{"paper_id":"8ed62d82-5af3-4449-b06a-71677cd53371","body_text":"Turkiye Klinikleri J Case Rep. 2021;29(1):20-3\n20\nEndometriosis refers to the presence of endome-\ntrial tissue outside of the endometrial cavity.1 Its symp-\ntoms and findings may involve pelvic pain, \ndysmenorrhea, dyspareunia, infertility, and adnexal \nmass. Endometriosis in overall population has been re-\nported at a varying prevalence from 10% to 44% \namong symptomatic and asymptomatic individuals, \novaries being the most common site of involvement.\n2 \nAlthough genital tract and adjacent organs are pre-\ndominantly affected, extragenital involvement may also \noccur with a reported prevalence of 8.9%.\n2 Sites of ex-\ntragenital involvement, in decreasing order of fre-\nquency, are bowel, urinary tract, skin, and thorax. \nEndometriosis with extragenital involvement takes \nplace along with pelvic involvement in 84% of inflicted \nwomen.\n2 Extragenital endometriosis usually has a \npelvic, peritoneal or ovarian manifestation. It may also \ninvolve pouch of Douglas, and abdominal wall, the lat-\nter to a lesser extent. Medical or surgical treatment \nmight be envisaged for these cases.\n3 Several theories \nhave been postulated to explain the cause why en-\ndometrial tissue is located outside the uterus which in-\nclude metaplasia, retrograde menstruation, lymphatic \nor vascular metastasis, and mechanic implantation dur-\ning surgery.\n4 For instance, incisional endometriomas \nmay arise secondary to hysterectomy, Cesarean section, \nepisiotomy, tubal ligation, insertion of a laparoscopic \ntrocar, or amniocentesis. Endometrial tissue is believed \nto be inoculated through mechanic implantation.\n5 \nAccording to the literature data, incision scar en-\ndometriomas most often develop following Cesarean \nsections and may lead to malignancy.\n6,7 In this report, \nwe present a case previously implanted with a mesh \ndue to umbilical hernia which caused endometrioma \nthat we have detected upon pathological investiga-\ntion of anterior abdominal wall. \nEndometriosis in Abdominal Fascia Mesh \n     Mehmet Ferdi KINCIa,      Mehmet Onur ARSLANERa,      Özge ŞEHİRLİ KINCIa, \n     Ezgi KARAKAŞ PASKALb,      Melek ÜNÇELc,      Ahmet Akın SİV ASLIOĞLUa \naClinic of Obstetrics and Gynecology, Muğla Training and Research Hospital, Muğla, TURKEY \nbClinic of Obstetrics and Gynecology, Başakşehir Çam ve Sakura City Hospital, İstanbul, TURKEY \ncClinic of Pathology, Muğla Training and Research Hospital, Muğla, TURKEY \nABS TRACT Endometriosis is a common clinical problem in women of reproductive age. Endometriosis usually involves pelvis, peritoneum, \novaries, pouch of Douglas, and uterosacral ligaments, in addition to abdominal wall, albeit rarely. Meshes are frequently impla nted today for \nthe purpose of hernia repair. Synthetic mesh placement has been growing in number with an intent of improving success of certai n surgical \nprocedures and prolonging treatment response. With increasing use of meshes, however, mesh-associated complications are coming to light. \nSuch complications cover a broad spectrum including chronic erosion, dyspareunia, pain, infection, injury to rectum, bladder, and vessels. Here, \nwe present a case who previously had undergone surgery due to umbilical hernia and was implanted with a mesh for whom total lap aroscopic \nhysterectomy was indicated as she had uterine myoma and menometrorrhagia refractory to medical treatment. During her surgery, m esh in-\nfection was suspected upon which excision was performed and pathology report, in turn, revealed endometrioma. \n \nKeywords: Endometriosis; mesh; complications; umbilical hernia; laparoscopy\nDOI: 10.5336/caserep.2020-78230\nCASE REPORT\nCorrespondence: Mehmet Ferdi KINCI \nMuğla Sıtkı Koçman University Education and Research Hospital, Obstetrics and Gynecology Department, Muğla, TURKEY \nE-mail: drferdikinci@gmail.com  \nPeer review under responsibility of Turkiye Klinikleri Journal of Case Reports.  \nRe ce i ved: 23 Jul 2020          Received in revised form: 14 Dec 2020         Ac cep ted: 21 Dec 2020          Available online:21 Jan 2021  \n2147-9291 / Copyright © 2021 by Türkiye Klinikleri. This is an open \naccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).\nTurkiye Klinikleri Journal of Internal Medicine \nTürkiye Klinikleri Journal of Case Reports\n\n\n CASE REPORT \nA 49-year-old gravida 3 para 2 woman visited our \noutpatient clinic complaining of groin pain and drug-\nresistant menometrorrhagia ongoing for the last 2-3 \nyears. Despite using cyclic progesterone for 6 months \nbetween the 15\nth and 25th days, she did not get any re-\nsponse. She then used levonogestrel intrauterine de-\nvice for a year. In the detailed history of the patient, \nhernia repair was performed 7 years ago due to an an-\nterior abdominal wall hernia. She doesn’t know the \ntype of the mesh. The patient did not mention any com-\nplaints in relation to her past mesh surgery. In transvagi-\nnal ultrasonography, multiple myomas with the largest \nbeing approximately 4*4 cm were observed. Consid-\nering previous abdominal surgery with mesh implanta-\ntion, open laparoscopic surgery (LS) was planned for \nthe patient. To enable trocar insertion, access through a \nsupraumbilical open LS was attempted. During the \ncourse of the entry, discharge of dark color and dense \nconsistency suggestive of intestinal injury was noted \nand shift to open surgery was decided. All bowel seg-\nments were checked and confirmed to be intact. Mesh \nof the patient was excised out, and hysterectomy was \nperformed (\nFigure 1). The surgery was completed with-\nout any complications. \nRespective pathology report indicated the excised \nmesh. Accumulation of hemosiderin-loaded \nmacrophages as well as new bleeding areas around the \ncystic dilated endometrial glands (HE, x100).  \nTherefore, endometrioma was considered on the \nmesh (\nFigure 1). Area of granulation tissue consisting \nof histiocytes with foamy cytoplasm and multinucle-\nated giant cells containing foreign body material (HE, \nx200). This situation made us think of foreign body \nreaction (\nFigure 2, Figure 3 ). In her follow-up ap-\npointment 6 months after the surgery, the patient had \nno relapse of hernia. \n DISCuSSION \nEndometriosis is described as the presence of en-\ndometrial tissue outside the uterine cavity, among \nvarious forms of which extra-pelvic manifestation \nstands for 8.9% of all cases.\n8 Abdominal wall en-\ndometriosis (AWE) might have cutaneous or subcu-\ntaneous location at a site in an incision scar, \numbilicus, or rectus abdominis muscle. The risk to \ndevelop after Cesarean section is 0.1%.\n9 Among 34 \nwomen with extragenital endometriosis, 44% had en-\nMehmet Ferdi KINCI et al. Turkiye Klinikleri J Case Rep. 2021;29(1):20-3\n21\nFIGURE 1: Excised mesh endometrioma [Accumulation of hemosiderin-loaded \nmacrophages as well as new bleeding areas around the cystic dilated endomet-\nrial glands. (HE, x100)].\nFIGURE 2: Response to foreign body [Area of granulation tissue consisting of his-\ntiocytes with foamy cytoplasm and multinucleated giant cells containing foreign \nbody material (HE, x200)].\nFIGURE 3: Endometrioma (epithelial).\n\nMehmet Ferdi KINCI et al. Turkiye Klinikleri J Case Rep. 2021;29(1):20-3\n22\ndometriosis along Pfannenstiel incision tract. 10 The \ntheory that most likely explains development of scar \nendometriosis is direct inoculation of endometrial \ncells to subcutaneous tissue and abdominal fascia.\n10 \nSynthetic meshes have a wide range of applica-\ntion in surgical treatment of stress urinary inconti-\nnence and pelvic organ prolapse as well as in \nsurgeries for abdominal wall hernia, and hence an in-\ncreasing rate of use.\n11 Intended use of synthetic \nmeshes encompasses substitution for weak support-\nive tissue, augmentation of insufficient tissue, stimu-\nlation of supportive tissue regeneration, and \ncompensation for deficiencies which might be caused \nby surgical technique.\n12 Recent surge to mesh utilization \nposes a higher risk of mesh-related complications. \nChronic mesh erosion, infection, rejection, dyspareu-\nnia, and other painful symptoms warranting surgery as \nwell as surgical removal of implant are among the com-\nplications documented by an increasing number of pa-\npers.\n13-14 \nIn the event of AWE, the cyclical pattern whereby \npain worsens and mass size increases during menstru-\nation shall raise suspicion.\n15 These leading symptoms \nare encountered in 50% of patients. Of the reported \nAWE cases from a study, 63.8% had a history of Ce-\nsarean section.\n16 Our patient was distinct from formerly \nreported cases for being asymptomatic regarding en-\ndometrioma, without a history of past uterine surgery or \nendometriosis. Given the tendency of symptom recur-\nrence following medical treatment with drugs such as \nprogesterone and danazol, recommended treatment \nmodality for scar endometriosis is wide excision of the \nlesion allowing at least 1 cm of circumferential surgi-\ncal margin.\n17 Once resection is completed, mesh repair \ncan be considered where a wide recess is left, or fascia \ndefect is noted.\n17 Accordingly, we have implemented \ntotal excision with a 1 cm margin of surrounding tis-\nsue. We have closed the abdominal layers primarily, \nwithout any mesh re-insertion. \nIn conclusion, while examining the patients par-\nticularly those who had undergone surgery present-\ning with a mass located in the vicinity of incision \ntrack, the patients should be queried whether they \nhave any pain deteriorating during menstruation and \nendometriosis should be kept in mind. It should also \nbe kept in mind, however, that some patients may re-\nmain asymptomatic, as in our case, without any his-\ntory of previous uterine surgery or endometriosis and \nmay develop endometriosis around foreign bodies. In \nsuch cases of endometriosis, wide excision should be \nperformed ensuring prevention of surgical recur-\nrences. \nInformed Consent \nThe patient whose story is told in this case report signed permis-\nsion for its publication. \nSource of Finance \nDuring this study, no financial or spiritual support was received \nneither from any pharmaceutical company that has a direct con-\nnection with the research subject, nor from a company that pro-\nvides or produces medical instruments and materials which may \nnegatively affect the evaluation process of this study. \nConflict of Interest \nNo conflicts of interest between the authors and / or family mem-\nbers of the scientific and medical committee members or members \nof the potential conflicts of interest, counseling, expertise, working \nconditions, share holding and similar situations in any firm. \nAuthorship Contributions \nIdea/Concept: Mehmet Ferdi Kıncı, Özge Şehirli Kıncı; Design: \nMehmet Ferdi K ıncı, Mehmet Onur Arslaner; Control/Supervi-\nsion: Ahmet Akın Sivaslıoğlu, Ezgi Karaka ş Paskal; Data Col-\nlection and/or Processing: Ezgi Karaka ş Paskal, Özge Şehirli \nKıncı, Melek Ünçel; Analysis and/or Interpretation: Ahmet Akın \nSivaslıoğlu; Literature Review: Ezgi Karaka ş Paskal, Özge \nŞehirli Kıncı; Writing the Article: Mehmet Ferdi Kıncı, Mehmet \nOnur Arslaner, Melek Ünçel; Critical Review: Ahmet Ak ın \nSivaslıoğlu; References and Fundings: Mehmet Onur Arslaner, \nMehmet Ferdi K ıncı; Materials: Mehmet Ferdi K ıncı, Mehme-\ntOnur Arslaner, Melek Ünçel.\n\nMehmet Ferdi KINCI et al. Turkiye Klinikleri J Case Rep. 2021;29(1):20-3\n23\n1. Giudice LC. Clinical practice. Endometriosis. \nN Engl J Med. 2010;362(25):2389-98.[Cross-\nref] [PubMed] [PMC]  \n2. Oral E, Api M, Ata B, Kumbak Aygün B, Berker \nB, Biberoğlu KÖ, et al. [Turkish Guideline of \ndiagnosis and management of endometriosis]. \nTurkiye Klinikleri J Gynecol Obst-Special Top-\nics. 2016;9(2):80-112.\n[Link]  \n3. Olive DL, Pritts EA. Treatment of endometrio-\nsis. N Engl J Med. 2001;345(4):266-75.[Cross-\nref] [PubMed]  \n4. Vinatier D, Orazi G, Cosson M, Dufour P. The-\nories of endometriosis. Eur J Obstet Gynecol \nReprod Biol. 2001;96(1):21-34.\n[Crossref] \n[PubMed]  \n5. Francica G, Giardiello C, Angelone G,  \nCristiano S, Finelli R, Tramontano G. Abdom-\ninal wall endometriomas near cesarean  \ndelivery scars: sonographic and color  \ndoppler findings in a series of 12 patients.  \nJ Ultrasound Med. 2003;22(10):1041-7. \n[Crossref] [PubMed]  \n6. Leng J, Lang J, Guo L, Li H, Liu Z.  \nCarcinosarcoma arising from atypical en-\ndometriosis in a cesarean section scar. Int J \nGynecol Cancer. 2006;16(1):432-5. \n[Crossref] \n[PubMed]  \n7. Horton JD, Dezee KJ, Ahnfeldt EP, Wagner M. \nAbdominal wall endometriosis: a surgeon's \nperspective and review of 445 cases.  \nAm J Surg. 2008;196(2):207-12. \n[Crossref] \n[PubMed]  \n8. Douglas C, Rotimi O. Extragenital en-\ndometriosis--a clinicopathological review of a \nGlasgow hospital experience with case illus-\ntrations. J Obstet Gynaecol. 2004;24(7):804-\n8.\n[Crossref] [PubMed]  \n9. Khoo JJ. Scar endometriosis presenting as an \nacute abdomen: a case report. Aust N Z J Ob-\nstet Gynaecol. 2003;43(2):164-5.\n[Crossref] \n[PubMed]  \n10. Ridley JH, Edwards IK. Experimental en-\ndometriosis in the human. Am J Obstet Gy-\nnecol. 1958;76(4):783-9; discussion 789-90. \n[Crossref] [PubMed]  \n11. Önol FF, Avc ı E, Ergönenç T. [The use of \"self-\ncut\" polypropylene meshes in the manage-\nment of stress urinary incontinence and pelvic \norgan prolapse]. Turkish Journal of Urology. \n2009;35(2):117-23.\n[Link]  \n12. Baessler K, Maher CF. Mesh augmentation \nduring pelvic-floor reconstructive surgery: risks \nand benefits. Curr Opin Obstet Gynecol. \n2006;18(5):560-6.\n[Crossref] [PubMed]  \n13. Wu MP. The use of prostheses in pelvic re-\nconstructive surgery: joy or toy? Taiwan J Ob-\nstet Gynecol. 2008;47(2):151-6.\n[Crossref] \n[PubMed]  \n14. Falagas ME, Velakoulis S, Iavazzo C, Athana-\nsiou S. Mesh-related infections after pelvic \norgan prolapse repair surgery. Eur J Obstet \nGynecol Reprod Biol. 2007;134(2):147-56. \n[Crossref] [PubMed]  \n15. Agarwal A, Fong YF. Cutaneous endometrio-\nsis. Singapore Med J. 2008;49(9):704-9. \n[PubMed]  \n16. Nominato NS, Prates LF, Lauar I, Morais J, \nMaia L, Geber S. Caesarean section greatly \nincreases risk of scar endometriosis. Eur J \nObstet Gynecol Reprod Biol. 2010;152(1):83-\n5.\n[Crossref] [PubMed]  \n17. Lipscomb GH, Givens VM, Smith WE. En-\ndometrioma occurring in abdominal wall inci-\nsions after cesarean section. J Reprod Med. \n2011;56(1-2):44-6.\n[PubMed] \n REFERENCES","source_license":"CC0","license_restricted":false}