{"paper_id":"bebacfa8-e245-4106-a63f-799ce082114f","body_text":"~ 368 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2020; 4(2): 368-371 \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com\n \n2020; 4(2): 368-371 \nReceived: 25-01-2020 \nAccepted: 27-02-2020 \nReetu Hooda \nDepartment of Obstetrics and \nGynaecology, PGIMS, Rohtak, \nHaryana, India \nAnkita Jaglan \nDepartment of Obstetrics and \nGynaecology, PGIMS, Rohtak, \nHaryana, India \nDaya Sirrohiwal  \nDepartment of Obstetrics and \nGynaecology, PGIMS, Rohtak, \nHaryana, India \nManish Chaudhry \nDepartment of Pathology, \nMMIMSR, Mullana, Haryana, \nIndia \nCorresponding Author: \nAnkita Jaglan \nDepartment of Obstetrics and \nGynaecology, PGIMS, Rohtak, \nHaryana, India \nPost-surgical endometriosis with varying scenarios: A \nretrospective study \nReetu Hooda, Ankita Jaglan, Daya Sirrohiwal and Manish Chaudhry \nDOI: https://doi.org/10.33545/gynae.2020.v4.i2f.556 \nAbstract\nEndometriosis is ectopic presence of endometrial tissue outside the uterus. Patients who were admitted in \nthe department of Obstetrics and Gynecology PGIMS Rohtak, with surgical site endometriosis from Jan \n2015 to Dec 2019, were analysed in detail. Challenges faced during management, histopathological \nfindings, complication and recurrence, if any, were noted. All the patients presented with a periodic painful \nswelling. Location varied according to previous surgical sites- abdominal swelling with history of cesarean \nsection or laprotomy and perineal with history of vaginal delivery with episiotomy. Diagnosis was made by \nclinical examination supplemented by ultrasonography. Treatment was done by wide surgical excision, \ntaking care to include all the endometriotic tissue and confirmed by histopathology. No recurrence was \nnoted in patients after resuming their normal menstruation. It is very important to detect this condition, as \nearly detection gives us scope for timely intervention and better management. \nKeywords: Endometriosis, cesarean, surgical excision, scar \nIntroduction  \nEndometriosis is a condition defined as the ectopic presence of endometrial tissue (glands and \nstroma) outside the uterus. It is a common benign gynaecological condition and predominantly \naffects women of reproductive age group. Pelvic viscera and peritoneum are the most frequent \ndocumented sites of implantation. Its appearance varies from few minimal lesions on otherwise \nintact pelvic organs, to massive ovarian endometriotic cysts and extensive adhesions involving \nbowel, bladder, and ureter [1]. Endometriosis can only be diagnosed after surgery either open or \nlaproscopic, so its exact prevalence is unknown. It is seen in 3-10% of young fertile women. It \nhas also been reported in extrapelvic sites including almost all organs and systems like central \nnervous system, nose, breast, lung, spleen, gastro-intestinal tract, kidney, abdominal wall and \nperineum, but scar endometriosis is very rare [2]. Its incidence in post-caesarean and post- \nhysterotomy scar tissue is approximately is 0.03-0.4% and 1.08-2% respectively [3]. \nPatients of scar endometriosis are often either referred or present directly to the general surgeons \nbecause of the clinical presentation which suggests a surgical cause [4]. Scar tissue endometriosis \nmay present as a discrete painful mass and can mimic a variety of surgical conditions like \ninguinal hernia, incisional hernia, abdominal wall tumor, stitch granulomas, etc. [5] So, it is very \nimportant for us to recognize this treatable condition to avoid potential clinical pitfall in the \ndiagnosis. \nAs there is rise in the incidence of caesarean sections and gynaecological surgeries, we are \nencountering this rare condition, frequently. After conducting a retrospective study, here we are \npresenting this paper to increase the awareness among general surgeons and gynaecologist \nregarding varying presentation of scar endometriosis, its diagnosis and challenges surgeon can \nface during management. \nObjectives \nTo evaluate the different surgical site endometriosis and challenges faced in their management. \nMaterial and Methods \nThis retrospective case study was done on patients who were admitted and managed from \nJanuary 2015 to December 2019, with diagnosis of surgical site endometriosis, in the \nDepartment of Obstetrics and Gynaecology, PGIMS Rohtak. Parameters noted were age of \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 369 ~ \npatient, presenting symptoms, site, size of endometriosis, time \nduration between surgery and onset of symptoms and other risk \nfactors, radiological, surgical and histopathological findings, line \nof management, complication in post-operative period a nd \nrecurrence, if any.  \nRoutine hematological and biochemical examinations were done \nfollowing medical history and physical examination. \nTable 1: Case summaries \nCase \nNo. \nAge \n(in \nyears) \nObstetric \nscore \nSurgery- \nPresentation \ninterval \nPresentation Examination \nfindings \nInitial \ndiagnosis FNAC USG/MRI Management Surgical \nfindings HPE Complication Recurrent \ndisease \n1 32 P2L2A1 8 years \n(LSCS) \nSwelling at \nanterior \nabdominal \nwall \n4x3 cm firm \nnodule at right \nmargin of scar \nof Ceserean \nsection \n? Scar \nendometriosis Not done \nAbout 4x3x4 \ncm \nhypoechoic \nmass right \nside of scar \nWide surgical \nexcision \n4.5x3x4 cm \nfirm nodule \nextending up \nto superficial \npart of rectus \nsheath \nDiagnosis \nconfirmed No No \n2 36 P3L2A1 \n10 years \n(laparotomy \nf/b \nhysterotomy) \nPain & \nswelling in \nsuprapublic \nregion during \nmenses \nVertical scar \n+ 3x2 cm \ntender mass \nabove public \nsymphysis \nScar \nendometriosis \nEndometrial \nglandular \ncells with \nhemosiderin \nladen \nmacrophages \n2 Hypoechoic \nlesion seen in \ns/c plane & \nwithin left \nrectus muscle \nWide surgical \nexcision \n4x5 cm mass \nadherent to \nrectus sheath \nDiagnosis \nconfirmed No No \n3 28 P3L3 \n6 years \n(vaginal \ndelivery) \nSwelling & \ncyclical pain \nin perineal \narea since 1 \nyear \n4x3 cm \nnodule in \nmiddle of \nprevious \nepisiotomy \nscar \nEndometriotic \nnodule Not done \n5x4.5 cm \nhypoechoic \nlesion right \nside in close \nrelation with \nanus and \nrectum \nWide excision \nwith \nsphincteroplasty \nInjleuprolide \nacetate 3.75 gm \ns/c single dose \nNodule \naround 6x5 \ncm attached to \nexternal anal \nsphincter \ninfiltrating \nupto \nlevatorani \nmuscle \nDiagnosis \nconfirmed \nAfter 20 days \npatient came \nwith wound \ninfection \nNo \n4 25 P1L1 2 years \n(LSCS) \nPain & \nswelling in \nlower side of \nstitch line \n3x3 cm tender \nmass in \nsuprapubic \nregion at \nstitch line \nStitch abscess \nFew \ndegenerated \ninflammatory \ncells \n15x14x12 mm \nhypoechoic \nlesion at scar \nsite \nExcision of scar \ntissue \n2.5x3 cm \nnodule \nDiagnosis \nconfirmed No No \n5 26 P1L1 2.5 years \n(LSCS) \nSwelling and \ncyclical pain \nwith blood \nlike discharge \nfrom right \nextent of \nstitch line \n1x1 cm firm \nnodule with \npint of \ndischarge at \nright margin \nof transverse \nscar of LSCS \nScar \nendometriosis Not done \n1.5x1.5 cm \nhypoechoic \nlesion on right \nextent of scar \nWide surgical \nexcision \n2x2 cm \nnodule \nDiagnosis \nconfirmed No No \n6 26 P1L1 5 years \n(LSCS) \nSwelling and \ncyclical pain \nnear stitch \nline \n3x3 cm mass \nnear stitch line \nScar \nendometriosis Not done \n3.5x3 cm \nhypoechoic \nlesion in \nsubcutaneous \nplane \ninvolving \nsneath \nWide surgical \nexcision \n4x4 cm \nendometriotic \ntissue \ninvolving \nsheath \nDiagnosis \nconfirmed No No \n7 35 P3L3 6 years \n(LSCS) \nPain & \nswelling in \nmiddle of \nstitch line \n2x2 cm \nnodule in \nstitch line \nScar \nendometriosic Not done \n3x2 cm \nhypoechoic \nlesion at scar \nsite \nWide local \nexcision \n3x2 cm scar \nendometriotic \ntissue \nDiagnosis \nconfirmed No No \n8 22 P3L3 2 years \n(LSCS) \nPain & \nswelling in \nstitch line \n1.5x1.5 cm \nnodule in \nstitch line \nScar \nendometriosic \nScar \nNot done \n1.5x1.5 cm \nhypoechoic \nlesion at scar \nsite \nWide local \nexcision \n1.5x1.5 cm \nnodule \nremoved \nDiagnosis \nconfirmed No No \n9 30 P2L2 5 years \n(LSCS) \nPain & cyclic \nswelling in \nstitch line \n4x4 cm \nnodule on \nright side and \n1x1 cm \nnodule on left \nside of stitch \nline \nScar \nendometriosis Not done \nTwo \nhypoechoic \nlesion 4x4 cm \non right side \nand 1x2 cm on \nleft side of \nstitch line \nWide local \nexcision \n4x3 cm \nnodule on \nright side and \n1x2 cm \nnodule on left \nside \nDiagnosis \nconfirmed No No \n10 10 28 P11L1 1 and half \nyear (LSCS) \nPain & cyclic \nswelling at \nsuprapubic \nregion \nNo definite \nnodule \npalpable \nbecause of \nobesity \nScar \nendometriosis Not done \nMixed echoic \nsolid-cystic \nlesion with ill-\ndefined border \nof 3.3x2.4 cm \nin suprapubic \nregion in \nmidline \nabutting \nmuscle. \nWide local \nexcision \nMultiple \nendometriotic \nnodule with \nlocal \nsubcutaneous \nspread in \nabdominal \nwall \nDiagnosis \nconfirmed Wound No sepsis \non Day 5 \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 370 ~ \nFig 1: Specimen of scar endometriotic tissue after wide surgical \nremoval. You can notice bleeding point in lesion (arrow mark) \nFig 2: Per-Op endometriotic nodule (bluish-purple with arrow mark) \npeeping out and in close relation with anus in patient with perineal \nendometriosis \n(a) Low power field (b) at high power field (×20) \nFig 3: H&E stained section showing endometrial glands with fibrovascular \nstroma in the scar tissue at (a) low power field, (b) at high power field (×20) \nResults \nMain complaint of our cases on admission was a palpable mass \non incision site and cyclic pain. One patient also presented with \nhistory of dark colored bloody discharge from complaint site. \nPatients age ranged from 25-36 years. Location varied according \nto surgical sites-abdominal swelling with history of either \ncaesarean section, hysterotomy or laparotomy. Perineal swelling \nwas associated with history of vaginal delivery with episiotomy. \nWide range of time interval between surgery and clinical \npresentation from one and half to ten years of the last operation \nand it had been noted that more the time gap of presentation of \nsymptoms from last operation, larger the size and deeper was the \ninfiltration of mass. \nInitial diagnosis of scar endometriosis was made by clinical \nexamination supplemented by USG. In two cases FNAC had \nalso been done (patients already had report from outside). \nTreatment in all the cases was done by wide surgical excision, \ntaking care to include all the endometriotic tissue. In one case \n(perineal endometriosis) single shot of Injection Leupurolide \nacetate 3.75 gm S/C was also given confirmation of all cases \nwas done by histopathology, in which endometrial gland with \nstroma and hemosiderin pigment can be seen. Immediate post-op \nperiod was uneventful. Patient with perineal endometriosis was \npresented to hospital after discharge with infected wound on day \n20, which was managed conservatively. And one more patient \nwith abdominal wall endometriosis had wound sepsis on post-\noperative day 5, which can be attributed to obesity and extensive \nsubcutaneous tissue involvement in that case. No recurrence \nwere noted on follow-up after 3 months of resumption of \nmenstruation, in any case. \nDiscussion \nScar endometriosis most commonly occurs after pelvic \nsurgeries. Patients may be asymptomatic. The pathognomonic \nfeatures are a painful nodule at incision site and cyclical pain in \na reproductive age woman with a history of gynecological or \nobstetrical surgery. The intensity of pain and size of nodule vary \nwith menstrual cycle. Most of these patients may have \nconcomitant pelvic endometriosis [6]. \nThe frequency of scar endometriosis has increased in the recent \npast because of the increasing numbers of cesarean sections and \nlaparoscopies being performed [7]. Out of two main theories \nbehind the pathogenesis of scar endometriosis, mechanical \nimplantation at the time of uterine surgery, followed by \nproliferation of seeded tissue at new site under same hormonal \ninfluences, is the most plausible cause [8]. Metaplasia theory \npostulates differentiation of multipotent mesenchymal cells to \nendometrial tissue in their site after puberty and show patho-\nphysiological changes as a response to hormonal stimuli. Major \nfactor responsible for endometrioma development is iatrogenic \ninoculation of endometrial tissue into the incision site [9]. \nHigh index of clinical suspicion is needed to diagnose this \ncondition. This require clinical differentiation from other \nsurgical conditions such as lipoma, incisional hernia, abscess, \nseroma, keloid, neoplastic tissue, or even metastatic carcinoma. \nMalignancy should be suspected in fast growing and large \nendometrioma or if there is frequent recurrence [10]. \nImaging procedures help, rather than confirm, in obtaining a \ndifferential diagnosis and can facilitate total surgical excision. \nUSG is the best and most commonly used procedure for \nabdominal masses. The mass may appear as a solid, hypoechoic \nand heterogeneous mass with different internal echoes with \nspeculated margins, infiltrating the surrounding tissue. FNAC is \nalso a method to make the diagnosis of scar endometriosis. \nHistology is the Gold standard for definitive diagnosis. It is \nsatisfactory when endometrial glands, stroma, and hemosiderin \npigment are seen [11]. \nPrimary medical therapy with danazol, progesterone, GnRH \nagonists provide only partial relief and does not cure the disease, \nhence recurrence occurs after cessation of the treatment with \nextreme side effects [12]. The treatment of choice remains the \nwide local excision with histologically proven free margins, \nproviding both diagnostic and therapeutic benefit. \nConclusion \nScar endometriosis is a rare clinical condition but its incidence \nhas increased in the recent past because of increasing number of \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 371 ~ \ncaesarean sections. Diagnosis can be made by high index of \nsuspicion in reproductive age women having localised cyclical \nsymptoms in a scar, following a previous obstetric or \ngynecological procedure. Imaging methods like doppler USG, \nCT and MRI can be used for differential diagnosis. Medical \ntreatment is helpful in selected cases but wide surgical excision \nis treatment of choice to prevent future recurrence. Early \ndetection gives us scope for timely intervention and better \nmanagement. \nConflicts of Interest \nThe authors have none to declare \nReferences \n1. Akbulut S, Sevinc MM, Bakir S, Cakabay B, Sezgin A.\nScar endometriosis in the abdominal wall: a predictable\ncondition for experienced surgeons. Actachir Belg. 2010;\n110:303-07\n2. Bektas H, Bilsel Y, Sari YS et al . Abdominal wall\nendometrioma; a 10 year experience and brief review of the\nliterature. J Surg Res. 2010; 164:e77-81.\n3. Chatterjee SK. Scar endometriosis: a clinicopathological\nstudy of 17 cases. Obstet Gynecol. 1980; 56(1):81-4.\n4. Wolf Y, Haddad R, Werbin N, Skornick Y, Kaplan O.\nEndometriosis in abdominal scars: a diagnostic pitfall. Am\nSurg. 1996; 62:1042-4.\n5. Goel P, Sood SS, Dalal A, Romilla. Cesarean scar\nendometriosis- repot of two cases. Indian J Med Sci. 2005;\n59(11):495-8.\n6. Patterson GK, Winburn GB. Abdominal wall\nendometriomas: report of eight cases. Am Surg 1999;\n65(1):36-9.\n7. Aydin O. Scar endometriosis - A gynaecologic pathology\noften presented to the general surgeon rather than the\ngynaecologist: Report of two cases. Langenbecks Arch Surg\n2007; 392:105-9.\n8. Hensen JH, Van Breda Vriesman AC, Puylaert JB.\nAbdominal wall endometriosis: clinical presentation and\nimaging features with emphasis on sonography. Am J\nRoentgenol. 2006; 186(3):616-20\n9. Horton JD, Dezee KJ, Ahnfeldt EP, Wagner M. Abdominal\nwall endometriosis: a surgeon perspective and review of\n445 cases. Am J Surg. 2008; 196:207-12.\n10. Vellido-cotelo R, Munoz-Gonzalez JL, Oliver-Perez MR et\nal. Endometriosis node in gynaecological scars: a study of\n17 patients and the diagnostic considerations in clinical\nexperience in tertiary care centre. BMC Women’s Health.\n2015; 15:13.\n11. Kinkel K, Frei KA, Balleyguier C, Chapron C. Diagnosis of\nendometriosis with imaging: A review. EurRadiol. 2006;\n16:285-98.\n12. Rivlin ME, Das SK, Patel RB, Meeks GR. Leuprolide\nacetate in the management of cesarean scar endometriosis.\nObstet Gynecol. 1995; 85:838-9.","source_license":"CC0","license_restricted":false}