{"paper_id":"d739e5f0-dd04-4935-9dfb-18b451ca86b8","body_text":"TECHNIQUES AND INSTRUMENTA TION\nUltrasound-guided wired localisation for resection\nof impalpable anterior abdominal wall scar endometriomas\nM. M. H. Lee & N. K. Robson & T. T. Carpenter\nReceived: 24 February 2011 / Accepted: 4 April 2011 / Published online: 13 May 2011\n# Springer-V erlag 2011\nAbstract The identification and subsequent complete\nexcision of abdominal scar endometriosis is particularly\nchallenging due to the difficulty in defining the endometriotic\ndeposit from the surrounding scar tissue. This case demon-\nstrates a technique to precisely identify the lesion using\nultrasound, and by the use of wire localisation, guide the\nsurgeon to the disease location. This allowed precise and\ncomplete wide local incision of the lesion.\nKeywords Caearean section . Scar . Endometriosis .\nUltrasound . Localisation . Resection\nIntroduction\nAbdominal wall scar endometriosis is defined as endometrial\ntissue deposited in abdominal surgical scar which is superfi-\ncial to peritoneum [ 1, 2]. It represents between 0.03% and\n3.5% [ 3] of all endometriosis. This is significant when\nparietal, appendiceal, pleuropulmonary and diaphragmatic\nendometriosis represent 5% of endometriosis cases [ 4].\nPost-Caesarean section endometriosis represents 57% [ 1]\nof all abdominal scar endometriosis with an overall incidence\nbetween 0.03% and 0.47% [ 3, 5, 6]. Scar endometriosis can\nalso occur after hysterectomies, laparotomy and even\nlaparoscopy for ovarian cystectomy or appendectomy [ 7, 8].\nDiagnosing abdominal wall scar endometriosis can be\ndifficult. Only 47.5 –70% of all diagnosis is correct pre-\noperatively [5, 9]. Symptoms include a mass in abdomen in\nup to 96% [ 1], abdominal pain in 87% [ 1], and pain which\ncan be cyclical in 40% [ 9] or non-cyclical in 45% [ 9]. Other\ndifferential diagnoses includ e incisional hernias, late\nabscesses or suture granulomas [ 10].\nRadiological techniques including power doppler, ultra-\nsound, 3D ultrasound, magnetic resonance imaging can all\nassist diagnosing and identify the extent of the lesion [ 10,\n11]. The definitive diagnosis, however, remains through\nhistology which can be obtained by either after resection or\nvia ultrasound-guided biopsy [ 12].\nThe management of choice is wide local excision of\nlesion, with recurrence only occurring in between 4.3% and\n9.1% of cases [ 1, 9]. This surgery however can be complex\nas the lesion is, by definition, embedded within scar tissue,\nand thus clear identification of the lesion within this\nabnormal tissue can be difficult. As such, lesions may be\nmissed or incompletely excised making recurrent surgery\nnecessary\nThe case below demonstrates a simple technique to\nexactly mark the location of the lesions prior to surgery,\nthereby optimising the surgical procedure.\nCase\nA 31-year-old obese (BMI 43) patient presented with a\nhistory of pain in the suprapubic area just above and to the\nleft of a previous Caesarean scar. This worsened on a\ncylical basis and was exacerbated by exercise and on sitting\nfrom a lying position. She had history of endometriosis and\nM. M. H. Lee ( *) : N. K. Robson : T. T. Carpenter\nDepartment of Obstetrics and Gynaecology, Poole NHS\nFoundation Trust,\nLongfleet Road,\nPoole BH15 2JB Dorset, UK\ne-mail: menelik.lee@gmail.com\nN. K. Robson\ne-mail: Nicola.robson@poole.nhs.uk\nT. T. Carpenter\ne-mail: tyrone.carpenter@poole.nhs.uk\nGynecol Surg (2012) 9:103 –105\nDOI 10.1007/s10397-011-0678-4\n\nhad previously undergone surgery to excise endometriosis\nform this incision around 7 years earlier. Examination\nrevealed tethering over the area but no mass was palpable.\nSubsequently, she had chronic abdominal pain in the same\narea causing significant discomfort for many years. Her\npain mainly involved the suprapubic area just above and to\nthe left in relation to her previous Caesarean scar. This was\nworst whenever she does any exercise and when she is\ntrying to sit up from lying. She does also note her pain\nworsens during her cycle. However on examination, no\nmass was palpable.\nSteroid injections to the scar had been ineffective. The\nprogesterone pill provided some improvement in pain,\nhowever, this was not complete and the symptoms\nincreased on cessation.\nUltrasound of the anterior abdominal using a Philips\nIU22 (Philips Medical Systems) machine and both a curved\nsector 5 MHz and a linear 12.5 MHz transducer revealed a\n24×40 mm relatively well-defined hypoechoic heteroge-\nneous echotextural mass with internal hyperechoic echoes\non greyscale imaging in the subcutaneous tissues in the\nmidline below the Pfannenstiel scar (Fig. 1). Although a\nvariety of ultrasound features of endometriomas have been\ndescribed, including cystic masses [ 13], solid appearances\nas here have also been described [ 14], and in the correct\nclinical setting would be consistent with an endometrial\nnodule.\nIn view of the previous surgery to excise this lesion\nand the difficulty in locating these lesions, it was decided\nto use ultrasound imaging to mark the lesion prior to\nsurgery.\nProcedure\nPrior to surgery the radiologist identified the lesion with\nultrasound using a linear 12.5 MHz transducer. Using an\naseptic technique, approximately 2 ml of 2% lidocaine\nhydrochloride were infiltrated into the skin and subcutane-\nous tissues a short distance from the left lateral border of\nthe lesion. A Hawkins III Angiotech localisation needle\n(Medical Devices Technologies, USA) was then inserted\nthrough the anaesthetised tissue at 90° to the skin surface\ndown to the level of the lesion and then pushed in a parallel\noblique direction to the skin under ultrasound visualisation\nthrough the nodule (Fig. 2). The needle was then withdrawn\nleaving the central localisation wire behind. This opened\nthe hook at the tip of the wire to secure it in position. The\nexternal wire was coiled and secured to the skin with tape\nunder a gauze dressing.\nThe patient was subsequently transferred to the\noperating theatre. After rout ine aseptic preparation, a\n6 cm incision was made throug ht h el o wt r a n s v e r s es c a r .\nThe subcutaneous fat, anterior rectus sheath and associated\nscar tissue was divided down to the tip of the guide wire. At\nthis point, the endometrial tissue began leaking haemoserous\nfluid. Knowing the dimensions of the lesion, the appropriate\nmargining laterally and inferiorly were defined and this was\nconfirmed by the cessation of haemoserous leakage. The\nlesions were fully excised by cutting diathermy and the\nresultant defect in the rectus sheath was closed with\ncontinuous 1.0 vicryl (polyglaction 910) suture. A suction\ndrain was cited in the superficial layer and the superficial\nfat/scar tissue was opposed using 2.0 Vicryl (polyglaction\n910). The skin incision closed with 2.0 vicryl rapide\n(polyglaction 910).\nThe following day, the suction drain was removed and\npatient discharged. Histology confirmed endometriosis with\nclear margins.\nThe patient was reviewed 3 and 7 months post-\noperatively, patient was completely pain free with no\nresidual symptoms.\nFig. 1 Ultrasound diagnosis of Caesarean scan endometrioma\nFig. 2 Ultarosund image showing guidewire in the centre of the\nlesion\n104 Gynecol Surg (2012) 9:103 –105\n\nDiscussion\nUltrasound-guided guide wire localisation and resection of\nsuperficial impalpable masses is a well-established tech-\nnique in surgery. Breast surgeons have been performing\nwire localisation and subsequent lumpectomy for breast\ncancers for years [ 15] and ear, nose and throat surgeons use\nsuch techniques for removal of impalpable deep lower\ncervical lymph nodes [ 16].\nWith the increasing rate of Caesarean section along and\nthe increasing body mass index of the population, such\nlesion will become increasingly common and difficult to\nlocate. This is particularly true of small, sometimes multiple\nlesions. This technique is simple and effective, utilising\nskills already available in most hospitals. With accurate,\ncomplete excision symptomatic improvement is highly\nlikely and the need for subsequent surgery is minimised.\nThe authors are aware that longer follow-ups and further\ncases will be required to establish the efficacy of this\ntreatment and eliminate the possible placebo effect of\nsurgery. However, it is well -established that surgery\nimproves symptoms in 80% at 6 months compared to\n30% due to placebo effect surgery [ 17] and recurrence rate\nis low after complete excision.\nDeclaration of interest The authors report no conflicts of interest.\nThe authors alone are responsible for the content and writing of the\npaper.\nConflict of interest There is no actual or potential conflict of\ninterest in relation to this article.\nReferences\n1. Horton JD, Dezee KJ, Ahnfeldt EP , Wagner M (2008) Abdominal\nwall endometriosis: a surgeon ’s perspective and review of 445\ncases. 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J Ultrasound Med 8:487– 491\n14. Francica G et al (2003) Abdominal wall endometriomas near\ncesarean delivery scars: sonographic and color Doppler findings in\na series of 12 patients. J Ultrasound Med 22:1041 –1047\n15. Rissanen TJ, Makarainen HP , Kiviniemi HO, Suramo II (1994)\nUltrasonographically guided wire localization of nonpalpable\nbreast lesions. J Ultrasound Med 13(3):183 –188\n16. Bryant JA, Siddiqu NJ, Loveday EJ, Irvine GH (2005) Presurgical,\nultrasound-guided anchor-wire marking of impalpable cervical\nlymph nodes. J Laryngol Otol 119(8):627–628\n17. Abbott J, Hawe J, Hunter D, Holmes M, Finn P , Garry R (2004)\nLaparoscopic excision of endometriosis: a randomized, placebo-\ncontrolled trial. Fertil Steril 82(4):878–884\nGynecol Surg (2012) 9:103 –105 105","source_license":"CC0","license_restricted":false}