{"paper_id":"3396ee47-443d-4c9b-82d2-d6d741a259b3","body_text":"SSRG International Journal of Medical Science                                     Volume 10 Issue 6, 32-35, Nov-Dec 2023 \nISSN: 2393–9117 / https://doi.org/10.14445/23939117/IJMS-V10I6P105                                                     © 2023 Seventh Sense Research Group®  \n This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) \nCase Series \n \nScar Endometriosis-A Case Series of 8 Cases of this Rare \nEntity \n \nMala Raj1, Sharanya2, S. Roshini3  \n \n1,2,3Department of Obstetrics and Gynecology, Firm Hospitals, Chennai, Tamilnadu, India \n \n1Corresponding Author : drmalaraj@gmail.com  \n \nReceived: 29 September 2023              Revised: 04 November 2023              Accepted: 21 November 2023              Published: 09 December 2023 \n \nAbstract - Background: Endometriosis affects 5-15% of reproductive -aged women and involves endometrial tissue outside \nthe uterine cavity. Scar endometriosis, an unusual subtype, occurs at surgical incision sites, notably after caesarean section \n(CS) (incidence, 0.03 -1%). Scar endometriosis is a rare but important complication of C-sections. Patients develop cyclic \npain and swelling at the abdominal scar months to years after surgery.  Accurate diagnosis is often challenging, leading to \nmisdiagnosis of other surgical conditions. Objective: This retrospective analysis examined eight patients treated at a tertiary \nhospital. Materials and methods:  Eight patients with scar endometriosis underwent surgical management at FIRM \nHospitals. All patients were informed about the surgical procedure and provided written informed consent.  Results: All \npatients had previous obstetrical and gynaecological surgeries, particularly Lower Segment Caesarean Sections (LSCS ). \nThe chief complaints included pain, swelling, and bleedin g in the abdo minal wall scar area, usually appearing months to \nyears after surgery.  The masses were located in various scarring regions.  The clinical diagnosis was scar endometriosis, \nsupported by radiological findings.  Conclusion: Women who  have undergone gynaecological or obstetric surgery and \nexperience recurring painful swelling at their abdominal scar should be highly suspected of having scar endometriosis.  \nKeywords - Scar endometriosis, Lower segment caesarean sections, Abdominal scar. \n \n1. Introduction \nEndometriosis is the presence of endometrial glands \nand stroma outside the uterine cavity, affecting \napproximately 5 -15% of women of reproductive age . [1] It \ncan be categorised as pelvic or extrapelvic endometriosis. \nPelvic endometriosis, the more common form, affects \nstructures such as the ovaries, uterosacral ligaments, and the \npelvic peritoneum. Extrapelvic endometriosis, a rarer form, \noccurs in the abdominal wall, urinary and gastrointestinal \ntract, skin, brain, and lungs . [2] Scar endometriosis, a \nspecific type of endometriosis that develops at surgical \nincision sites following obstetric or gynaecological \nsurgeries, including caesarean section (CS), has an \nincidence of 0.03 -1% post -CS. [3] Its symptoms, which \noften mimic those of hernias, lipomas, or haematomas, can \ncontribute to misdiagnoses.  \n \nPatients with scar endometriosis typically experience \ncyclic pain and swelling at the incision site, making surgical \nintervention necessary for both treatment and definitive \ndiagnosis. [4] Although the exact patho physiology of scar \nendometriosis remains unclear, it is generally believed to \narise from introducing endometrial tissue into the surgical \nwound during the procedure. Hormonal stimuli at the \nwound site can promote cell proliferation and metaplasia . \n[5] In this retrospective analysis, we examined eight patients \ntreated at a tertiary hospital for scar endometriosis.  \n2. Patients and Methods \nA study was conducted on eight patients treated for scar \nendometriosis at FIRM hospitals through surgical \nmanagement. Before surgery, each patient was fully \ninformed of the procedure and provided written consent. \n \nEach patient had a history of obstetric and \ngynaecological surgeries, and initial caesarean sections were \nperformed at different medical facilities.  The diagnosis was \nsuspected through pelvic ultrasonography following clinical \nassessment. \n \nThe study analysed patients' age, number and type of \nprevious surgeries, symptoms, mass size, and radiological \nfeatures. \n \nThe surgical intervention involved wide local excision \nof the scar  endometriosis through sharp dissection with a \nscalpel within the area of the previous caesarean section \nincision. The fibrosis cystic mass was carefully removed \nwith safe margins. The abdominal wall was reconstructed in \nanatomical layers. \n\nMala Raj et al. / IJMS, 10(6), 32-35, 2023 \n \n33 \nIn all cases, the final diagnosis was confirmed by \npathological examination. \n3. Case Series \nCase 1, aged 37, had two previous LSCS (Lower \nSegment Caesarean Section) and one D&C (Dilation and \nCurettage). She presented with bleeding at the right end of \nthe scar for two years. The mass was measured at 1.6 x 1.4 \ncm in the right lateral end of the scar. The clinical diagnosis \nwas scarred endometriosis. Radiological features revealed a \nwell-defined endometriotic nodule (2.1 x 1.4 cm within the \nright rectus muscle plane. The surgical procedure involved a \nwide local excision. \n \nCase 2, aged 26 years, had a previous LSCS. She \ncomplained of swelling and pain during cycling for nine \nmonths. A 1.2 x 1.0 cm mass was observed on the left side \nof the LSCS scar. The clinical diagnosis was scarr ed \nendometriosis. Radiological features showed a 1.5 x 1.2 cm \nendometriotic nodule in the anterior abdominal wall of the \nLSCS scar. The surgical procedure included wide local \nexcision with LSCS. \n \nCase 3, aged 28 years, had a previous LSCS. She \nexperienced pain during cycles for 11 months. A 3.7 x 2.8 \ncm nodule was f ound at the left end of the LSCS scar. The \nclinical diagnosis was scarred endometriosis. Radiological \nfeatures indicated a heterogenous hypoechoic echotexture of \n4.2 x 3.1 cm in the left LSCS scar , along with internal echos \nand fibrotic changes. The surgical procedure involved a \nwide local excision. \n \nCase 4, aged 29 years, had a previous LSCS. She \nexperienced swelling in the LSCS scar during cycles for one \nyear. A 4 x 4.6 cm nodule was located in the midline of the \nLSCS scar. The clinical diagnosis was scarr ed \nendometriosis. Radiological features revealed an \nendometriotic nodule of 4 x 4.6 cm x 3.6 cm in the anterior \nabdominal wall at the LSCS scar in the midline, along with \nvascularity. The surgical  procedure included wide local \nexcision with LSCS. \n \nCase 5, aged 34, had one previous LSCS and one lap \nST (laparoscopic sterilisation). She complained of bleeding \nand pain around the umbilical region for one year. A 2.2 x \n1.5 cm nodule was found in the umbilical region. The \nclinical diagnosis was scarred endometrios is. Radiological \nfeatures showed a well -defined soft tissue nodule (2.5 x 1.8 \ncm with heterogeneous hypoechoic echotexture and a \nstreaky appearance in the surrounding tissue. The surgical \nprocedure involved a wide local excision. \n \nCase 6, aged 30 years, had a previous LSCS. She had \nswelling at the right end of the scar for eight months. A 2.5 \nx 2 cm nodule was located at the right end of the scar. The \nclinical diagnosis was scarred endometriosis. Radiological \nfeatures indicated a 2.3 x 2 cm endometriotic nod ule in the \nanterior abdominal wall of the right LSCS scar with fibrotic \nchanges. The surgical procedure involved a wide local \nexcision. \n \nCase 7, aged 40, had two previous LSCS. She had \nexperienced pain during cycling over the left side of the \nLSCS scar for two years. A 4.3 x 3.5 cm nodule was found \nat the left end of the scar. The clinical diagnosis was scarred \nendometriosis. Radiological features revealed a \nheterogeneous hypoechoic area in the abdominal incision \nwithin the surrounding hyperechoic fat an d an internal \nhypoechoic area of 4.5 x 3.5 cm. The surgical procedure \nincluded wide local excision. \n \nCase 8, aged 30, had two previous LSCS. She \nexperienced pain during cycles in the right scar region for \n1.5 years. A 3.7 x 2.6 cm nodule was located at the right end \nof the scar. The clinical diagnosis was scarred \nendometriosis. Radiological features revealed a well -defined \nendometriotic nodule measuring 3.8 x 2.8 cm with \nvascularity changes in the right end of the LSCS scar. The \nsurgical procedure involved a wide local excision. \n \nFig. 1 Ultrasonography of scar endometriosis \nA well-defined heterogeneous hypoechoic lesion with a \nlobulated margin was noted in the subcutaneous plane of the \nlower part of the anterior abdominal wall at the LSCS scar \nsite, which is 3.7 cm x 2.81 cm (Figure 1). \n \n \n\n\nMala Raj et al. / IJMS, 10(6), 32-35, 2023 \n \n34 \n \nFig 2. Intraoperative image of scar endometriosis \n \n \nFig. 3 Histopathological examination \nHematoxylin and Eosin  (H&E)-stained sections of \nexcised tissue showed endometrial glands and stroma in the \ndeep dermis at low -power and high -power magnification \n(Figure 3). \n4. Discussion \nIn eight cases of scar endometriosis, the patients shared \ncommon traits.  All had previous obstetric and \ngynaecological surgeries, particularly Lower Segment \nCaesarean Sections (LSCS).  The chief complaints included \npain, swelling, and bleeding in the abdominal wall scar area, \nusually appearing months to years after surgery.  The masses \nwere located in various scarring regions.  The c linical \ndiagnosis was scar endometriosis, supported by radiological \nfindings. Surgical management involves wide local \nexcision, occasionally combined with LSCS.  These shared \ncharacteristics highlight the typica l clinical presentation and \nmanagement of scar endometriosis following surgery. \nEndometriosis occurs when endometrial tissue, the \ntissue that lines the uterus, grows outside of the uterus. \nEndometriomas are cysts that contain endometrial tissue. \nExtrapelvic endometrio sis can affect various sites in the \nbody, including the bladder, kidney, bowel, omentum, \nlymph nodes, lungs, pleura, extremities, umbilicus, hernial \nsacs, and abd ominal wall . [6] Scar endometriosis is a rare \ncondition that occurs when endometrial tissue grows in a \nsurgical scar . [7] [8]  It is most common following post -\nuterine and tubal operations, particularly caesarean sections. \nScar endometriosis typically presents as painful cyclic \nchanges in the nodule size. [9] \nThe development of scar endometriosis is  believed to \ninvolve the direct implantation of endometrial tissue during \nsurgery, which subsequently grows under the influence of \nhormones. [10] Another theory s uggests that peritoneal \nmesothelial cells, which are cells that line the abdominal \ncavity, may transform into endometrial cells at the incision \nsite, leading to scar endometriosis. However, theories \ninvolving lymphatic or vascular spread and retrograde \nmenstruation are less widely accepted . [2][7] Interestingly, \nscar endometriosis can sometimes be found in patients who \nhave not undergone prior surgery, often in areas such as the \nvulva, perineum, groin, umbilicus, extremities, and \nnasolacrimal areas . [11] An accurate diagnosis of scar \nendometriosis requires meticulous examination, precise \nquestioning, and careful consideration of endometriosis as a \npotential cause.  Patients with scar endometriosis typically \nexperience cyclical pain of variable duration, with common \nsymptoms including pain and increased mass size, which are \ninfluenced by hormonal changes. [12] \nDiagnosing scar endometriosis can be challenging, \noften leading to mistaken identification as other surgical \nconditions like hernias, hematomas, neuromas , lipomas, \nabscesses, sebaceous cysts, or even neoplastic tissue . [13] \nAccurately diagnosing scar endometriosis before surgery is \nonly achieved in 20 -50% of cases. While imaging \ntechniques can assist in differential diagnosis, histology \nremains the definitive method for diagnosis. Medical \ntherapy may provide temporary relief, but surgical excision \n\nMala Raj et al. / IJMS, 10(6), 32-35, 2023 \n \n35 \nremains th e preferred treatment option, ensuring complete \nremoval of the endometrial tissue and minimizing the risk of \nrecurrence. [12][14] Residual endometrial t issue increases \nthe risk for recurrence. Theoretically, scar endometriosis can \nundergo malignant transformation; therefore, histological \nevaluation is crucial.  Malignant changes are rare, \nparticularly in the case of CS scars, occurring in only 4% of \ncases at extragonadal pelvic sites. [6] [15] \n5. Conclusion \nThe increasing prevalence of caesarean secti ons has \nparalleled the increase in scar endometriosis.  Therefore, \nwomen presenting with recurring painful swelling at their \nabdominal scars, especially those with a history of \ngynaecological or obstetric surgery, should be closely \nevaluated for scar endometriosis.  \nThis condition can be misdiagnosed as another surgical \ncomplication, but imaging techniques and fine -needle \naspiration cytology (FNAC) can aid in accurate diagnosis.  \nAlthough medical therapy may be effe ctive in some cases, \nsurgical excision remain s the preferred treatment option.  \nOngoing patient monitoring is essential to detect potential \nrecurrence.  \n \nReferences  \n[1] Eleni S. Tsamantioti, and Heba Mahdy, Endometriosis, StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing , 2023. [Google \nScholar] [Publisher Link] \n[2] Nikolaos Machairiotis et al., “Extrapelvic Endometriosis: A Rare Entity or An Underdiagnosed Condition?,” Diagnostic Pathology, vol. 8, \nno. 1, pp. 1-12, 2013. 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