Post-surgical endometriosis with varying scenarios: A retrospective study

Endometriosis is ectopic presence of endometrial tissue outside the uterus. Patients who were admitted in the department of Obstetrics and Gynecology PGIMS Rohtak, with surgical site endometriosis from Jan 2015 to Dec 2019, were analysed in detail. Challenges faced during management, histopathological findings, complication and recurrence, if any, were noted. All the patients presented with a periodic painful swelling. Location varied according to previous surgical sites- abdominal swelling with history of cesarean section or laprotomy and perineal with history of vaginal delivery with episiotomy. Diagnosis was made by clinical examination supplemented by ultrasonography. Treatment was done by wide surgical excision, taking care to include all the endometriotic tissue and confirmed by histopathology. No recurrence was noted in patients after resuming their normal menstruation. It is very important to detect this condition, as early detection gives us scope for timely intervention and better management.

Endometriosis, cesarean, surgical excision, scar

Endometriosis is a condition defined as the ectopic presence of endometrial tissue (glands and stroma) outside the uterus. It is a common benign gynaecological condition and predominantly affects women of reproductive age group. Pelvic viscera and peritoneum are the most frequent documented sites of implantation. Its appearance varies from few minimal lesions on otherwise intact pelvic organs, to massive ovarian endometriotic cysts and extensive adhesions involving bowel, bladder, and ureter [1]. Endometriosis can only be diagnosed after surgery either open or laproscopic, so its exact prevalence is unknown. It is seen in 3-10% of young fertile women. It has also been reported in extrapelvic sites including almost all organs and systems like central nervous system, nose, breast, lung, spleen, gastro-intestinal tract, kidney, abdominal wall and perineum, but scar endometriosis is very rare [2]. Its incidence in post-caesarean and post- hysterotomy scar tissue is approximately is 0.03-0.4% and 1.08-2% respectively [3]. Patients of scar endometriosis are often either referred or present directly to the general surgeons because of the clinical presentation which suggests a surgical cause [4]. Scar tissue endometriosis may present as a discrete painful mass and can mimic a variety of surgical conditions like inguinal hernia, incisional hernia, abdominal wall tumor, stitch granulomas, etc. [5] So, it is very important for us to recognize this treatable condition to avoid potential clinical pitfall in the diagnosis. As there is rise in the incidence of caesarean sections and gynaecological surgeries, we are encountering this rare condition, frequently. After conducting a retrospective study, here we are presenting this paper to increase the awareness among general surgeons and gynaecologist regarding varying presentation of scar endometriosis, its diagnosis and challenges surgeon can face during management.

To evaluate the different surgical site endometriosis and challenges faced in their management.

This retrospective case study was done on patients who were admitted and managed from January 2015 to December 2019, with diagnosis of surgical site endometriosis, in the Department of Obstetrics and Gynaecology, PGIMS Rohtak. Parameters noted were age of International Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com ~ 369 ~ patient, presenting symptoms, site, size of endometriosis, time duration between surgery and onset of symptoms and other risk factors, radiological, surgical and histopathological findings, line of management, complication in post-operative period a nd recurrence, if any. Routine hematological and biochemical examinations were done following medical history and physical examination. Table 1: Case summaries Case No. Age (in years) Obstetric score Surgery- Presentation interval Presentation Examination findings Initial diagnosis FNAC USG/MRI Management Surgical findings HPE Complication Recurrent disease 1 32 P2L2A1 8 years (LSCS) Swelling at anterior abdominal wall 4x3 cm firm nodule at right margin of scar of Ceserean section ? Scar endometriosis Not done About 4x3x4 cm hypoechoic mass right side of scar Wide surgical excision 4.5x3x4 cm firm nodule extending up to superficial part of rectus sheath Diagnosis confirmed No No 2 36 P3L2A1 10 years (laparotomy f/b hysterotomy) Pain & swelling in suprapublic region during menses Vertical scar + 3x2 cm tender mass above public symphysis Scar endometriosis Endometrial glandular cells with hemosiderin laden macrophages 2 Hypoechoic lesion seen in s/c plane & within left rectus muscle Wide surgical excision 4x5 cm mass adherent to rectus sheath Diagnosis confirmed No No 3 28 P3L3 6 years (vaginal delivery) Swelling & cyclical pain in perineal area since 1 year 4x3 cm nodule in middle of previous episiotomy scar Endometriotic nodule Not done 5x4.5 cm hypoechoic lesion right side in close relation with anus and rectum Wide excision with sphincteroplasty Injleuprolide acetate 3.75 gm s/c single dose Nodule around 6x5 cm attached to external anal sphincter infiltrating upto levatorani muscle Diagnosis confirmed After 20 days patient came with wound infection No 4 25 P1L1 2 years (LSCS) Pain & swelling in lower side of stitch line 3x3 cm tender mass in suprapubic region at stitch line Stitch abscess Few degenerated inflammatory cells 15x14x12 mm hypoechoic lesion at scar site Excision of scar tissue 2.5x3 cm nodule Diagnosis confirmed No No 5 26 P1L1 2.5 years (LSCS) Swelling and cyclical pain with blood like discharge from right extent of stitch line 1x1 cm firm nodule with pint of discharge at right margin of transverse scar of LSCS Scar endometriosis Not done 1.5x1.5 cm hypoechoic lesion on right extent of scar Wide surgical excision 2x2 cm nodule Diagnosis confirmed No No 6 26 P1L1 5 years (LSCS) Swelling and cyclical pain near stitch line 3x3 cm mass near stitch line Scar endometriosis Not done 3.5x3 cm hypoechoic lesion in subcutaneous plane involving sneath Wide surgical excision 4x4 cm endometriotic tissue involving sheath Diagnosis confirmed No No 7 35 P3L3 6 years (LSCS) Pain & swelling in middle of stitch line 2x2 cm nodule in stitch line Scar endometriosic Not done 3x2 cm hypoechoic lesion at scar site Wide local excision 3x2 cm scar endometriotic tissue Diagnosis confirmed No No 8 22 P3L3 2 years (LSCS) Pain & swelling in stitch line 1.5x1.5 cm nodule in stitch line Scar endometriosic Scar Not done 1.5x1.5 cm hypoechoic lesion at scar site Wide local excision 1.5x1.5 cm nodule removed Diagnosis confirmed No No 9 30 P2L2 5 years (LSCS) Pain & cyclic swelling in stitch line 4x4 cm nodule on right side and 1x1 cm nodule on left side of stitch line Scar endometriosis Not done Two hypoechoic lesion 4x4 cm on right side and 1x2 cm on left side of stitch line Wide local excision 4x3 cm nodule on right side and 1x2 cm nodule on left side Diagnosis confirmed No No 10 10 28 P11L1 1 and half year (LSCS) Pain & cyclic swelling at suprapubic region No definite nodule palpable because of obesity Scar endometriosis Not done Mixed echoic solid-cystic lesion with ill- defined border of 3.3x2.4 cm in suprapubic region in midline abutting muscle. Wide local excision Multiple endometriotic nodule with local subcutaneous spread in abdominal wall Diagnosis confirmed Wound No sepsis on Day 5 International Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com ~ 370 ~ Fig 1: Specimen of scar endometriotic tissue after wide surgical removal. You can notice bleeding point in lesion (arrow mark) Fig 2: Per-Op endometriotic nodule (bluish-purple with arrow mark) peeping out and in close relation with anus in patient with perineal endometriosis (a) Low power field (b) at high power field (×20) Fig 3: H&E stained section showing endometrial glands with fibrovascular stroma in the scar tissue at (a) low power field, (b) at high power field (×20)

Main complaint of our cases on admission was a palpable mass on incision site and cyclic pain. One patient also presented with history of dark colored bloody discharge from complaint site. Patients age ranged from 25-36 years. Location varied according to surgical sites-abdominal swelling with history of either caesarean section, hysterotomy or laparotomy. Perineal swelling was associated with history of vaginal delivery with episiotomy. Wide range of time interval between surgery and clinical presentation from one and half to ten years of the last operation and it had been noted that more the time gap of presentation of symptoms from last operation, larger the size and deeper was the infiltration of mass. Initial diagnosis of scar endometriosis was made by clinical examination supplemented by USG. In two cases FNAC had also been done (patients already had report from outside). Treatment in all the cases was done by wide surgical excision, taking care to include all the endometriotic tissue. In one case (perineal endometriosis) single shot of Injection Leupurolide acetate 3.75 gm S/C was also given confirmation of all cases was done by histopathology, in which endometrial gland with stroma and hemosiderin pigment can be seen. Immediate post-op period was uneventful. Patient with perineal endometriosis was presented to hospital after discharge with infected wound on day 20, which was managed conservatively. And one more patient with abdominal wall endometriosis had wound sepsis on post- operative day 5, which can be attributed to obesity and extensive subcutaneous tissue involvement in that case. No recurrence were noted on follow-up after 3 months of resumption of menstruation, in any case.

Scar endometriosis most commonly occurs after pelvic surgeries. Patients may be asymptomatic. The pathognomonic features are a painful nodule at incision site and cyclical pain in a reproductive age woman with a history of gynecological or obstetrical surgery. The intensity of pain and size of nodule vary with menstrual cycle. Most of these patients may have concomitant pelvic endometriosis [6]. The frequency of scar endometriosis has increased in the recent past because of the increasing numbers of cesarean sections and laparoscopies being performed [7]. Out of two main theories behind the pathogenesis of scar endometriosis, mechanical implantation at the time of uterine surgery, followed by proliferation of seeded tissue at new site under same hormonal influences, is the most plausible cause [8]. Metaplasia theory postulates differentiation of multipotent mesenchymal cells to endometrial tissue in their site after puberty and show patho- physiological changes as a response to hormonal stimuli. Major factor responsible for endometrioma development is iatrogenic inoculation of endometrial tissue into the incision site [9]. High index of clinical suspicion is needed to diagnose this condition. This require clinical differentiation from other surgical conditions such as lipoma, incisional hernia, abscess, seroma, keloid, neoplastic tissue, or even metastatic carcinoma. Malignancy should be suspected in fast growing and large endometrioma or if there is frequent recurrence [10]. Imaging procedures help, rather than confirm, in obtaining a differential diagnosis and can facilitate total surgical excision. USG is the best and most commonly used procedure for abdominal masses. The mass may appear as a solid, hypoechoic and heterogeneous mass with different internal echoes with speculated margins, infiltrating the surrounding tissue. FNAC is also a method to make the diagnosis of scar endometriosis. Histology is the Gold standard for definitive diagnosis. It is satisfactory when endometrial glands, stroma, and hemosiderin pigment are seen [11]. Primary medical therapy with danazol, progesterone, GnRH agonists provide only partial relief and does not cure the disease, hence recurrence occurs after cessation of the treatment with extreme side effects [12]. The treatment of choice remains the wide local excision with histologically proven free margins, providing both diagnostic and therapeutic benefit.

Scar endometriosis is a rare clinical condition but its incidence has increased in the recent past because of increasing number of International Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com ~ 371 ~ caesarean sections. Diagnosis can be made by high index of suspicion in reproductive age women having localised cyclical symptoms in a scar, following a previous obstetric or gynecological procedure. Imaging methods like doppler USG, CT and MRI can be used for differential diagnosis. Medical treatment is helpful in selected cases but wide surgical excision is treatment of choice to prevent future recurrence. Early detection gives us scope for timely intervention and better management. Conflicts of Interest The authors have none to declare

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