{"paper_id":"5f2bdad2-9413-4036-af17-29b026d7ce97","body_text":"Review began\n 02/08/2023 \nReview ended\n 02/14/2023 \nPublished\n 02/16/2023\n© Copyright \n2023\nDurairaj et al. This is an open access article\ndistributed under the terms of the Creative\nCommons Attribution License CC-BY 4.0.,\nwhich permits unrestricted use, distribution,\nand reproduction in any medium, provided\nthe original author and source are credited.\nSurgical Scar Endometriosis: An Emerging\nEnigma\nAnitha Durairaj \n \n, \nHarini \nSivamani \n \n, \nMahalakshmi \nPanneerselvam \n1.\n Obstetrics and Gynaecology, Velammal Medical College Hospital and Research Institute, Madurai, IND\nCorresponding author: \nAnitha Durairaj, \ndranithasrinidhi@gmail.com\nAbstract\nIntroduction\nSurgical scar endometriosis is a subtype of extra-pelvic endometriosis that is characterized by the formation\nof endometrial tissue near the incision site in patients who have previously undergone surgery. In recent\ntimes, with the increasing trend in Caesarean sections, the incidence of surgical scar endometriosis has also\nemerged. This study aims to describe the clinical characteristics and management of surgical scar\nendometriosis.\nMethodology\nWe conducted this cross-sectional, observational study over eight years (2015-2022) in a tertiary care centre\nin Madurai district, Tamil Nadu, India. We conducted this study after acquiring an ethical certificate from the\ninstitutional ethics committee (IEC No. VMCIEC/22/2018). In this study, we sampled all women (n = 32) with\na pathological diagnosis of scar endometriosis during the study period from hospital records (universal\nsampling). We searched the data for both general characteristics and lesion characteristics of the patients.\nThe general characteristics include age, body mass index (BMI), parity, mode of delivery, symptoms, and\nimaging by ultrasound. We have recorded the lesion characteristics of the patient, including location and size\nof scar endometriosis, layers involved in scar endometriosis, and surgical technique from surgical notes\nwritten in the case sheet. The minimum sample size required for this study was 31 study subjects. We\nentered the data into Excel (Microsoft, Redmond, WA, USA) and analyzed it in SPSS version 21 (IBM Corp.,\nArmonk, NY, USA). We expressed the quantitative variables in terms of mean and standard deviation and the\nqualitative variables in terms of frequency and percentage.\nResults\nThe mean age of the study participants was 34 years (range 23-55 years). In our study, 29 patients (90.6%)\nwere multi-para, and only three (9.4%) were nullipara. Among 29 parous women, the majority (25, or 77.7%)\nhad delivered by Caesarean section, while only four (12.5%) delivered by normal vaginal delivery. The\nsurgical procedures preceding the scar endometriosis were predominantly obstetric procedures (87.4%), out\nof which 25 patients underwent a Caesarean section and only three underwent an episiotomy. The most\ncommon presenting symptom of scar endometriosis in our study was cyclical pain in the scar site (90.4%),\nfollowed by swelling (81.25%). In 62.5% of patients, the duration between the presentation of surgical scar\nendometriosis and surgical intervention was greater than one year. Subcutaneous tissue (90.6%) was the\nmost commonly involved layer in surgical scar endometriosis, followed by the rectus sheath (86.2%). The\nsurgical procedure done for scar endometriosis was wide local excision in 78% of patients, and the\nremaining 22% of patients had wide local excision with mesh repair.\nConclusion\nCesarean section is an obvious risk factor for surgical scar endometriosis. Clinicians should have a high index\nof suspicion for surgical scar endometriosis in women presenting with cyclic pain at the scar site. Ultrasound\nis accurate in diagnosing scar endometriosis. Surgical management by wide local excision with a clear\nmargin with or without mesh repair is the treatment of choice.\nCategories:\n Medical Education, Obstetrics/Gynecology, General Surgery\nKeywords:\n cross-sectional study, lesion characteristics, demographic characteristics, surgical management, surgical\nscar endometriosis, cesarean section\nIntroduction\nEndometriosis is a benign gynecological disorder characterized by the growth of endometrial glands and\nstroma outside the uterine cavity. Endometriosis is an estrogen-dependent chronic inflammatory disease\nthat can affect either the pelvic or extra-pelvic regions of a woman’s body. We classify it as either pelvic or\nextra-pelvic endometriosis \n[1]\n.\n1\n1\n1\n \n Open Access Original\nArticle\n \nDOI:\n 10.7759/cureus.35089\nHow to cite this article\nDurairaj A, Sivamani H, Panneerselvam M (February 16, 2023) Surgical Scar Endometriosis: An Emerging Enigma. Cureus 15(2): e35089. \nDOI\n10.7759/cureus.35089\n\nEndometriosis is a common condition that affects 5-10% of all women and can cause severe discomfort as\nwell as infertility. It is estimated that endometriosis affects 89 million women of reproductive age around\nthe world \n[2]\n.\nWhen endometriotic implants are found in areas of the body that are not associated with the pelvic organs,\nwe refer this condition to as having extra pelvic endometriosis. These locations include the gastrointestinal\ntract, the urinary tract, the lungs, the abdominal wall, and the central nervous system.\nSurgical scar endometriosis, also known as SSE, is a subtype of extra-pelvic endometriosis that is\ncharacterized by the formation of endometrial tissue near the incision site in patients who have previously\nundergone surgery. The researchers have described only a few examples of surgical scar endometriosis in the\nmedical literature, making this a rare clinical condition. There have been reports of scar endometriosis\ndeveloping after obstetric and gynecological surgeries, such as Cesarean sections, vaginal deliveries in\nepisiotomy sites, laparotomies or laparoscopic port sites for hysterectomy, tubectomy, ectopic pregnancies,\novarian cystectomies, hernial repair sites, and even needle tracked after amniocentesis \n[3,4]\n. This iatrogenic\nresult is still a mystery, and the exact etiology of surgical scar endometriosis is unknown; there are several\nhypotheses that attempt to explain its development. There is a wide range of variation in the incidence of\nsurgical scar endometriosis, ranging from 0.03% to 1.08% \n[5,6]\n.\nDue to the unusual presentation of these patients, general physicians, surgeons, or dermatologists may be\ntheir initial point of contact. Because of this, it is imperative that medical professionals have more\neducation regarding this disorder \n[7]\n. In recent times, with the increasing trend of Caesarean sections, the\nincidence of SSE has also emerged. This study aims to describe the clinical characteristics and management\nof surgical scar endometriosis.\nMaterials And Methods\nStudy design, duration, and ethical clearance\nWe conducted this cross-sectional, observational study over eight years (2015-2022) in a tertiary care centre\nin Madurai district, Tamil Nadu, after acquiring an ethical certificate from the institutional ethics committee\nof Velammal Medical College Hospital and Research Institute, Madurai (IEC No. VMCIEC/22/2018).\nStudy sampling and data collection\nIn this study, we sampled all women (n = 32) with a pathological diagnosis of scar endometriosis during the\nstudy period from hospital records (universal sampling). We searched the data for both general\ncharacteristics and lesion characteristics of the patients. The general characteristics include age, body mass\nindex (BMI), parity, mode of delivery, symptoms, the duration between index surgery and the onset of\nsymptoms, and imaging by ultrasound (diagnosis). We have recorded the lesion characteristics of the\npatient, including location and size of scar endometriosis, layers involved in scar endometriosis, and surgical\ntechnique from surgical notes written in the case sheet.\nSample size\nThe minimum sample size required for this study was 31 study subjects. We calculated the sample size by\nusing the formula 3.84*p*q/d\n2\n, where p is prevalence, q is the complement of p, and d is absolute precision\n(which was 5%). We collected the prevalence from the study by Yuan et al. in China, where they conclude\nthat the prevalence of abdominal wall endometriosis is 1.96% \n[8]\n.\nStatistical analysis\nWe entered the data into Excel (Microsoft, Redmond, WA, USA) and analyzed it in Statistical Package for\nSocial Sciences (SPSS) version 21 (IBM Corp., Armonk, NY, USA). We expressed the quantitative variables in\nterms of mean and standard deviation, and we expressed the qualitative variables in terms of frequency and\npercentage. The current study was an exploratory one, and we did not assign an outcome variable.\nResults\nWe included about 32 patients with a pathological diagnosis of surgical scar endometriosis in our study, and\nwe analyzed their results. Table \n1\n shows the general characteristics of patients with surgical scar\nendometriosis. The mean age of the study participants was 34 years (range 23-55 years). The mean BMI in\nour study was 29.15, of which 43.8% were obese. In our study, 29 patients (90.6%) were multi-para, and only\nthree (9.4%) were nullipara. Among 29 parous women, the majority (25, or 77.7%) had delivered by\nCaesarean section, while only four (12.5%) delivered by normal vaginal delivery.\n2023 Durairaj et al. Cureus 15(2): e35089. DOI 10.7759/cureus.35089\n2\n of \n7\n\nGeneral characteristics\nFrequency\nPercent\nAge (in years)\nMean – 34.47   standard deviation – 8.39\nBMI (kg/m\n2\n)\nMean – 29.15   standard deviation – 4.72\nUnderweight (18)\n0\n0\nNormal (18.5 – 24.9)\n7\n21.8\nOverweight (25 – 29.9)\n11\n34.4\nObese >30\n14\n43.8\nParity\nNullipara\n3\n9.4\nMultipara\n29\n90.6\nMode of delivery\nNormal vaginal delivery\n4\n12.5\n1 LSCS\n8\n25.0\n2 LSCS\n17\n52.5\nTABLE\n 1: General characteristics of the study participants (n=32)\nBMI – Body Mass Index, LSCS – Lower Segment Cesarean Section\nTable \n2\n shows the lesion characteristics of patients with surgical scar endometriosis. The surgical procedures\npreceding the scar endometriosis were predominantly obstetric procedures (87.4%), out of which 25 patients\nunderwent a Caesarean section and only three underwent an episiotomy. Two of the procedures preceding\nscar endometriosis were hysterectomy and endometriotic cyst excision. The mean interval between index\nsurgery and clinical presentation of surgical scar endometriosis was 6.19 years. The most common\npresenting symptom of scar endometriosis in our study was a cyclical pain in the scar site (90.4%), followed\nby swelling (81.25%).\nLesion characteristics\nFrequency\nPercent\nIndex surgery\nEpisiotomy\n3\n9.4\nLSCS\n25\n78.0\nHysterectomy\n2\n6.3\nLaparoscopic cyst excision for endometriosis\n2\n6.3\nDuration between index surgery and onset of symptoms (in years)\nMean – 6.19   Standard deviation – 4.25\nSymptoms\nCyclical pain at scar\n29\n90.4\nSwelling or lump\n26\n81.25\nCyclical bleeding from lump \n4\n12.5\nDysmenorrhea\n21\n65.6\nUltrasound diagnosis of scar endometriosis\nCorrect\n31\n96.8\nWrong\n1\n3.2\nPreoperative medical management\n11\n34.4\n2023 Durairaj et al. Cureus 15(2): e35089. DOI 10.7759/cureus.35089\n3\n of \n7\n\nDuration between onset of symptom and surgery\nWithin 1 year\n12\n37.5\nMore than 1 year\n23\n62.5\nLocation of scar endometriosis\nAbdominal wall scar\nI\nSuprapubic transverse scar\ni) Left lateral\n17\n52.5\nii) midline\n5\n15.5\niii) Right lateral\n5\n15.5\nII\nPort site scar\ni) Left Lateral\n1\n3.1\nii) Umbilical\n1\n3.1\nEpisiotomy scar\n3\n9.4\nSize of scar endometriosis                  \n \nLayers involved in scar endometriosis\nSkin involvement\n12/32\n37.5\nSubcutaneous tissue\n29/32\n90.6\nRectus sheath\n25/29\n86.2\nRectus muscle\n4 /29\n13.7\nPeritoneum\n12/29\n3.1\nPerineal muscle\n1/3\n3.1\nSurgical Procedure\nWide local excision\n25\n78.0\nWide local excision with mesh repair\n7\n22.0\nTABLE\n 2: Lesion characteristics and symptoms of the study participants (n=32)\nLSCS – Lower Segment Cesarean Section\nPreoperative imaging included ultrasonography in all patients, which is accurate in 96.8% of cases. 34.4% of\npatients had tried medical management of scar endometriosis before definitive surgical intervention. In\n62.5% of patients, the duration between the presentation of surgical scar endometriosis and surgical\nintervention was greater than one year. In our study we reported the location of surgical scar endometriosis\nin three sites, namely abdominal wall suprapubic transverse scar in 27 patients (83.5%), abdominal wall port\nscar in two patients (9.4%), and perineal episiotomy scar in three patients (9.4%). The mean size of the\nsurgical scar endometriosis lesion was 4.5 x 3.5 cm. Subcutaneous tissue (90.6%) was the most commonly\ninvolved layer in surgical scar endometriosis, followed by the rectus sheath (86.2%). The surgical procedure\ndone for scar endometriosis was wide local excision in 78% of patients, and the remaining 22% of patients\nhad wide local excision with mesh repair.\nDiscussion\nSurgical scar endometriosis remains an enigma. The exact cause and natural progression of endometriosis\nare yet to be determined. Surgeons transplant directly active endometrial cells onto the layers of a surgically\nincised lesion, and these cells defy immune-mediated apoptosis, allowing an ectopic endometrial cell to\nsurvive \n[9,10]\n. The estrogen-dependent inflammatory response theory explains the natural progression of\nendometriosis and its symptoms. We analyzed this emerging iatrogenic complication in the present study.\n2023 Durairaj et al. Cureus 15(2): e35089. DOI 10.7759/cureus.35089\n4\n of \n7\n\nThe mean age of the women with surgical scar endometriosis in our study was 34 years. A study by Yildirim\net al. \n[11]\n and Zhang et al. \n[12]\n also reported a mean age of 31 and 34 years, respectively. We attributed this\nhigh prevalence among women of childbearing age to an increase in surgical scar endometriosis patients\nfollowing Caesarean sections. In our study, patients presenting beyond the reproductive age group were\nfollowing gynecological procedures. The mean BMI in our study was 29.15, among which 43.8% were obese,\nwhich suggests an increased prevalence of scar endometriosis in obese individuals. This finding was similar\nto the results of the study conducted by Sumathy et al. \n[13]\n and Ding et al. \n[14]\n. Obesity can provide a wide\nsurgical surface for the entrapment of active endometrial cells and may start the process \n[10]\n.\nAmong 29 parous women with surgical scar endometriosis, the majority (25, or 77.7%) had delivered by\nCaesarean section and only four (12.5%) had delivered by normal vaginal delivery. The index surgery is the\none that results in the development or occurrence of endometriosis at the surgical scar site, and we thought\nit to be an obvious risk factor for surgical scar endometriosis. The index surgeries preceding the scar\nendometriosis in our study were predominantly obstetric procedures (87.4%), out of which 25 patients were\nfollowing a Caesarean section. We considered scar endometriosis to increase with parity because of more\nadhesions and non-closure of peritoneal layers, exposing endometrial cells to the abdominal cavity \n[15]\n.\nOnly three women in our study had surgical scar endometriosis after episiotomy, which is because of\nshedding decidual endometrial tissue implants on the episiotomy site \n[16]\n. In our study, four women\ndeveloped surgical scar endometriosis following gynecological procedures, of which two underwent\nlaparoscopic endometriotic cystectomy and two underwent abdominal hysterectomy. This could be because\nof the inoculation of endometrial cells onto the incision site while removing the specimen.\nThe mean interval between index surgery and the clinical presentation of surgical scar endometriosis was\n6.19 years (range 2-10 years). Scar endometriosis has a sluggish onset, initially manifesting as cyclical\ndiscomfort that is frequently misdiagnosed as dysmenorrhea. The patient usually presents when there is the\ndevelopment of a lump at the scar site.\nThe most common presenting symptoms of surgical scar endometriosis were cyclical pain, followed by a\nlump at the scar site. In our study, we observed a cyclical pain, a characteristic symptom of scar\nendometriosis, in 90% of participants. We found similar findings in a study conducted by Zhang et al. \n[12]\nand Buscemi et al. \n[17]\n. Cyclical hemorrhage of functioning endometrium in response to hormonal changes\nis the reason for cyclic pain at the scar site. Cyclical bleeding from the scar site is the specific feature of\nsurgical scar endometriosis, but we report it in only 12.5% of the patients in our study.\nIn our study, we found surgical scar endometriosis in three locations: the abdominal wall suprapubic\ntransverse scar, the abdominal wall laparoscopic port site, and the episiotomy scar. Among the 27 cases of\nabdominal wall suprapubic transverse scar endometriosis, 25 were following Caesarean sections, and only\ntwo were following abdominal hysterectomy. Two cases of abdominal wall port site endometriosis were\nfollowing laparoscopic endometriotic cyst excision, and three cases of episiotomy scar endometriosis were\nfollowing vaginal delivery. The mean size of the surgical scar endometriosis lesion was 4.5 by 3.5\ncentimeters. Subcutaneous tissue involvement (90.6%), followed by involvement of the rectus sheath\n(86.2%), was the most prevalent pattern of involvement in surgical scar endometriosis. The study conducted\nby Sumathy et al. showed 100% of the individuals had subcutaneous tissue involvement and 75% had rectus\nsheath involvement \n[13]\n.\nWe only used imaging as a supplement to a high index of clinical suspicion for diagnosing SSE.\nUltrasonography was accurate in 96.8% of patients with scar endometriosis in our study. This finding is\ncomparable to those by Yuan et al. \n[8]\n and Zhang et al. \n[12]\n. The sonographic appearance of scar\nendometriosis is predominantly hypoechoic and heterogeneous, with scattered internal echoes at the\nsurgical scar site with limited vascularity \n[18,19]\n. Ultrasound imaging eliminates differential diagnoses such\nas suture granuloma, hematoma, neuroma, hernia, and neoplasia of surgical scar endometriosis, which not\nonly helps in making an accurate diagnosis but also aids in presurgical mapping \n[20]\n.\nThe treatment options for surgical scar endometriosis are medical therapy and surgical interventions.\nMedical therapy with oral contraceptive pills (OCPs), gonadotropin-releasing hormone (GnRH), and danazol\nis usually futile, providing only temporary symptomatic relief that will recur at a later date. In our study,\n34.4% of patients had tried medical management of scar endometriosis before definitive surgical\nintervention. Hence, surgical intervention is the definitive treatment. We should consider abdominal wall\nreconstruction with mesh besides wide local excision in larger lesions involving the rectus sheath or muscle\nthat leave a wide post-excisional defect \n[13]\n. Failure to do so might cause an incisional hernia, as the\napproximation of layers is under tension and weak. Complete resection with a 1 cm clear margin and\navoiding contamination while handling is critical to preventing recurrence after surgery.\nThe complications of surgical scar endometriosis are recurrence and malignant transformation. A study\nconducted by Ding and Zhu reported a recurrence rate of 1.5% \n[14]\n. The key to preventing SSE recurrence\nafter surgery is complete resection with a 1 cm clear margin and avoiding endometriotic cell contamination\nof the field while handling. Transformation of SSE is multifactorial, involving genetic, immunological, and\nenvironmental factors. Clear cell carcinoma is the most common histological subtype, followed by\n2023 Durairaj et al. Cureus 15(2): e35089. DOI 10.7759/cureus.35089\n5\n of \n7\n\nendometrial carcinoma \n[21]\n.\nPrevention of surgical scar endometriosis is an absolute need. We must keep the contamination of the\nsurgical incision layers with decidual or endometrial cells to a minimum in order to accomplish this\nprevention. They prevented cesarean scar endometriosis by performing an intro-flexed suture of the uterine\nincision and by closing the visceral and parietal peritoneum \n[22]\n. Placing the specimen in an endo-bag and\nirrigating the port with saline will prevent the development of endometriosis at the port site \n[23]\n. Changing\ngloves before repairing an episiotomy scar and making sure the wound is free of decidua are both effective\nways to reduce the risk of endometriosis developing in the scar tissue \n[24]\n.\nLimitation of the study\nThough our study met the minimum required sample size, a multi-centric study with a larger sample size\nmay yield better results. Our study didn’t estimate the recurrence rate since this was a cross-sectional study.\nSince this study was an exploratory study, we did not assign an outcome variable, and we performed no\ninferential statistics.\nConclusions\nWe directly related surgical scar endometriosis to obstetrics and gynecological surgeries. Cesarean section is\nan obvious risk factor for surgical scar endometriosis. Clinicians should have a high index of suspicion for\nsurgical scar endometriosis in women presenting with cyclic pain on the scar site. Ultrasound is accurate in\ndiagnosing scar endometriosis. Medical management offers only temporary relief to be presented at a later\ndate, and hence surgical intervention is the definitive treatment. Surgical management by wide local\nexcision with a clear margin with or without mesh repair is the treatment of choice. We can prevent this\niatrogenic complication by practicing certain surgical precautions.\nAdditional Information\nDisclosures\nHuman subjects:\n Consent was obtained or waived by all participants in this study. Institutional Ethics\nCommittee of Velammal Medical College Hospital and Research Institute, Madurai \nissued approval\nVMCIEC/22/2018. \nAnimal subjects:\n All authors have confirmed that this study did not involve animal\nsubjects or tissue. \nConflicts of interest:\n In compliance with the ICMJE uniform disclosure form, all authors\ndeclare the following: \nPayment/services info:\n All authors have declared that no financial support was\nreceived from any organization for the submitted work. \nFinancial relationships:\n All authors have declared\nthat they have no financial relationships at present or within the previous three years with any\norganizations that might have an interest in the submitted work. \nOther relationships:\n All authors have\ndeclared that there are no other relationships or activities that could appear to have influenced the\nsubmitted work.\nReferences\n1\n. \nChmaj-Wierzchowska K, Pieta B, Czerniak T, Opala T: \nEndometriosis in a post-laparoscopic scar--case\nreport and literature review\n. Ginekol Pol. 2014, 85:386-9. \n10.17772/gp/1737\n2\n. \nDanielpour PJ, Layke JC, Durie N, Glickman LT: \nScar endometriosis - a rare cause for a painful scar: a case\nreport and review of the literature\n. Can J Plast Surg. 2010, 18:19-20. \n10.1177/229255031001800110\n3\n. \nPaşalega M, Mirea C, Vîlcea ID, et al.: \nParietal abdominal endometriosis following Cesarean section\n. Rom J\nMorphol Embryol. 2011, 52:503-8.\n4\n. \nKhachani I, Filali Adib A, Bezad R: \nCesarean scar endometriosis: an uncommon surgical complication on the\nrise? Case report and literature review\n. Case Rep Obstet Gynecol. 2017, 2017:8062924.\n10.1155/2017/8062924\n5\n. \nChatterjee SK: \nScar endometriosis: a clinicopathologic study of 17 cases\n. Obstet Gynecol. 1980, 56:81-4.\n6\n. \nTeng CC, Yang HM, Chen KF, Yang CJ, Chen LS, Kuo CL: \nAbdominal wall endometriosis: an overlooked but\npossibly preventable complication\n. Taiwan J Obstet Gynecol. 2008, 47:42-8. \n10.1016/S1028-4559(08)60053-4\n7\n. \nGoel P, Devi L, Tandon R, Saha PK, Dalal A: \nScar endometriosis - a series of six patients\n. Int J Surg. 2011,\n9:39-40. \n10.1016/j.ijsu.2010.08.003\n8\n. \nYuan L, Zhang JH, Liu XS: \n[Clinicopathological features of 151 cases with abdominal wall endometriosis]\n.\nZhonghua Fu Chan Ke Za Zhi. 2013, 48:113-7.\n9\n. \nWang PH, Juang CM, Chao HT, Yu KJ, Yuan CC, Ng HT: \nWound endometriosis: risk factor evaluation and\ntreatment\n. J Chin Med Assoc. 2003, 66:113-9.\n10\n. \nUçar MG, Şanlıkan F, Göçmen A: \nSurgical treatment of scar endometriosis following cesarean section, a\nseries of 12 cases\n. Indian J Surg. 2015, 77:682-6. \n10.1007/s12262-013-0978-1\n11\n. \nYıldırım D, Tatar C, Doğan O, et al.: \nPost-cesarean scar endometriosis\n. Turk J Obstet Gynecol. 2018, 15:33-8.\n10.4274/tjod.90922\n12\n. \nZhang P, Sun Y, Zhang C, Yang Y, Zhang L, Wang N, Xu H: \nCesarean scar endometriosis: presentation of 198\ncases and literature review\n. BMC Womens Health. 2019, 19:14. \n10.1186/s12905-019-0711-8\n13\n. \nSumathy S, Mangalakanthi J, Purushothaman K, Sharma D, Remadevi C, Sreedhar S: \nSymptomatology and\nsurgical perspective of scar endometriosis: a case series of 16 women\n. J Obstet Gynaecol India. 2017, 67:218-\n23. \n10.1007/s13224-016-0945-4\n14\n. \nDing Y, Zhu J: \nA retrospective review of abdominal wall endometriosis in Shanghai, China\n. Int J Gynaecol\n2023 Durairaj et al. Cureus 15(2): e35089. DOI 10.7759/cureus.35089\n6\n of \n7\n\nObstet. 2013, 121:41-4. \n10.1016/j.ijgo.2012.11.011\n15\n. \nMinaglia S, Mishell DR Jr, Ballard CA: \nIncisional endometriomas after Cesarean section: a case series\n. J\nReprod Med. 2007, 52:630-4.\n16\n. \nDadhwal V, Sharma A, Khoiwal K, Nakra T: \nEpisiotomy scar endometriosis\n. Med J Armed Forces India. 2018,\n74:297-9. \n10.1016/j.mjafi.2017.06.004\n17\n. \nBuscemi S, Maiorana A, Fazzotta S, et al.: \nScar endometriosis: not a rare cause for a painful scar\n. Clin Ter.\n2021, 172:129-33. \n10.7417/CT.2021.2299\n18\n. \nRadswiki T: \nScar endometriosis\n. Radiopaedia. 2023, \n10.53347/rID-15358\n19\n. \nHensen JH, Van Breda Vriesman AC, Puylaert JB: \nAbdominal wall endometriosis: clinical presentation and\nimaging features with emphasis on sonography\n. AJR Am J Roentgenol. 2006, 186:616-20.\n10.2214/AJR.04.1619\n20\n. \nBusard MP, Mijatovic V, van Kuijk C, Hompes PG, van Waesberghe JH: \nAppearance of abdominal wall\nendometriosis on MR imaging\n. Eur Radiol. 2010, 20:1267-76. \n10.1007/s00330-009-1658-1\n21\n. \nMihailovici A, Rottenstreich M, Kovel S, Wassermann I, Smorgick N, Vaknin Z: \nEndometriosis-associated\nmalignant transformation in abdominal surgical scar: a PRISMA-compliant systematic review\n. Medicine\n(Baltimore). 2017, 96:e9136. \n10.1097/MD.0000000000009136\n22\n. \nPlotski A: \nEndometriosis of postoperative scar\n. Scars. Chiriac A (ed): IntechOpen, London; 2019.\n10.5772/intechopen.88246\n23\n. \nAo X, Xiong W, Tan SQ: \nLaparoscopic umbilical trocar port site endometriosis: a case report\n. World J Clin\nCases. 2020, 8:1532-7. \n10.12998/wjcc.v8.i8.1532\n24\n. \nBindra V, Reddy N, Reddy CA, Swetha P, Alapati KV, Nori M: \nRecurrent perineal scar endometriosis: a case\nreport\n. Case Rep Womens Health. 2022, 36:e00457. \n10.1016/j.crwh.2022.e00457\n2023 Durairaj et al. Cureus 15(2): e35089. DOI 10.7759/cureus.35089\n7\n of \n7","source_license":"CC0","license_restricted":false}