Large Abdominal Wall Endometrioma Following Laparoscopic Hysterectomy

Jonathan Y Song, J.Y. Song, Song JY, Borncamp E, Erik Borncamp, Mehaffey P, Philip C. Mehaffey, Philip Mehaffey, Rotman C, Carlos Rotman
JSLS : Journal of the Society of Laparoendoscopic Surgeons · 2011 · vol. 15(2) , pp. 261–263 · doi:10.4293/108680811x13071180407078 · PMID:21902990 · PMC3148886 · W2056158998
article OA: gold CC0 ⤵ 6 in-corpus citations
📄 Open PDF Full text JSON View on OpenAlex View on PubMed View at publisher
⚙ AI-generated summary by claude@2026-06, 2026-06-08 ⓘ

A 45-year-old woman developed a large 9cm abdominal wall endometrioma two years after a laparoscopic hysterectomy, presenting as a pelvic mass and pain.

One-sentence paraphrase of the abstract; not a substitute for reading it. No clinical advice. How this works

⚙ AI-generated deep summary by claude@2026-06, 2026-06-13 · read from full text ⓘ

This case report describes a 43-year-old woman who developed a large abdominal wall endometrioma two years after an uneventful laparoscopic supracervical hysterectomy for fibroids, initially evaluated as a ventral hernia on CT and intraoperatively not confirmed during subsequent laparoscopic cholecystectomy. After a mini-laparotomy for a firm abdominal wall mass, frozen section and final pathology confirmed two resected endometriosis masses, with the authors noting no endometrial lesions at the time of hysterectomy and that prior pathology showed multiple small fibroids and adenomyosis. The paper reviews theories of endometriosis pathogenesis and argues that inadvertent iatrogenic transfer during specimen extraction (with adenomyosis coming into contact with the abdominal wall after extending a suprapubic port) may explain this rare laparoscopic-incision–associated abdominal wall endometriosis; a key limitation is that it is a single case with no definitive mechanism established. This paper is centrally about endometriosis — it reports an abdominal wall endometrioma after hysterectomy and discusses a potential iatrogenic mechanism involving adenomyosis contact with the incision.

Read from the paper's body, not the abstract. Not a substitute for reading the paper. No clinical advice. How this works

Abstract

BACKGROUND: Endometriosis is a common condition in women that affects up to 45% of patients in the reproductive age group by causing pelvic pain. It is characterized by the presence of endometrial tissue outside the uterine cavity and is rarely found subcutaneously or in abdominal incisions, causing it to be overlooked in patients with abdominal pain. METHODS: A 45-year-old woman presented with lower abdominal pain 2 years following a laparoscopic supracervical hysterectomy. She was found to have incidental cholelithiasis and a large abdominal mass suggestive of a significant ventral hernia on CT scan. RESULTS: Due to the peculiar presentation, surgical intervention took place that revealed a large 9cm×7.6cm×6.2cm abdominal wall endometrioma. CONCLUSION: Although extrapelvic endometriosis is rare, it should be entertained in the differential diagnosis for the female patient who presents with an abdominal mass and pain and has a previous surgical history.
Full text 6,752 characters · extracted from pmc-nxml · 4 sections · click to expand

Case

A 43-year-old nulligravida women with no significant medical history experienced menometrorrhagia resulting in anemia. The patient had multiple small uterine fibroids with no pelvic pain. After exhausting all conservative measures, the patient, who was not married and had no desire to bear children, declined an endometrial ablation and preferred to undergo definitive surgical management. The patient desired to keep her cervix and based on her age, the decision was made to preserve her ovaries. The patient underwent an uneventful outpatient laparoscopic supracervical hysterectomy. A small 12-week size, multi-leiomyomatous uterus was removed through the suprapubic port after the incision was extended, following our simplified laparoscopic abdominal morcellation (SLAM) technique where the specimen was cut into longitudinal strips. No endometrial lesions were seen. The pathology revealed multiple small fibroids and adenomyosis. The patient recovered without issues and presented 2 years later with abdominal pain. Examination revealed a mass cephalad to the suprapubic incision, and a CT of the abdomen and pelvis was suggestive of a large ventral hernia ( Figure 1 ) . Incidentally, the patient was found to have extensive gallstones. Subsequently, the patient underwent a laparoscopic cholecystectomy that provided the opportunity to assess the abdominal wall; no hernia was seen. Due to the palpable mass and the possibility of a Desmoid tumor, a mini-laparotomy was performed, and a 4cm×4.1cm×3.7cm firm mass was resected and sent for a frozen section that revealed endometriosis ( Figures 2 and 3 ) . The resection was then completed, and an additional 5cm×3.5cm×2.5cm mass was resected, which was again confirmed to be endometriosis. The patient recovered uneventfully and was sent home the following day. The patient has done well since. CT of the abdomen reveals a mass suggestive of a ventral hernia. Resected abdominal mass sent for frozen section. Hematoxylin and eosin stains reveal presence of benign endometrial glands and stroma with blood, embedded in unremarkable soft tissue. No features were present to suggest a malignant process.

Discussion

Present day theories regarding endometriosis pathogenesis include: endometrium implantation theory, coelomic metaplasia epithelioid theory, lympho-vascular dissemination theory, and immunologic theory. 13 , 14 Endometriosis occurring in different parts of the body may be attributed to different pathogeneses, but inadvertent, iatrogenic transfer of endometrial tissue is the most likely reason that results in abdominal incision endometriosis, and typical cases appear following cesarean deliveries. 15 In our case, a similar theory is speculated. The morcellated uterus was removed from the body through the suprapubic incision after it was extended, allowing the adenomyosis to come in contact with the abdominal wall. Nothing during the initial surgery produced any suspicion of endometriosis, and we have utilized this morcellation technique in close to 1000 cases cumulatively by the authors, including but not limited to myomectomy, hysterectomy, and ovarian cystectomy specimens both large and small. This is the first time we have encountered such a finding in all of our surgeries. Why certain specimens can successfully inoculate the abdominal wall and others do not, even if some are obvious for endometriosis and adenomyosis, still remains to be answered. Extrapelvic endometriosis in general is very difficult to diagnose due to its rarity; the possibility does not readily come into the minds of the treating physicians. The most common differential diagnoses include stitch granuloma, cellulitis, and hernia. Umbilical endometriosis can pose a diagnostic quandary, because it can mimic a malignant melanoma or the “sister Mary Joseph nodule” associated with intraabdominal malignancies. Although sonography can also be used to facilitate the process of making the diagnosis in addition to CT and MRI, no pathognomonic radiological findings exist for an AWE. 16 Some literature suggests that there may be cyclical abdominal pain in patients who still have ovaries, 17 but this was not the case in our patient. We believe clinical suspicion and examination remain the mainstay for intervention and treatment. A needle aspiration may be considered for confirming the diagnosis, but if the patient is experiencing pain, excision of the mass will be both therapeutic and diagnostic.

Conclusions

Based on a comprehensive review of the literature, as Garg et al 4 and Poli-Neto et al 7 mentioned in their findings, endometriosis is a complex disease, and existing theories are not sufficient to explain its pathophysiology or its site of occurrence. As in our case report, in a patient with no evidence, symptoms, or history of endometriosis with an incidental finding of adenomyosis on subsequent pathology, the presentation may not seem sufficient enough to entertain the diagnosis of AWE. However, as stated earlier, the AWE in our patient is most likely the result of inoculation of the abdominal wall via direct contact with the specimen during its extraction. Even the utilization of automatic morcellators, however, does not provide complete immunity to inadvertent inoculation as described by Sepilian's group, 18 supporting the notion that we still do not have a complete understanding of this disease. Based on our experience, vigorous irrigation of the abdomen, pelvis, and abdominal wall should take place prior to closure, and all surgeons should include AWE in their differential diagnosis for the female patient who presents with an abdominal mass and pain and has a previous surgical history.

Introduction

In spite of being a common cause for pelvic pain in women, endometriosis remains a diagnostic and sometimes a therapeutic challenge due to its variability in clinical presentation. 1 – 4 The pelvis is the most common site for disease occurrence, thus manifesting in pelvic pain, dyspareunia, dysmenorrhea, infertility, and cyclical bowel or bladder symptoms. Extrapelvic endometriosis however is quite rare, with an incidence of 0.03% to 0.47%, 5 – 7 and more commonly found in cesarean delivery scars as incisional or cutaneous endometriosis. 8 Although abdominal wall endometrioma (AWE) is associated with laparotomy incisions, a comprehensive literature review revealed this relationship involving laparoscopy scars to be extremely rare. 9 – 12 This article describes an interesting presentation that was first interpreted as a ventral hernia by the radiologist, but due to its questionable presentation, a surgical intervention revealed the contrary, ironically yielding possibly the largest AWE originating from a laparoscopy incision reported in the literature.

Text is read by the "Ask this paper" AI Q&A widget below. Extraction quality varies by source — PMC NXML preserves structure cleanly, OA-HTML may include some navigation residue, and OA-PDF can have broken hyphenation. The publisher copy (via DOI) is the canonical version.

My notes (saved in your browser only)

⚙ Ask this paper AI returns verbatim quotes from the full text · source: pmc-nxml ⓘ

Answers must be backed by verbatim quotes from this paper's full text. Hallucinated quotes are dropped automatically; if no verbatim passage answers the question, we say so. How this works

Condition tags

endometriosisendometrioma

MeSH descriptors

Abdominal Wall Endometriosis Hysterectomy Laparoscopy Adult Cholecystectomy, Laparoscopic Diagnosis, Differential Endometriosis Endometriosis Female Gallstones Gallstones Gallstones Hernia, Ventral Hernia, Ventral Humans Hysterectomy Incidental Findings Laparoscopy Leiomyoma

Citation neighborhood

Papers in the corpus that this work cites (lower rings, blue) and that cite this one (upper rings, green). Dot size scales with the paper's in-corpus citation count — bigger dot = more influential within the endo/adeno field. Click a dot to open that paper. [ expand to 2 hops ] — adds papers reached through this work's immediate citers/citees. Heavier; up to 60 extra dots.

References (19)

Cited by (6)

Source provenance

europepmc
last seen: 2026-07-26T06:08:39.051465+00:00
openalex
last seen: 2026-06-10T17:14:06.276822+00:00
pubmed
last seen: 2026-05-13T22:16:35.898691+00:00
License: CC0 · commercial use OK