Cesarean scar endometriosis: A case report

Endometriosis is a chronic gynaecological disorder where presence of functional and morphological endometrial gland present outside the uterine cavity. Cesarean scar endometriosis is an unusual manifestation of extra pelvic endometriosis. Here, we report a case of caesarean scar endometriosis diagnosed after 6 years of cesarean delivery and was treated by surgical wide enbloc excision under spinal anaesthesia. Main aim is to increase awareness of this entity.

Cesarean scar endometriosis (CSE); Surgical wide En Bloc excision; Sclerotherapy

Endometriosis is a condition where the functional and morphological endome- trial glands and stromal structures are found outside the uterus. It mainly affects women in reproductive ages. Endometriosis occurs most often in pelvis, on the surface lining of the pelvic cavity, peritoneum, ovaries, pos- terior cul-de-sac, and uterosacral liga- ments. Rarely, implants outside pelvis and named as extra pelvic endometrio- sis. Scar endometriosis an extremely rare site (incidence 0.03-3.5%) of extra pelvic endometriosis, is presence of endometriosis at or near previous surgery scar site as a painful discrete tumoral mass known as Endometrioma or admixed with native tissue. (1,2) SE usually develops after General surgery and Obstetrics and Gynecological surg- eries, most commonly after hysterectomy (1.08-2% cases) cesarean delivery (0.03- 0.04% cases) and rarely after Appendici- tis, T ubal ligation, Ectopic pregnancy, Inguinal herniorrhaphy, in laparoscopic trocar tract and needle tract after diag- nostic amniocentesis and in perineal epi- siotomy incision.(3) Most of them present to surgeons because of similarity to her- nia, lipoma, keloid and other anterior abdominal masses. The great variability of symptoms and clinical presentations as well as limited knowledge on disease can lead to delayed treatment, misdiagnosis, unnecessary intervention discomfort to the patient. https://ijpccr.com/ 58 Zeba et al. / International Journal of Preclinical & Clinical Research 2021;2(3):58–61 Case details A 28-year-old woman P2L2 Reported to Gynecology OPD with painful palpable mass at left angle of previous incision scar since 6 months. She delivered Full term alive healthy male baby by emergency LSCS for fetal distress and post-operative period uneventful. Within a year she conceived again and delivered a full term, alive healthy male baby by emergency LSCS for threatened scar rupture and post-operative unevent- ful. Patient presented with painful palpable swelling at left angle previous LSCS scar incision since 6 months. On exami- nation palpable tender subcutaneous mass located 1cm above the left angle of LSCS incision site measuring approximately 2x 2 cm. Rest systemic examination uneventful. Sonogra- phy examination revealed ill-defined heterogeneous lesion measuring 24x 19 mm in the subcutaneous plane in lower abdomen on left side of the incision with minimal vascu- larity. Under spinal anaesthesia, Surgical wide en bloc exci- sion performed and lesion was removed and defects repaired. Gross examination revealed irregular fibro fatty mass with brownish – black pigmented area with areas of congestion and hemorrhage. Histopathology examination revealed subcuta- neous islands of endometrial glands with stroma noted along with congested blood vessels and areas of hemorrhage with dense lymphocytes infiltration in fibrosis without evidence of malignancy. HPE findings suggestive of Scar endometriosis. On follow up after 6 months she did not report any recurrence and was completely relieved of her symptoms. Fig 1. Clinical examination

Abdominal wall endometriosis is largely related to previ- ous history of surgery. (3) Endometriosis implants develop- Fig 2. USG finding Fig 3. Intraoperative findings Fig 4. ross examination https://ijpccr.com/ 59 Zeba et al. / International Journal of Preclinical & Clinical Research 2021;2(3):58–61 Fig 5. Microscopy ing in the subcutaneous tissue of surgical scars occur most frequently after gynaecological and obstetrical procedures, including cesarean sections, hysterectomies, cystectomies, tubal ligations, and amniocenteses (1). The pathogenesis of endometriosis is complex and CSE is believed to be the

of a mechanical iatrogenic implantation, through the direct inoculation of the abdominal fascia and/or subcuta- neous tissue with endometrial cells during the surgical inter- vention, which, stimulated by estrogen, become active and expand. (4) W ang et al. examined the factors contributing to CSE and defined possible causes, including the easy separa- tion and transport of endometrial cells by the amniotic fluid flowing into the pelvic cavity after hysterectomy; the large amount of endometrial cells liberated into the pelvis before hysterectomy closure and that can potentially be trapped in the wound; and the nurturing role of blood and hor- mones, after inoculation of the cells, allowing them to grow and develop into subcutaneous masses. (2) Endometriosis in cesarean scar is a rarely observed disease. There are a lim- ited number of publications focusing on CSE, and most of them are case reports. It is difficult to perform well-controlled clinical trials in rarely observed disease. The common pre- sentation of CSE includes palpable subcutaneous mass, typ- ically accompanied by cyclic, noncyclic, or constant pain. Menstruation usually aggravates disease. The mass under a cesarean section scar and the symptoms in a cyclic manner fairly facilitate the diagnosis of the illness. Awareness of its typical clinical manifestation remains the mainstay for inter- vention and diagnosis. Iatrogenic mechanical transplanta- tions on incision scare during the operations are the most accepted pathogenesis. (2) T o minimize endometriosis con- tamination, some authors recommend careful isolation of the wall incision and lavage with normal saline before clo- sure of the wall. (5) The others hypothesized that failure to close the parietal and visceral peritoneum with sutures at time of ceserean section may markedly increase the postopera- tive occurrence of endometrioma in the skin incision scar. (6) Replacing instruments and needles with the new one is rec- ommended when suturing other abdominal layers.(7) Medical management- Hormonal treatment offers temporary allevi- ation of symptoms, but recurrence is common after cessa- tion of treatment. (8) Sclerotherapy used for endometriotic cysts has been reserved for those patients who have high sur- gical risk, are pregnant, or refuse surgical intervention. In the literature ultrasound-guided aspiration and sclerother- apy with 95% ethanol provides a valid alternative to surgery in treating endometrial cysts. (9)Intralesional ethanol injec- tion may result in difficult-to-repair necrosis on the ante- rior muscles of the abdominal wall in large lesions. Also, in endometriosis foci extending into the intraperitoneal region, it may cause complications including chemical peritonitis and severe pain as a result of alcohol penetration into the peri- toneum. According to Bozkurt M et al planned sclerother- apy by ultrasound-guided ethanol to the patient with intra- muscular anterior wall endometriosis (A WE). Further inves- tigations of large series are needed to compare the surgical operation with ethanol injection treatment. Hence complete wide excision with clear margins is both diagnostic and ther- apeutic and is accepted as treatment of choice in ceserean scar endometriosis.

Endometriosis in Cesarean scar is rarely observed disease. Cesarean section is an apparent risk factor for the presence of endometriosis. T o avoid unnecessary referrals, awareness of its typical clinical manifestations remains the mainstay for intervention. Medical treatment gives only partial relief and recurrence of the condition after cessation of medication. Preventive measures like exclusion of the decidua during the uterine closure, minimal tissue handling, and closure of parietal and visceral peritoneum can avoid iatrogenic inoculation of endometrial cells. Complete wide excision with clear margins is both diagnostic and therapeutic. https://ijpccr.com/ 60 Zeba et al. / International Journal of Preclinical & Clinical Research 2021;2(3):58–61

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