Endometriosis in Abdominal Fascia Mesh

Endometriosis; mesh; complications; umbilical hernia; laparoscopy DOI: 10.5336/caserep.2020-78230 CASE REPORT Correspondence: Mehmet Ferdi KINCI Muğla Sıtkı Koçman University Education and Research Hospital, Obstetrics and Gynecology Department, Muğla, TURKEY E-mail: [email protected] Peer review under responsibility of Turkiye Klinikleri Journal of Case Reports. Re ce i ved: 23 Jul 2020 Received in revised form: 14 Dec 2020 Ac cep ted: 21 Dec 2020 Available online:21 Jan 2021 2147-9291 / Copyright © 2021 by Türkiye Klinikleri. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Turkiye Klinikleri Journal of Internal Medicine Türkiye Klinikleri Journal of Case Reports CASE REPORT A 49-year-old gravida 3 para 2 woman visited our outpatient clinic complaining of groin pain and drug- resistant menometrorrhagia ongoing for the last 2-3 years. Despite using cyclic progesterone for 6 months between the 15 th and 25th days, she did not get any re- sponse. She then used levonogestrel intrauterine de- vice for a year. In the detailed history of the patient, hernia repair was performed 7 years ago due to an an- terior abdominal wall hernia. She doesn’t know the type of the mesh. The patient did not mention any com- plaints in relation to her past mesh surgery. In transvagi- nal ultrasonography, multiple myomas with the largest being approximately 4*4 cm were observed. Consid- ering previous abdominal surgery with mesh implanta- tion, open laparoscopic surgery (LS) was planned for the patient. To enable trocar insertion, access through a supraumbilical open LS was attempted. During the course of the entry, discharge of dark color and dense consistency suggestive of intestinal injury was noted and shift to open surgery was decided. All bowel seg- ments were checked and confirmed to be intact. Mesh of the patient was excised out, and hysterectomy was performed ( Figure 1). The surgery was completed with- out any complications. Respective pathology report indicated the excised mesh. Accumulation of hemosiderin-loaded macrophages as well as new bleeding areas around the cystic dilated endometrial glands (HE, x100). Therefore, endometrioma was considered on the mesh ( Figure 1). Area of granulation tissue consisting of histiocytes with foamy cytoplasm and multinucle- ated giant cells containing foreign body material (HE, x200). This situation made us think of foreign body reaction ( Figure 2, Figure 3 ). In her follow-up ap- pointment 6 months after the surgery, the patient had no relapse of hernia.

Endometriosis is described as the presence of en- dometrial tissue outside the uterine cavity, among various forms of which extra-pelvic manifestation stands for 8.9% of all cases. 8 Abdominal wall en- dometriosis (AWE) might have cutaneous or subcu- taneous location at a site in an incision scar, umbilicus, or rectus abdominis muscle. The risk to develop after Cesarean section is 0.1%. 9 Among 34 women with extragenital endometriosis, 44% had en- Mehmet Ferdi KINCI et al. Turkiye Klinikleri J Case Rep. 2021;29(1):20-3 21 FIGURE 1: Excised mesh endometrioma [Accumulation of hemosiderin-loaded macrophages as well as new bleeding areas around the cystic dilated endomet- rial glands. (HE, x100)]. FIGURE 2: Response to foreign body [Area of granulation tissue consisting of his- tiocytes with foamy cytoplasm and multinucleated giant cells containing foreign body material (HE, x200)]. FIGURE 3: Endometrioma (epithelial). Mehmet Ferdi KINCI et al. Turkiye Klinikleri J Case Rep. 2021;29(1):20-3 22 dometriosis along Pfannenstiel incision tract. 10 The theory that most likely explains development of scar endometriosis is direct inoculation of endometrial cells to subcutaneous tissue and abdominal fascia. 10 Synthetic meshes have a wide range of applica- tion in surgical treatment of stress urinary inconti- nence and pelvic organ prolapse as well as in surgeries for abdominal wall hernia, and hence an in- creasing rate of use. 11 Intended use of synthetic meshes encompasses substitution for weak support- ive tissue, augmentation of insufficient tissue, stimu- lation of supportive tissue regeneration, and compensation for deficiencies which might be caused by surgical technique. 12 Recent surge to mesh utilization poses a higher risk of mesh-related complications. Chronic mesh erosion, infection, rejection, dyspareu- nia, and other painful symptoms warranting surgery as well as surgical removal of implant are among the com- plications documented by an increasing number of pa- pers. 13-14 In the event of AWE, the cyclical pattern whereby pain worsens and mass size increases during menstru- ation shall raise suspicion. 15 These leading symptoms are encountered in 50% of patients. Of the reported AWE cases from a study, 63.8% had a history of Ce- sarean section. 16 Our patient was distinct from formerly reported cases for being asymptomatic regarding en- dometrioma, without a history of past uterine surgery or endometriosis. Given the tendency of symptom recur- rence following medical treatment with drugs such as progesterone and danazol, recommended treatment modality for scar endometriosis is wide excision of the lesion allowing at least 1 cm of circumferential surgi- cal margin. 17 Once resection is completed, mesh repair can be considered where a wide recess is left, or fascia defect is noted. 17 Accordingly, we have implemented total excision with a 1 cm margin of surrounding tis- sue. We have closed the abdominal layers primarily, without any mesh re-insertion. In conclusion, while examining the patients par- ticularly those who had undergone surgery present- ing with a mass located in the vicinity of incision track, the patients should be queried whether they have any pain deteriorating during menstruation and endometriosis should be kept in mind. It should also be kept in mind, however, that some patients may re- main asymptomatic, as in our case, without any his- tory of previous uterine surgery or endometriosis and may develop endometriosis around foreign bodies. In such cases of endometriosis, wide excision should be performed ensuring prevention of surgical recur- rences. Informed Consent The patient whose story is told in this case report signed permis- sion for its publication. Source of Finance During this study, no financial or spiritual support was received neither from any pharmaceutical company that has a direct con- nection with the research subject, nor from a company that pro- vides or produces medical instruments and materials which may negatively affect the evaluation process of this study. Conflict of Interest No conflicts of interest between the authors and / or family mem- bers of the scientific and medical committee members or members of the potential conflicts of interest, counseling, expertise, working conditions, share holding and similar situations in any firm. Authorship Contributions Idea/Concept: Mehmet Ferdi Kıncı, Özge Şehirli Kıncı; Design: Mehmet Ferdi K ıncı, Mehmet Onur Arslaner; Control/Supervi- sion: Ahmet Akın Sivaslıoğlu, Ezgi Karaka ş Paskal; Data Col- lection and/or Processing: Ezgi Karaka ş Paskal, Özge Şehirli Kıncı, Melek Ünçel; Analysis and/or Interpretation: Ahmet Akın Sivaslıoğlu; Literature Review: Ezgi Karaka ş Paskal, Özge Şehirli Kıncı; Writing the Article: Mehmet Ferdi Kıncı, Mehmet Onur Arslaner, Melek Ünçel; Critical Review: Ahmet Ak ın Sivaslıoğlu; References and Fundings: Mehmet Onur Arslaner, Mehmet Ferdi K ıncı; Materials: Mehmet Ferdi K ıncı, Mehme- tOnur Arslaner, Melek Ünçel. Mehmet Ferdi KINCI et al. 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