{"paper_id":"82eeed9d-2502-4ff0-9254-84ea50f2f07b","body_text":"~ 13 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2021; 5(5): 13-15 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2021; 5(5): 13-15 \nReceived: 03-06-2021 \nAccepted: 08-08-2021 \n \nDr. Seemitha Shetty \nJunior Resident, Department of \nObstetrics and Gynaecology, A. J. \nInstitute of Medical Sciences and \nResearch Center, Mangalore, \nKarnataka, India \n \nDr. Anitha S \nAssistant Professor, Department of \nObstetrics and Gynaecology, A. J. \nInstitute of Medical Sciences and \nResearch Center, Mangalore, \nKarnataka, India \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 \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nDr. Seemitha Shetty \nJunior Resident, Department of \nObstetrics and Gynaecology, A. J. \nInstitute of Medical Sciences and \nResearch Center, Mangalore, \nKarnataka, India \n \nRare case of scar endometriosis \n \nSeemitha Shetty and Anitha S \n \nDOI: https://doi.org/10.33545/gynae.2021.v5.i5a.1007 \n \nAbstract \nEndometriosis can sometimes occur in a previous surgical scar. The symptoms are nonspecific, typically \ninvolving abdominal wall pain at the incision site at the time of menstruatio n. A 31 -year old woman with \nprevious two caesarean section presents with cyclical abdominal pain and bleeding from the healed incision \nsite. Examination revealed a well -healed caesarean scar, no mobile , firm, nodular, contender  subcutaneous \nmass. Ultrasonography revealed a heterogeneous  hypoechoic area with minimal internal vascularity. She \nwas planned for scar excision after failed medical management. Intraoperatively, dense scar adhesions \nnoted hence proceeded with total hysterectomy. Histopathological ex amination report confirmed the \ndiagnosis of scar endometriosis. In conclusion, endometriosis is rare and difficult to diagnose. It should be \nsuspected in woman of childbearing age with cyclic, painful nodule in a scar from a previous obstetric or \ngynecologic procedure, after excluding other differential diagnoses. Diagnosis is by imaging modalities \nand treatment of choice is usually surgical resection. \n \nKeywords: Endometriosis, incisional endometriosis, painful scar, ultrasonography, scar excision \n \nIntroduction  \nEndometriosis is a common gynaecological condition where the endometrial glands and stromal \nstructures are found outside the uterus. Recently, the occurrence of scar endometriosis has been \nincreasing together with the increase of CS incidence.  The incidence of endometriosis in women \nof reproductive age is reported to be around 5– 15% \n[1]. AWE (Abdominal wall endometriosis) \nthat develops at the site of the surgical incision after obstetric or gynaecological surgeries, \nincluding CS (Caesarean section), i s called scar or incisional endometriosis. The incidence of \nAWE after CS is 0.03 –1% of women that underwent obstetric or gynaecological  surgeries \n[2]. \nUsually there is delay in diagnosing AWE, the most common clinical symptoms and signs are \nswelling, tende rness on local site, and cyclic pain. The most accepted cause is mechanical \niatrogenic implantation. Endometrial cells are inoculated directly into the surgical area and can \nprogress to endometriosis in optimal conditions [3]. The most common treatment opt ions for scar \nendometriosis include medical therapy and surgery [4]. We present a case of incisional scar \nendometriosis and followed by management and discussion regarding this rare case.  \n \nCase Report \nA 31-year old woman presented to our OPD in November 2 018 with the complaint of pain in the \nlower abdomen – on the caesarean scar since one year. She also gives history of cyclic bleeding \nfrom the same scar. She is a known case of type 2 diabetes mellitus on irregular medication. Her \nobstetric history –  P2L2 with two LSCS, 13 and 8 years back, in view of fetal distress and \nprevious LSCS, respectively. Post -operative period of the first LSCS, she gives history of \ncaesarean wound infection and hence was discharged on POD-15.  \nGeneral examination was within norma l limits. Local examination revealed a well -healed lower \nabdomen caesarean scar, non -mobile, firm, nodular, non- tender subcutaneous mass of size 3x2 \ncm in the midline. \nUltrasonography revealed a heterogeneous  hypoechoic area with few cystic changes measuring \n3.8x2cm in the lower abdominal wall in midline with minimal internal vascularity with fixation \nto anterior wall of uterus. A diagnosis of scar endometriosis was made and was started on \nInjection DEPO-PROVERA (Medroxyprogesterone acetate) 150mg monthly for 3 months. She \nwas asked to review after 3 months for follow -up. Three months following her treatment, she \npresented in January 2019 with similar complaints o f bleeding from the scar. She was later \nplanned for scan excision. \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 14 ~ \nAll routine blood investigations were done and was found to \nhave uncontrolled glucose values and was started on Injectable \ninsulin for immediate control. After obtaining fitness for \nsurgery, she was then taken up for the required surgery. \nIntraoperatively, endometrioma noted over the rectus sheath and \nuterus was adhered to rectus sheath. A rent was noted in the \nanterior wall of uterus, communicating with anterior abdominal \nwall.  \nDense scar adhesions were noted in the supravesical area and \nbetween anterior part of uterus to the bladder. Dissection of the \nscar tissue was done from the above mentioned areas, adhesions \nseparated. Intraop eratively, due to dense bladder adhesions, \nurologist was consulted and they advised total abdominal \nhysterectomy to avoid further resection of bladder and reducing \nthe bladder volume. Total hysterectomy and vault closure done \nby routine steps and abdomen c losed in layers. The specimens \nwere sent for histopathological examination and the report \nconfirmed the diagnosis of scar endometriosis along with \nproliferative endometrium, normal histological myometrium.  \nPostoperatively, no complications noted pertainin g to surgery \nand has no signs of recurrence till date. \n \n \n \nFig 1: Well-healed lower abdomen caesarean scar with mass of size \n3x2 cm in the midline \n \n \n \nFig 2: A rent noted noted in the anterior wall of uterus \nDiscussion \nThe incidence of scar endometriosis has been reported to be \nbetween 0.03% and 1.7%. \n[5] Abdominal wall endometrioma \npresents as a painful swelling resembling surgical lesions such \nas hernia s, hematomas, granulomas, abscess and tumors. \nTherefore, that is why these cases generally first report to \ngeneral surgeons.  \nThe pathogenesis of abdominal wall endometriosis is best \nexplained by a combination of theories. One mechanism consists \nof the direct implantation of endometrial tissue during a surgic al \nprocedure on the endometrium \n[6]. The clinical diagnosis is based \non the patient’s medical history and physical examination. \nAmong the methods that may be useful in diagnosing scar \nendometriosis are USG, CT, MRI as well as US -guided fine -\nneedle aspiration biopsy [7]. On the other hand, because \nincisional biopsy will cause endometriosis to spread even \nfurther, some studies have advised aga inst performing this \nprocedure \n[5]. \nManagement of scar endometri osis includes hormonal treatment \nand surgical resection. Surgery remains the mainstay of \ntreatment, including disease recurrence. Yela et al.  stated that \nultimate treatment is achieved through a total surgical removal \nof the mass together with at least 1 cm of surrounding healthy \ntissue, without impairing the integrity of the mass\n [8]. Other \ntherapeutic options include pharmacologic therapy with \nhormonal suppression agents, such as progestogens or \ngonadotropin-releasing hormone (GnRH) analogs to down -\nregulate the hypothalamus -pituitary-ovarian pathway. However, \nthe success rate with medical therapy is low, offering only \ntemporary relief of symptoms and is of ten followed by \nrecurrence after the cessation of drug therapy \n[5]. \n \nConclusion \nScar endometriosis is a rare and maybe difficult to diagnose \nhence one should have a high index of suspicion when women \npresent with these vague symptoms of cyclical pain in the \nincisional site of previous surgery. This condition can be \nconfused with other surgical conditions like hematoma, \nneuroma, granuloma or even hernia. The entire tumor with the \nhealthy tissue must be removed during the surgery. The patients \nmust be definitively followed up postoperatively for recurrence.\n \n \nAcknowledgements  \nWe would like to thank our patient and colleague in treating this \ncase.  \n \nReferences \n1. Alessandro P, Luigi N, Felice S, Maria P, Benedetto M, Stef\nano A. Research development of a new GnRH a ntagonist \n(Elagolix) for the treatment of endometriosis: A review of \nthe literature.  Arch Gynecol Obstet  2017. \nhttps://doi.org/10.1007/s00404-017-4328-6 \n2. Maillot J, Brun J, Dubuisson V, Bazot M, Grenier N, \nCornelis F. Mid-term outcomes after percutaneous \ncryoablation of symptomatic abdominal wall endometriosis: \nComparison with surgery alone in a single institution.  Eur \nRadiol 2017. https://doi.org/10.1007/s00330-017-4827-7 \n3. Hassan A. A Case Series of 10 Cases of Scar \nEndometriosis. Austin J Obstet Gynecol 2018;5(9):1130. \n4. Zhang P, Sun Y, Zhang C, Yang Y, Zhang L, Wang N, et \nal: Cesarean scar endometriosis: presentation of 198 cases \nand literature review . B MC Womens Health \n2019;19:14. 10.1186/s12905-019-0711-8 \n5. Y ı l d ı r ı m  D ,  T a t a r  C ,  D o ğ a n  O ,  et al. Post-cesarean s car \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 15 ~ \nendometriosis. Turk J Obstet Gynecol 2018;15(1):33-38.  \n6. Malutan AM, Simon I, Ciortea R, Mocan -Hognogi RF, \nDudea M, Mihu D. Surgical scar endometriosis: a series of \n14 patients and brief review of literature.  Clujul Med  \n2017;90(4):411-415.  \n7. Tatli F, Goz eneli O, Uyanikoglu H, et al. The clinical \ncharacteristics and surgical approach of scar endometriosis: \nA case series of 14 women. Bosn J Basic Med Sci. \n2018;18(3):275-278.  \n8. Yela DA, Trigo L, Benetti-Pinto CL. Evaluation of cases of \nabdominal wall endometriosis at Universidade Estadual de \nCampinas in a period of 10 years. Revista Brasileira de \nGinecologia e Obstetrícia 2017;39(8):403-407.","source_license":"CC0","license_restricted":false}