{"paper_id":"7aeb0db3-2033-4da6-ba7f-6b482612f260","body_text":"Karnataka Medical Journal • Volume 47 • Issue 1 • January-June 2024 | 35\nCase Report\nAbdominal wall endometriosis: A rare case report\nS. Y . Mulkipatil1\n1Department of Surgery, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India.\n*Corresponding author: \nS. Y . Mulkipatil, \nDepartment of Surgery, \nKarnataka Institute of Medical \nSciences, Hubli, Karnataka, \nIndia.\ndrsympatil@yahoo.com\nReceived: 07 May 2024  \nAccepted: 07 May 2024  \nPublished: 03 September 2024\nDOI \n10.25259/KMJ_16_2024\nQuick Response Code:\nINTRODUCTION\nEndometriosis was first described in 1860 by an Austrian pathologist, Karl Freiherr von \nRokitansky, who referred to the disease as adenomyoma. It is defined as an oestrogen-dependent, \nbenign inflammatory disease characterised by the presence or growth of endometrial tissue \noutside the uterine cavity. It occurs in 5–10% of all women. Abdominal wall endometriosis \n(AWE) is a rare condition that occurs after a caesarean section or pelvic surgery, and it has an \nincidence of 0.03–1.5% in women with previous caesarean delivery. [1] The most common sites \nof endometriosis, in decreasing order, are the ovaries, anterior/posterior cul-de-sac, broad and \nuterosacral ligaments, fallopian tubes, sigmoid colon and appendix. AWE, being a rare entity, is a \nbenign tumour defined as ectopic functional, endometrial tissue located in the abdominal wall.[2] \nThe disease is characterised with the triad of mass in the abdominal wall, periodic pain associated \nwith menses and a history of abdominal surgery. Its differential diagnosis includes lipoma, \ngranuloma, fibroma, desmoid tumour, incisional hernia, lymphoma and primary and metastatic \ncancer. Medical management (non-steroidal anti-inflammatory drugs, oral contraceptives and \ngonadotropin-releasing hormone agonists and aromatase inhibitors) has been the first line of \ntreatment. However, as it is rarely seen by general surgeons, it is often diagnosed on histological \nexamination postoperatively; wide surgical excision being the treatment of choice in the literature.\nCASE REPORT\nWe report a 35-year-old lady (P₂, L₂ and A₀) who presented with a swelling over the anterior \nabdominal wall for 4 years associated with cyclic pain. Her medical history was negative except \nABSTRACT\nAbdominal wall endometriosis (AWE) is a rare condition that occurs after a caesarean section or pelvic surgery, \nand it has an incidence of 0.03–1.5% in women with previous caesarean delivery. While commonly seen in the \ncutaneous and subcutaneous fat tissue at the caesarean scar level, but the involvement of muscle is quite rare. \nThe predominant clinical feature is cyclic pain over the mass; however, the presentation varies. The presence \nof endometrial tissue in the abdomen, whether cutaneous, subcutaneous, or intramuscular, is called AWE. Its \ntreatment options include excision of the lesion and/or hormonal therapies or ultrasound-guided ethanol injection \n(sclerotherapy), but wide surgical excision is the treatment of choice in the literature, although it may create a \ndefect in the abdominal wall and may increase the risk of hernia formation. This case report describes the clinical \nand radiological findings and treatment modalities of endometriosis that has appeared in the subcutaneous tissue \nwith rectus abdominis muscle involvement in a 35-year-old patient at the caesarean scar level.\nKeywords: Abdominal wall, Endometriosis, Desmoid tumour, Fine-needle aspiration cytology\nhttps://karnatakamedj.com/\nKarnataka Medical Journal\nThis is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others \nto remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.\n©2024 Published by Scientific Scholar on behalf of Karnataka Medical Journal\n\nMulkipatil: Abdominal wall endometriosis: A rare case report.\nKarnataka Medical Journal • Volume 47 • Issue 1 • January-June 2024 | 36\nfor a lower segment caesarean delivery 6  years before her \npresentation. The pain was localised to the lower abdomen, \ncrampy and cyclic and worsened particularly in the first \n2 days of menstruation and was partially relieved by taking \nsome analgesics. She had no history of chronic diseases, \nmenstrual irregularities, or any abdominal or pelvic surgeries \nexcept for the caesarean section. Routine laboratory findings \nwere in a normal range. Abdominal examination showed \na hard, immobile, painful, palpable mass lesion, about \n2.5  cm  ×  2cm, located above the lower-segment caesarean \nsection scar in the left iliac region and a probable diagnosis of \ngranuloma was made.\nUltrasound scan was performed, which showed a \nwell-defined hypoechoic lesion of size 24  mm × 28  mm in \nthe subcutaneous plane of the lower abdomen, suggestive of \ndesmoid tumour. Given these findings, fine-needle aspiration \ncytology (FNAC) was performed on the patient. The smear \nstudies showed stromal epithelial cells with orderly spaced \nnuclei, features suggestive of endometriosis. The patient was \nscheduled for elective surgery, that is wide surgical excision \nunder subarachnoid block.\nIntraoperatively, to our surprise, the lesion was found to \nbe fixed to some fibres of the left rectus abdominis muscle, \nwhich meant that those muscle fibres involved had to be \nremoved along with the excision of the endometrial mass.\nProcedure\nSubarachnoid block was given.\nEn bloc excision was performed for the wide surgical excision \nof the endometrial mass [Figure 1-2]. Since the mass was \nfound to be adhered to the rectus abdominis muscle, a few of \nthe muscle fibres were removed along with the mass excised \n[Figure 3-4]. The patient’s post-operative condition was \nuneventful, and she was discharged on the post-operative \nFigure 4: Image showing the excised endometrial mass.\nFigure  3: Intraoperative image showing the involvement of rectus \nabdominis muscle fibres.\nFigure 2: Intraoperative image showing the endometrial mass.\nFigure 1: Pre-excisional image of endometriosis.\n\nMulkipatil: Abdominal wall endometriosis: A rare case report.\nKarnataka Medical Journal • Volume 47 • Issue 1 • January-June 2024 | 37\nday 2 with an advice of oral administration of Tablet Danazol \n100  mg BD for 3  months to prevent recurrence. She was \nfollowed up at our outpatient department 1  week later \nand the surgical area looked healthy with no signs of site \ninfection. Pathology revealed the presence of endometrial \nstromal cells in singles and clusters with benign epithelial \ncells in broadsheets and clusters.\nDISCUSSION\nThe AWE is an uncommon site of extrapelvic endometriosis, \nwith involvement of rectus abdominis muscle fibres being \nquite rare. The differential diagnosis for AWE includes \nlipoma, granuloma, desmoid tumour, hematomas and benign \nas well as malignant tumours. Different pathophysiological \ntheories concerning the origins of endometriosis have \nbeen proposed, including the implantation of reflux, direct \nextension, coelomic metaplasia (claiming that endometriosis \ndevelops from metaplasia of peritoneum), iatrogenic direct \nimplantation (suggesting that sloughed endometrium results \nin endometriosis), embryonic rest (claiming a specific stimulus \nto a Mullerian origin stem cell nest produces endometriosis) \nand lymphatic and vascular metastasis.\nAWE can also arise in a male from the prostatic utricle, which \nis a remnant of the uterus from the time when the male \nand female urogenital systems in the embryo are separated \nbetween the 8th week and the 4 th month. [3]\nAWE is associated with certain risk factors. The first risk \nfactor, and the most common one, is a previous caesarean \nsection, which is strongly supported by the theory of \niatrogenic spread. Furthermore, the other risk factors include \nan early hysterotomy in pregnancy, increased menstrual flow \nand alcohol consumption. High parity has been shown to be \na protective factor against AWE.[4]\nThe clinical presentation of AWE is varicoloured. The most \ncommon symptoms include mass sensation, pain, bleeding, \ndysmenorrhoea and dyspareunia. Some patients may be \nasymptomatic, that is painless palpable mass. Palpable mass \npresents in 96% of patients.\nPatients with endometriosis in a surgical scar are often \nreferred to general surgeons due to clinical suspicion \nof incisional hernia. Radiological examination of this \nendometrial lesion is also non-specific, ultrasono graphy \nshowing hypoechoic inhomogeneous texture in subcutaneous \ntissue, indicating desmoid tumour, lipoma or granuloma. \nAWE cannot be diagnosed purely clinically or radiologically. \nThus, an FNAC becomes necessary.\nFine-needle aspiration cytology can be a reliable diagnostic \ntool for the evaluation of subcutaneous AWE. It can detect \nthe presence of endometrial glands, endometrial stroma and \nhemosiderin pigment so that hormonal therapy can be initiated, \nthereby avoiding unnecessary surgery in selected cases.\nSeveral treatment options have been reported, including \npharmacological and surgical treatment. Medical treatment \nwith the use of progestogens, oral contraceptive pills and \ndanazol is not effective and gives only partial relief in symptoms \nand does not ablate the lesion. Moreover, due to side effects such \nas amenorrhoea, weight gain and hirsutism acne, compliance is \nunlikely. The definite treatment of AWE and the gold standard \nis wide surgical excision. Moazeni-Bistgani recommends either \nirrigation of the wound with high-jet saline solution before \nwound closure or repair of the peritoneum at the time of \ncaesarean section as a preventive measure.[5]\nThe rate of recurrence of AWE after surgical excision is varied. \nThe studies have reported recurrence in 7.7%, to 9.1% of cases.\nFew studies have shown less recurrence that is 4.3%. The most \nsignificant complication of AWE is malignant transformation, \nwhich is likely to occur in 0.3–1% of cases. The principal risk \nfactors of malignant transformation of endometriosis include \nthe advanced age of the patient, if they are menopausal, and \nif the tumour diameter of an endometriotic lesion is >9 cm.[6]\nPost-operative follow-up with a gynaecologist is recommended \nsince concomitant pelvic endometriosis may be encountered \nin patients with AWE in a surgical scar. Cancer antigen (CA) \n125 determination, a marker found on the derivatives of \ncoelomic epithelium, may be useful in predicting the presence \nand recurrence of endometriosis.\nCONCLUSION\nAWE is a very rare condition. Although AWE cannot be \ndiagnosed clinically and radiologically, it should not be ignored \nin the differential diagnosis of mass per abdomen, especially in \nwomen with a history of previous caesarean section.\nEthical approval\nThe Institutional Review Board approval is not required.\nDeclaration of patient consent\nThe authors certify that they have obtained all appropriate \npatient consent.\nFinancial support and sponsorship\nNil.\nConflicts of interest\nDr. S. Y . Mulkipatil is on the Editorial Board of the Journal.\nUse of artificial intelligence (AI)-assisted technology for \nmanuscript preparation\nThe authors confirm that there was no use of artificial \nintelligence (AI)-assisted technology for assisting in the \n\nMulkipatil: Abdominal wall endometriosis: A rare case report.\nKarnataka Medical Journal • Volume 47 • Issue 1 • January-June 2024 | 38\nwriting or editing of the manuscript and no images were \nmanipulated using AI.\nREFERENCES\n1. Bozkurt M, Said Cil A, Bozkurt DK. Intramuscular abdominal \nwall endometriosis treated by ultrasound-guided ethanol \ninjection. Clin Med Res 2014;12:160-5.\n2. Gachabayov M, Horta R, Afanasyev D, Gilyazov T. Abdominal \nwall endometrioma: Our experience in Vladmir, Russia. Niger \nMed J 2016;57:329-33.\n3. Kocaakusak A, Arpinar E, Arikan S, Demirbag N, Kabaca C. \nAbdominal wall endometriosis: A  diagnostic dilemma for \nsurgeons. Med Princ Pract 2005;14:434-7.\n4. Saliba C, Jaafoury H, El Hajj M, Nicolas G, Ahmad HH. Abdominal \nwall endometriosis: A case report. Cureus 2019;11:e4061.\n5. Anand M, Deshmukh DS. Massive abdominal wall \nendometriosis masquerading as desmoid tumour. J  Cutan \nAesthet Surg 2011;4:141-3.\n6. Cozzolino M, Magnolfi S, Corioni S, Moncini D, Mattei A. \nAbdominal wall endometriosis on the right port site after \nlaparoscopy: Case report and literature review. Ochsner J 2015 \nFall;15:251-5.\nHow to cite this article: Mulkipatil SY . Abdominal wall endometriosis: A rare \ncase report. Karnataka Med J. 2024;47:35-8. doi: 10.25259/KMJ_16_2024","source_license":"CC0","license_restricted":false}