft tissue density lesion in subcutaneous and intermuscular plane of left iliac region? Scar granu loma. \nA needle aspiration biopsy was done from the swelling which indicated scar endometriosis (Nigam et al., 2017). \n \n \nFigure 1 A healed scar site, with a non mobile, nodular, moderately pigmented \n \n\n\nMEDICAL SCIENCE l CASE REPORT \nMedical Science, 26, ms395e2111 (2022)                                                                                                                                             3 of 4 \n \nFigure 2 intraoperative scar endometriosis tissue areas in left iliac fossa \n \nFigure 3 Histopathological Examination of scar endometriosis \n \nSurgical excision was scheduled after a provisional diagnosis of multiple fibroid with scar endometriosis was made. A wide \nlocal excision of the endometriotic tissue with Laparoscopic myomectomy was done (Saha et al., 2014) . The scar was entirely \nremoved, and the tissue was sent for histological investigation, which revealed numerous, irregular, fibro fatty tissue fragm ents, as \nwell as greyish black tissue pieces measuring 3.2 x 2 x 1.6 cm and displaying histopathological si gn of scar endometriosis (Figure 2 \n& 3). The patient's recovery went uneventful after surgery. \n \n3. DISCUSSION \nScar endometriosis is a gynaecological condition that primarily affects women who have had a pelvic or abdominal operation in  the \npast. Many hypot heses have been proposed as to why scar endometriosis occurs; however, the most widely recognised theory \npostulates iatrogenic implantation of endometrial tissue to the edges of wound, following abdominal or pelvic surgery. Scar \nendometriosis diagnosis is difficult. Classic endometriosis is characterised by cyclical pain and fluctuations during menstruation in \nthe size of endometrial implants. However, only 20% of the individuals have reported these symptoms. A  hypertrophic scar and \nTenderness on palpation are common complaints (Gupta et al., 2015). \nEndometrial tissue at the incision site outside the uterine cavity after surgery is called as scar endometriosis. It is commonly seen \namong women of reproductive age. Endometriosis manifests itself at pelvic or peritoneal organs as small cysts or nodules which are \nbluish, black or dark red in colour (Nigam et al., 2017).  On histological examination, endometriosis is characterised by ect opic and \natypical endometrial glands with hemosiderin deposition in stroma or within the macrophages. Spindled endometrial stroma is also \npresent. The most prevalent cause of scar endometriosis is surgery on the fallopian tubes and uterus. It occurs in 1.08 -2 percent of \nwomen who have had a hysterectomy, but it occurs in 0.03 -0.4% of women who have had a caesarean section. The early decidual \ntissue has increased pleuripotent capacities, which can lead to cellular replication and endometrioma, which is why endometri oma \nis more common after hysterotomy. Various reports suggest that the duration between surgery and presentation ran ges from 3 - 4 \nmonths to 10 years. Abdominal wall Endometrioma is hypothesised to be caused by endometrial tissue being transported during \nsurgical operations and then being activated by oestrogen to generate endometrioma. It's rare for pelvic endometriosis  and scar \nendometriosis to develop at the same time. Because iatrogenic endometrial implantation is one of  causes of postoperative sca r \nendometriosis, procedures such as endobag and morcellator should be employed for specimen retrival whenever possible  (Missmer \net al., 2004).  \n\n\nMEDICAL SCIENCE l CASE REPORT \nMedical Science, 26, ms395e2111 (2022)                                                                                                                                             4 of 4 \nUSG and colour Doppler has a significant role in the accurate diagnosis, and authors suggest  that when paired with clinical data \nand assessment, sonography and colour Doppler may play a crucial role in the diagnosis pre operatively. Another reliable \ndiagnostic tool is FNAC. A large, well-circumscribed tumour is frequently visible on CT. Because of its great spatial resolution, MRI \nis more useful when the lesion is minor, and it also gives better results in detecting the planes between subcutaneous tissue  and \nmuscle, as compared to CT scan.  \nThe most common treatment is extensive excision of lesion, which need mesh implantation in some cases medical treatment \nwith progesterone and oral contraceptives. Danazol  is ineffective and only provides temporary symptomatic relief (Alhubaishi et \nal., 2020). Recently, the use of a gonadotrophin Agonist has been reported, although only with a rapid relief in symptoms, without \nany effect on reducing the size of the lesion. High chances of recurrence need f ollow up of the patient. Which if occurs, requires re -\nexcision. These patients must be followed up on. After 6 weeks follow up patient had no pain and any other complaints. The pa tient \nis now being monitored on a regular basis due to the possibility of recurrence. \n \n4. CONCLUSION \nScar endometriosis is a rather uncommon condition. Any woman who presents with swelling and  pain at any incisional site, \nespecially post pelvic surgery, should be treated with caution. Every surgeon should elicit a detailed history followed by a thorough \nphysical examination, and this entity should be kept in mind for differential diagnosis. Other surgical conditions can be mis taken \nwith this one. Imaging modalities and FNAC make it possible to diagnose prior to operative interventio n. The treatment is wide \nexcision of the scar endometriosis. \n \nAcknowledgement \nWe thank all the participants who have contributed in this Study.  \n \nInformed Consent  \nInformed Consent was obtained from the patient.  \n \nAuthor’s contribution \nAll the authors contributed equally to the case report. \n \nFunding \nThis study has not received any external funding. \n \nConflicts of interest \nThe authors declare that there are no conflicts of interests. \n \nData and materials availability \nAll data associated with this study are present in the paper. \n \nREFERENCES AND NOTES \n1. Alhubaishi FS, Rafeei LK, Albalooshi S, Suresh B. Post \nHysterectomy Scar Endometriosis: A Case Report. OALib \n2020; 07:1–6. doi:10.4236/oalib.1106684 \n2. Gupta P, Gupta S. Scar Endometriosis: a Case Report with \nLiterature Review. Acta Med Iran 2015; 53:793–795. \n3. Missmer SA, Hankinson SE, Spiegelman D, Barbieri RL, \nMarshall LM, Hunter DJ. Incidence of laparoscopically \nconfirmed endometriosis by demographic, a nthropometric, \nand lifestyle factors. Am J Epidemiol 2004; 160:784 –796. doi: \n10.1093/aje/kwh275 \n4. Nigam JS, Omhare A, Sharma A. Fine -needle aspiration \ncytology of a cesarean scar endometriosis. Tzu Chi Med J \n2017; 29:232–234. doi: 10.4103/tcmj.tcmj_37_17 \n5. Purbadi S, Purwoto G, Winarto H, Nuryanto KH, Scovani L, \nSotarduga GE. Case report: Caesarean scar endometriosis – \nA rare entity. Int J Surg Case Rep 2021; 85:106204. doi:  \n10.1016/j.ijscr.2021.106204 \n6. Saha K, Shahida SM, Mostafa G, Ahmed M. A case of \nabdominal wall scar endometriosis. Mymensingh Med J \n2014; 23:389–391. \n7. Vercellini P, Viganò P, Somigliana E, Fedele L. \nEndometriosis: pathogenesis and treatment. Nat Rev \nEndocrinol 2014; 10:261–275. doi: 10.1038/nrendo.2013.255","source_license":"CC0","license_restricted":false}