{"paper_id":"9e522dff-6e11-4124-bb5e-1da378df4eda","body_text":"~ 4 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2021; 5(2): 04-05 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2021; 5(2): 04-05 \nReceived: 17-12-2020 \nAccepted: 03-02-2021 \n \nDr. K Sanju \nPost Graduate, Department of \nOBG, Sri Ramachandra Institute \nOf Higher Education and \nResearch, Porur, Chennai, Tamil \nNadu, India \n \nDr. KS Rajeswari \nProfessor, Department of OBG, Sri \nRamachandra Institute of Higher \nEducation and Research, Porur, \nChennai, Tamil Nadu, India  \n \nDr. S Praveen \nDepartment of Radiology, Sri \nRamachandra Institute of Higher \nEducation and Research, Porur, \nChennai, Tamil Nadu, 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 \nCorresponding Author: \nDr. K Sanju \nPost Graduate, Department of \nOBG, Sri Ramachandra Institute \nOf Higher Education and \nResearch, Porur, Chennai, Tamil \nNadu, India \n \nA rare case report on rectus muscle endometriosis \n \nDr. K Sanju, Dr. KS Rajeswari and Dr. S Praveen \n \nDOI: https://doi.org/10.33545/gynae.2021.v5.i2a.854 \n \nAbstract \nBackground: Rectus muscle endometriosis is a rare entity. Though it occurs after previous surgeries, it can \nalso occur in patients without scar. A differential diagnosis of extra -pelvic endometriosis must be kept in \nmind when women of reproductive age presents with mass abdomen which becomes painful during \nmenstruation. CT/MRI can detect lesions and surgical excision remains the definitive treatment.  \nCase report: We present a case of a 30 year old, P2L2A1, with previous normal deliveries who presented \nwith swelling over left iliac fossa which was painful during menstruation. CECT done showed \nendometriosis over rectus muscle. She underwent excision of the mass, which showed features of \nendometriosis in histopathology. She was on followed up for 2 years with no features of recurrence. \n \nKeywords: Extra-pelvic endometriosis, left iliac fossa, excision, histopathology \n \nIntroduction  \nEndometriosis is defined as presence of endometrial glands and stroma outside uterus. The most \nfrequent site of implantation is pelvic viscera and peritoneum. It is predominantly found in \nreproductive women. Extra -pelvic endometriosis is rare and accounts for 1 -2%, which results \nfrom vascular or lymphatic dissemination of endometrial cells to many gynaecological and non -\ngynaecological sites. Endometriosis of abdominal wall represents 0.03 –2% of extra genital \nendometriosis [1]. Various non-gynaecological sites include bowel, lungs, pleural cavity, rectus \nmuscle, umbilicus and surgical sites. Though it commonly occurs after previous surgeries, there \nare few cases which was reported in women without previous history of surgery.  \n \nCase Report \nA 30 year old, P2L2A1 who had previous 2 normal deliveries and was not sterilized. She \npresented with complaints of swelling over lower abdomen, which was more painful during \ncycles and severe dysmenorrhea before and during cycles wi th moderate flow. She had regular \nmenstrual cycles. On examination she was found to have a swelling of 3x2 cm over left iliac \nfossa, which was firm in consistency, immobile and irreducible with tenderness on palpation.  \nCECT abdomen done showed a well -defined irregular homogenously enhancing solid mass of \nsize 2.7x1.7x3.5cm seen predominantly in the muscular plane in the Left iliac Fossa suggestive \nof endometriosis.  \n    \n \n \nFig 1: Picture showing mass over left iliac fossa and CECT image showing endometriotic lesion over left \nrectus muscle \n \nPatient was planned for excision biopsy of the mass. Intra -operatively, a 5x4 cm mass over left \nlateral wall of rectus muscle noted, same excised. Round ligament and left fallopian tube was \nfound densely adherent to peritoneum over the left lateral wall, below rectus muscle. \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 5 ~ \nAdhesiolysis was done. Specimen was sent for \nHistopathological examination. \nPost-operative period was uneventful. Histopathology was \nreported as Fibro -collagenous and muscular tissue with \nendometrial glands and stroma with hemosiderin laden \nmacrophages characteristic of endometriosis. Patient was \ndischarged and followed up.  \nPatient was discharged on Post -operative day 3 and was \ncomplaint with follow up post -operatively for 2 years without \nany recurrence. \n \n \n \nFig 2: Intra-operative picture of rectus muscle endometriosis \n \nDiscussion \nRectus muscle endometriosis is a rare entity. It accounts for \n0.03–2% of extragenital endometriosis [1]. The etiopathogenesis \nof endometriosis is explained by several theorie s, which \nincludes: the transplant theory - based on tubal reflux of \nendometrial fragments caused by retrograde menstruation; the \ntheory of coelomic metaplasia - in which there is metaplasia of \ncoelomic epithelial cells which predisposes to endometriosis; \nand finally, the metastatic theory - suggesting the possibility of \nhematogenous or lymphatic dissemination [2]. \nCT scan shows a solid and well circumscribed mass  [3]. MRI is \nbeneficial to assess the depth of extension of endometrioma. (4) \nThe sensitivity and specificity of MRI is 90% and 98% \nrespectively for the diagnosis of endometrioma [5].  \nMedical treatment can be used in cases with big masses, to \nreduce the size of the mass [4]. \nThe treatment of choice for rectus muscle endometriosis is wide \nexcision of t he lesion with negative margins. The surgical \nmargin should include 5 –10 mm of the surrounding healthy \ntissue and care should be taken while removing mass, as there \nare chances of reimplantation of microscopic remnants of \nendometrial tissue if mass is ruptured [3]. \nThorough washing of the abdominal cavity at the end of \nintervention (either laparotomy or  laparoscopy) helps in \npreventing recurrence [4]. \n \nConclusion \nThe Rectus muscle endometriosis is a rare entity. Despite the \nrare incidence, extra -pelvic endometriosis should be considered \nas differential diagnosis of a women of reproductive age group \nwho present with characteristic waxing and waning pain over \nmass in relation to the menstrual cycle. Though Surgical \nmanagement remains the definitive treatment, proper \ncounselling regarding the nature of the disease and the risk of \nrecurrence should be explained. \n \nReference \n1. Audebert A.  Women's iatrogenic endometriosis before \nmenopause 2013, 2. https://www.em-\nconsulte.com/en/article/810125. \n2. Beizig S. Parietal Endome triosis On Cesarean Scar: About \nTwo Observations.Journal of Surgery (Paris. 1908)  \n1992;129(6-7):327-329. \n3. Gupta P, Gupta S. Scar endometriosis: a case report with \nliterature review. Acta Med Iran Google Scholar 2015, 793-\n5. \n4. Saad Slaiki, Jihad Jamor, Endomet riosis of the rectus \nabdominis muscles: a rare case of dual location,  Journal of \nSurgical Case Reports , \n2020;9:360, https://doi.org/10.1093/jscr/rjaa360 \n5. Balleyguier C, Chapron C, Chopin N, Hélénon O, Menu Y. \nAbdominal wall and surgical scar endometriosis: results of \nmagnetic resonance imaging. Gynecol Obstet Invest \n2003;55:220-4.","source_license":"CC0","license_restricted":false}