{"paper_id":"4e3df0d6-70d4-48a2-ae47-c05ba8d0b241","body_text":"INTERNATIONAL JOURNAL OF PRECLINICAL AND\nCLINICAL RESEARCH\nCASE REPORT\n \n \nOPEN ACCESS\nReceived: 26.07.2021\nAccepted: 05.11.2021\nPublished: 26.11.2021\nCitation: Zeba K, Geetha HH,\nAnusha B, Gurupriya S. (2021).\nCesarean scar endometriosis: A case\nreport. International Journal of\nPreclinical & Clinical Research. 2(3):\n58-61. https://doi.org/\n10.51131/IJPCCR/v2i3.18\n\u0003\nCorresponding author.\ngeethahh96@gmail.com\nFunding: None\nCompeting Interests: None\nCopyright: © 2021 Zeba et al. This is\nan open access article distributed\nunder the terms of the Creative\nCommons Attribution License , which\npermits unrestricted use,\ndistribution, and reproduction in\nany medium, provided the original\nauthor and source are credited.\nPublished By Basaveshwara Medical\nCollege & Hospital, Chitradurga,\nKarnataka\nISSN\nPrint: XXXX-XXXX\nElectronic: 2583-0104\nCesarean scar endometriosis: A case\nreport\nKhaleel Zeba1, H H Geetha 2\u0003, B Anusha 1, S Gurupriya 1\n1 Postgraduate, Department of OBG, Basaveshwara Medical College and Hospital,\nChitradurga, 577502, Karnataka, India\n2 Professor and HOD, Department of OBG, Basaveshwara Medical College and Hospital,\nChitradurga, 577502, Karnataka, India\nAbstract\nEndometriosis is a chronic gynaecological disorder where presence of\nfunctional and morphological endometrial gland present outside the uterine\ncavity. Cesarean scar endometriosis is an unusual manifestation of extra\npelvic endometriosis. Here, we report a case of caesarean scar endometriosis\ndiagnosed after 6 years of cesarean delivery and was treated by surgical wide\nenbloc excision under spinal anaesthesia. Main aim is to increase awareness\nof this entity.\nKeywords: Cesarean scar endometriosis (CSE); Surgical wide En Bloc excision; Sclerotherapy\nIntroduction\nEndometriosis is a condition where the\nfunctional and morphological endome-\ntrial glands and stromal structures are\nfound outside the uterus. It mainly\naffects women in reproductive ages.\nEndometriosis occurs most often in\npelvis, on the surface lining of the\npelvic cavity, peritoneum, ovaries, pos-\nterior cul-de-sac, and uterosacral liga-\nments. Rarely, implants outside pelvis\nand named as extra pelvic endometrio-\nsis. Scar endometriosis an extremely\nrare site (incidence 0.03-3.5%) of extra\npelvic endometriosis, is presence of\nendometriosis at or near previous\nsurgery scar site as a painful discrete\ntumoral mass known as Endometrioma\nor admixed with native tissue. (1,2) SE\nusually develops after General surgery\nand Obstetrics and Gynecological surg-\neries, most commonly after hysterectomy\n(1.08-2% cases) cesarean delivery (0.03-\n0.04% cases) and rarely after Appendici-\ntis, T ubal ligation, Ectopic pregnancy,\nInguinal herniorrhaphy, in laparoscopic\ntrocar tract and needle tract after diag-\nnostic amniocentesis and in perineal epi-\nsiotomy incision.(3) Most of them present\nto surgeons because of similarity to her-\nnia, lipoma, keloid and other anterior\nabdominal masses. The great variability\nof symptoms and clinical presentations as\nwell as limited knowledge on disease can\nlead to delayed treatment, misdiagnosis,\nunnecessary intervention discomfort to\nthe patient.\nhttps://ijpccr.com/ 58\n\nZeba et al. / International Journal of Preclinical & Clinical Research 2021;2(3):58–61\nCase details\nA 28-year-old woman P2L2 Reported to Gynecology OPD\nwith painful palpable mass at left angle of previous incision\nscar since 6 months. She delivered Full term alive healthy male\nbaby by emergency LSCS for fetal distress and post-operative\nperiod uneventful. Within a year she conceived again and\ndelivered a full term, alive healthy male baby by emergency\nLSCS for threatened scar rupture and post-operative unevent-\nful. Patient presented with painful palpable swelling at left\nangle previous LSCS scar incision since 6 months. On exami-\nnation palpable tender subcutaneous mass located 1cm above\nthe left angle of LSCS incision site measuring approximately\n2x 2 cm. Rest systemic examination uneventful. Sonogra-\nphy examination revealed ill-defined heterogeneous lesion\nmeasuring 24x 19 mm in the subcutaneous plane in lower\nabdomen on left side of the incision with minimal vascu-\nlarity. Under spinal anaesthesia, Surgical wide en bloc exci-\nsion performed and lesion was removed and defects repaired.\nGross examination revealed irregular fibro fatty mass with\nbrownish – black pigmented area with areas of congestion and\nhemorrhage. Histopathology examination revealed subcuta-\nneous islands of endometrial glands with stroma noted along\nwith congested blood vessels and areas of hemorrhage with\ndense lymphocytes infiltration in fibrosis without evidence of\nmalignancy. HPE findings suggestive of Scar endometriosis.\nOn follow up after 6 months she did not report any recurrence\nand was completely relieved of her symptoms.\nFig 1. Clinical examination\nDiscussion\nAbdominal wall endometriosis is largely related to previ-\nous history of surgery. (3) Endometriosis implants develop-\nFig 2. USG finding\nFig 3. Intraoperative findings\nFig 4. ross examination\nhttps://ijpccr.com/ 59\n\nZeba et al. / International Journal of Preclinical & Clinical Research 2021;2(3):58–61\nFig 5. Microscopy\ning in the subcutaneous tissue of surgical scars occur most\nfrequently after gynaecological and obstetrical procedures,\nincluding cesarean sections, hysterectomies, cystectomies,\ntubal ligations, and amniocenteses (1). The pathogenesis of\nendometriosis is complex and CSE is believed to be the\nresult of a mechanical iatrogenic implantation, through the\ndirect inoculation of the abdominal fascia and/or subcuta-\nneous tissue with endometrial cells during the surgical inter-\nvention, which, stimulated by estrogen, become active and\nexpand. (4) W ang et al. examined the factors contributing to\nCSE and defined possible causes, including the easy separa-\ntion and transport of endometrial cells by the amniotic fluid\nflowing into the pelvic cavity after hysterectomy; the large\namount of endometrial cells liberated into the pelvis before\nhysterectomy closure and that can potentially be trapped\nin the wound; and the nurturing role of blood and hor-\nmones, after inoculation of the cells, allowing them to grow\nand develop into subcutaneous masses. (2) Endometriosis in\ncesarean scar is a rarely observed disease. There are a lim-\nited number of publications focusing on CSE, and most of\nthem are case reports. It is difficult to perform well-controlled\nclinical trials in rarely observed disease. The common pre-\nsentation of CSE includes palpable subcutaneous mass, typ-\nically accompanied by cyclic, noncyclic, or constant pain.\nMenstruation usually aggravates disease. The mass under a\ncesarean section scar and the symptoms in a cyclic manner\nfairly facilitate the diagnosis of the illness. Awareness of its\ntypical clinical manifestation remains the mainstay for inter-\nvention and diagnosis. Iatrogenic mechanical transplanta-\ntions on incision scare during the operations are the most\naccepted pathogenesis. (2) T o minimize endometriosis con-\ntamination, some authors recommend careful isolation of\nthe wall incision and lavage with normal saline before clo-\nsure of the wall. (5) The others hypothesized that failure to\nclose the parietal and visceral peritoneum with sutures at time\nof ceserean section may markedly increase the postopera-\ntive occurrence of endometrioma in the skin incision scar. (6)\nReplacing instruments and needles with the new one is rec-\nommended when suturing other abdominal layers.(7) Medical\nmanagement- Hormonal treatment offers temporary allevi-\nation of symptoms, but recurrence is common after cessa-\ntion of treatment. (8) Sclerotherapy used for endometriotic\ncysts has been reserved for those patients who have high sur-\ngical risk, are pregnant, or refuse surgical intervention. In\nthe literature ultrasound-guided aspiration and sclerother-\napy with 95% ethanol provides a valid alternative to surgery\nin treating endometrial cysts. (9)Intralesional ethanol injec-\ntion may result in difficult-to-repair necrosis on the ante-\nrior muscles of the abdominal wall in large lesions. Also, in\nendometriosis foci extending into the intraperitoneal region,\nit may cause complications including chemical peritonitis and\nsevere pain as a result of alcohol penetration into the peri-\ntoneum. According to Bozkurt M et al planned sclerother-\napy by ultrasound-guided ethanol to the patient with intra-\nmuscular anterior wall endometriosis (A WE). Further inves-\ntigations of large series are needed to compare the surgical\noperation with ethanol injection treatment. Hence complete\nwide excision with clear margins is both diagnostic and ther-\napeutic and is accepted as treatment of choice in ceserean scar\nendometriosis.\nConclusion\nEndometriosis in Cesarean scar is rarely observed disease.\nCesarean section is an apparent risk factor for the presence\nof endometriosis. T o avoid unnecessary referrals, awareness\nof its typical clinical manifestations remains the mainstay for\nintervention. Medical treatment gives only partial relief and\nrecurrence of the condition after cessation of medication.\nPreventive measures like exclusion of the decidua during\nthe uterine closure, minimal tissue handling, and closure\nof parietal and visceral peritoneum can avoid iatrogenic\ninoculation of endometrial cells. Complete wide excision with\nclear margins is both diagnostic and therapeutic.\nhttps://ijpccr.com/ 60\n\nZeba et al. / International Journal of Preclinical & Clinical Research 2021;2(3):58–61\nReferences\n1) Pas¸alega M, Mirea C, Vilcea ID. Parietal abdominal endometriosis\nfollowing cesarean section. Romanian Journal of Morphology and\nEmbryology. 2011;52(1):503–508.\n2) W ang PH, Juang CM, Chao HT , Y u KJ, Y uan CC, Ng HT . W ound\nendometriosis: risk factor evaluation and treatment. Journal of the\nChinese Medical Association. 2003;66(2):113–119.\n3) Mistrangelo M, Gilbo N, Cassoni P , Micalef S, Faletti R, Miglietta C,\net al. Surgical scar endometriosis. Surgery T oday. 2014;44(4):767–772.\nAvailable from: https://dx.doi.org/10.1007/s00595-012-0459-3 .\n4) Sasson IE, Taylor HS. Stem Cells and the Pathogenesis of Endometriosis.\nAnnals of the New Y ork Academy of Sciences . 2008;1127(1):106–115.\nAvailable from: https://dx.doi.org/10.1196/annals.1434.014.\n5) Picod G, Boulanger L, Bounoua F , Leduc F , Duval G. Abdominal wall\nendometriosis after caesarean section: report of fifteen cases. Gynecol\nObstet Fertil. 2006;34:8–13.\n6) Minaglia S, Jr DRM, Ballard CA. Incisional endometriomas after cesarean\nsection: a case series. J Reprod Med. 2007;52:630–634.\n7) W asfie T , Gomez E, Seon S. Abdominal wall endometrioma after cesarean\nsection: a preventable complication. Int Surg. 2002;87:175–177.\n8) Bats AS, Zafrani Y , Pautier P , Duvillard P , Morice P . Malignant\ntransformation of abdominal wall endometriosis to clear cell carcinoma:\ncase report and review of the literature. Fertility and Sterility .\n2008;90(4):1197.e13–1197.e16. Available from: https://dx.doi.org/10.\n1016/j.fertnstert.2007.08.080.\n9) Gatta G, Parlato V , Grezia GD, Porto A, Cappabianca S, Grassi R,\net al. Ultrasound-guided aspiration and ethanol sclerotherapy for\ntreating endometrial cysts. La radiologia medica. 2010;115(8):1330–1339.\nAvailable from: https://dx.doi.org/10.1007/s11547-010-0586-0 .\nhttps://ijpccr.com/ 61","source_license":"CC0","license_restricted":false}