{"paper_id":"c8bcf1ca-2ac6-458a-858d-27bd21a79c48","body_text":"~ 111 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2024; 8(4): 111-114 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2024; 8(4): 111-114 \nReceived: 06-05-2024 \nAccepted: 08-06-2024 \n \nSupriya Chaubey \nAssistant Professor, Department of \nObstetrics and Gynaecology, \nHamdard Institute of Medical \nSciences and Research, Okhla, \nPhase 3, New Delhi, India \n \nAruna Nigam \nProfessor and Head, Department \nof Obstetrics and Gynaecology, \nHamdard Institute of Medical \nSciences and Research, Okhla, \nPhase 3, New Delhi, India \n \nUmmay Kulsoom \nSenior Resident, Department of \nObstetrics and Gynaecology, \nHamdard Institute of Medical \nSciences and Research, Okhla, \nPhase 3, New Delhi, 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 \nCorresponding Author: \nSupriya Chaubey \nAssistant Professor, Department of \nObstetrics and Gynaecology, \nHamdard Institute of Medical \nSciences and Research, Okhla, \nPhase 3, New Delhi, India \n \nPost hysterectomy scar endometriosis: An unusual entity \n \nSupriya Chaubey, Aruna Nigam and Ummay Kulsoom \n \nDOI: https://doi.org/10.33545/gynae.2024.v8.i4b.1484 \n \nAbstract \nScar endometriosis is rare and poses a diagnostic difficulty. Though often asymptomatic, it may present as \nvague pain in the abdomen during menstruation. Differential diagnoses include abscess, hematoma, \nsarcoma, desmoid tumour, suture granuloma or metastatic malignancy. Diagnosis is frequently made only \nafter excision and histopathology report. We report a case of a 28 year old multiparous fe male with a \nsurgical history of uncomplicated cesarean sections followed by total abdominal hysterectomy presented \nwith lower abdominal pain. On examination, a well healed Pfannenstiel incisional scar with a 4x4cm lump \nin the midline was noted. A diagnosis  of scar endometriosis was made. The patient underwent laparotomy. \nLeft sided salpingo oophorectomy with excision of endometriotic cyst. Histopathology confirmed the \ndiagnosis of endometriosis. \nConclusion: Scar endometriosis is a rare entity occurring post  abdominal surgeries. It poses a diagnostic \nchallenge and confirmation is made only after histopathology. Hence a high degree of suspicion is required \nto make a diagnosis and guide further treatment. \n \nKeywords: Scar endometriosis, post hysterectomy, further treatment \n \nIntroduction  \nEndometriosis is the presence of endometrial glands and stromal tissue at any site away from the \nuterus. It occurs in 8% - 15% of reproductive age group females. Due to its variable \npresentations, its diagnosis is usually a chall enge and often confusing. Many theories like \nimplantation theory, tubal regurgitation, coelomic metaplasia or vascular spread have been given \nto explain its aetiology [1].  \n Pelvic endometriosis is most common and occurs around uterus and uterine ligaments  [2] while, \nextra pelvic endometriosis is rare and can involve  the lungs, brain, ureter, bowel, spleen, and \ninfrequently in the previous surgical scars like previous cesarean scar, episiotomy scar, ectopic \npregnancies, salpingostomy or even hysterectomy. E ndometriotic glands with stroma above the \nperitoneum is together called abdominal wall endometriosis [3, 4] . Cesarean scar endometriosis \nbeing the most common abdominal wall endometriosis has an incidence of 0.03 -0.4% [4–8]. Scar \nendometriosis occurs possibly due to direct ectopic implantation of the ectopic tissue during the \nprocedure (implantation theory) or by hematogenous or lymphatic spread. This ectopic \nendometrial tissue proliferates under the effect of cycling oestrogens in the body [9].  \nScar endometriosis is rare and poses a diagnostic difficulty. Though often asymptomatic, it may \npresent as vague pain in the abdomen during menstruation. Physical examination may reveal a \npainful nodule if the scar involved is located on the abdominal wall. However,  examination may \nbe absolutely normal if the lesion is located on the uterine scar. Differential diagnoses include \nabscess, hematoma, sarcoma, desmoid tumour, suture granuloma or metastatic malignancy [2]. \nHallmark symptoms of scar endometriosis include cy clic pain associated with drainage or \nbleeding from the surgical site, during menstruation but unfortunately, these symptoms are often \nnot seen [10].  \nDiagnosis is frequently made only after excision and histopathology report [11].  \nImaging modalities are not absolutely necessary but MRI is the most useful when further studies \nare needed [2].  \nManagement is primarily a wide margin of surgical excision. Recurrence rate is approximately \n4.3% and malignant transformation risk is between 0.3% - 1% [12, 13].  \nHere we present a typical case of scar endometriosis in a post hysterectomy woman with an \nintention to emphasize on  the need to establish and comprehensively assess and diagnose the \npotential cases of scar endometriosis.  \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 112 ~ \nCase report \nWe report a case of a 28 year old multiparous female with a \nsurgical history of uncomplicated cesarean sections in 2016 and \n2017 followed by total abdominal hysterectomy in 2017 in view \nof AUB-L. She presented to our OPD with complains of lower \nabdominal pain with painful micturition and swelling over stitch \nline for the last four years. The pain was severe and dull aching \nin nature, intermittent, aggravated by menstruation and urination \nand relieved on taking medications. Pain radiated to the back \nand thighs and was associated with deep dyspareunia and white \ndischarge on and off. On examination, a well healed \nPfannenstiel incisional scar with a 4x4cm lump in the midline \nwas noted. Moderate tenderness was present over the scar site. \nFurther examination revealed the mass as extra abdominal \nappearing separate from the vault.  \n An ultrasound showed evidence of a well -defined hypoechoic \nlesion of about 5.6x4.2 cm posterior to the abdominal wall scar \nsite with posterior acoustic enhancement and multiple fine \nseptations within, giving a  fish-net like appearance. The lesion \nappeared to be communicating with scar granuloma [Figure 1]. \n \n \n \nFig 1: Ultrasound showing scar site endometriosis \n \nA diagnosis of scar endometriosis was made. The patient \nunderwent laparotomy. Left sided salpingo ooph orectomy with \nexcision of endometriotic cyst. \nIntraoperatively, scar site cyst of around 4x4cm encased in \nfibrosed tissue extending from subcuticular-plane infiltrating the \nrectus sheath and the peritoneum muscle was excised. [Fig 2,  3, \n4]. Left sided salp ingo-oophorectomy with excision of \nendometriotic cyst was done while right ovary was not \nvisualised. Tissue was sent for histopathology which confirmed \nthe diagnosis of endometriosis. \n \n \n \nFig 2: Scar endometriosis \n \n \nFig 3: Left sided salpingo oophorectomy \n \n \n \nFig 4: Post operative period was uneventful and patient was started on \nHRT after 3 months of surgery. \n \nDiscussion \nEndometriosis at scar site is a rare entity occurring in less than \n2% population, where endometrial tissue and stroma implant at \nthe incision site following abdominal,  gynaecological or \nobstetrical surgeries [2]. Caesarean scar endometriosis is the most \ncommon subtype [2,14]. Symptoms can appear anywhere between \n1 year to over 20 years following the surgery [15].  \nThe widely accepted theory  for its occurrence is the iatrogenic \nimplantation theory, where a refluxed endometrial tissue from \ngynaecological and obstetrical surgical procedures is implanted \non the incision site, and under proper hormonal influence, \nendometrial tissue proliferates and forms scar endometriosis [4,16] \nEndometrium from an early pregnancy has more chances of \nimplanting at ectopic site than endometrium from a full-term \npregnancy which implies hysterectomy in pregnancy has a \nhigher risk of scar endometriosis than a full te rm cesarean \nsection and is preventable by deep cleaning of the abdominal \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 113 ~ \nwound intraoperatively [17].  \nScar endometriosis often presents as a tender mass within or \naround a surgical scar. Pain is cyclical associated with menses. It \nmay also be associated w ith swelling and rarely bleeding in the \nlesion area. high index of suspicion with proper history -taking \nand clinical examination is needed to make a diagnosis.  \nDifferential diagnoses include incisional hernia, abscess, suture \ngranuloma, abdominal wall tumour, hematoma, or neuroma [18].  \nMalignant transformation has also been found, among which \nendometrioid carcinoma is the most common one [19].  \nImaging such as USG, CT scan and MRI can aid in diagnosis \nand exclusion. Radiological features of endometriosis a re quite \nvariable and often create confusion in making a diagnosis. [20].  \nHistology features are the hallmark of diagnosis which is  made \nonly after excision of the lesion [20]. The treatment of choice is a \ntotal wide excision of the lesion with at least 5 -10mm free \nmargin and it is both diagnostic and therapeutic. Rupture of \nmass during excision can lead to re -implantation and thus \nrequires utmost care and precision [21, 22, 23]. \nMedical treatment strategies like oral contraceptive pills, \nprogesterone, GnRH agonist and danazol have been used  with \nvariable success and only temporary relief of symptoms [23, 24].  \nIn our case ultrasound was used to make the  pre-surgical \ndiagnosis instead of MRI due to affordability issues although \nMRI is a better modality. Our  patient has undergone laparotomy \nwith wide excision of endometriosis under general anaesthesia. \nThe specimen was sent for histopathology which led to the \ndefinitive diagnosis.  \nThe etiology in our patient could be a pre-existing asymptomatic \nscar endometr iosis prior to hysterectomy, which slowly \nprogressed after hysterectomy or there might have been spillage \nof endometriotic xyst while hysterectomy leading to re -\nImplantation as right ovary was absent and left ovary had an \nendometriotic cyst. \n \nConclusion \nScar endometriosis is  a rare entity occurring post abdominal \nsurgeries. It poses a diagnostic challenge and confirmation is \nmade only after histopathology. Hence a high degree of \nsuspicion is required to make a diagnosis and guide further \ntreatment. \n \nReferences \n1. Oosterlynck DJ, Cornillie FJ, Waer M, Vandeputte M, \nKoninckx PR. 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International Journal of Clinical Obstetrics and \nGynaecology. 2024;8(4):111-114  \n \n \n \nCreative Commons (CC) License \nThis is an open access journal, and articles are distributed under the terms \nof the Creative Commons Attribution -Non Commercial-Share Alike 4.0 \nInternational (CC BY -NC-SA 4.0) License, which allows others to remix, \ntweak, and build upon the work non -commercially, as long as appropriate \ncredit is given and the new creations are licensed under the identical terms.","source_license":"CC0","license_restricted":false}