Comparative outcomes of abdominal wall endometriosis surgery: Specialized endometriosis surgeons versus general surgical teams

Dana Josephy : Conceptualization, methodology, investigation, formal analysis (interpretation), writing—review and editing. Yael Yagur : Conceptualization, methodology, investigation, data curation, writing—original draft, writing—review and editing, supervision. May Weinberg : Formal analysis, writing—review and editing. Maya Ben‐Zion : Investigation, data curation, writing—review and editing. Merav Sharvit : Methodology, validation, writing—review and editing. Zvi Klein : Methodology, validation, writing—review and editing. Yair Daykan : Methodology, validation, writing—review and editing. Ron Schonman : Conceptualization, methodology, supervision, writing—review and editing.

No funding was either sought or obtained for this study.

During the study period, out of 422 women with pathologic conformation of endometriosis, 46 (10.9%) were surgically diagnosed with AWE confirmed by pathology. Among them, 27 (58.7%) women were diagnosed at the specialized endometriosis center and 19 (41.3%) by the general surgery specialists (Figure  1 ). A total of 17 (36.9%) patients were diagnosed before the opening of the specialized endometriosis center and 29 (63.1%) afterward. General surgeons were involved intraoperatively in eight cases requiring mesh placement for abdominal wall reconstruction. Flow diagram showing patient selection. Of 422 patients with histologically confirmed endometriosis, 46 (10.9%) had abdominal wall endometriosis and were included. Patients were categorized according to the treating department and timing relative to the establishment of the specialized endometriosis center. No cases were lost and complete data were available for all included patients. Table  1 presents the patient characteristics of the study groups. No significant differences were observed between the groups regarding age, smoking status, gravidity, parity, or surgical history (including cesarean section, abdominal, and laparoscopic surgeries). Table  2 presents the patient characteristics at diagnosis. No differences were observed between the groups in terms of preoperative symptoms. However, the preoperative evaluation differed significantly. While the patients in the general surgery group had either abdominal wall US or MRI/computed tomography (CT) scan, the endometriosis center patients also had endometriosis specific sonogram by an expert in endometriosis US (abdominal wall US, 25 [96.2%] vs 11 [57.9%], respectively P  = 0.005, MRI/CT 1 [3.7%] vs 8 [42.1%], respectively P  = 0.001, endometriosis US 27 [100%] vs 0 [0%], respectively P  < 0.001). Demographic characteristics of the study groups. Note : Data are shown as number (%), mean ± SD or median (range), as appropriate. Abbreviations: CD, cesarean delivery; SD, standard deviation. Patient characteristics at diagnosis. Note : Data are shown as number (%), mean ± SD or median (range), as appropriate. Abdominal wall ultrasound was performed by radiologists in both groups unless otherwise specified. Ultrasound by endometriosis specialist refers to dedicated gynecologic sonographic evaluation. Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging; SD, standard deviation. Urinary symptoms: Dysuria. Bowel symptoms: Dyschezia, constipation, diarrhea. The rate of correct diagnosis in the specialized endometriosis center was significantly higher than in the general surgery specialists' group (26 patients [96.3%] vs 8 patients [42.1%], respectively; P  < 0.001). In the general surgery group most patients where suspected with non‐endometriosis diagnosis prior to the surgery compared to only one misdiagnosis in the endometriosis group. Following the establishment of the specialized center, 23 of 29 patients (79.3%) received a correct preoperative diagnosis, compared with 11 of 17 patients (64.7%) before its establishment. No significant differences were observed between the groups in lesion size, sheath involvement, or surgical complications (Table  3 ). Lesion characteristics and follow‐up. Note : Data are shown as number (%), mean ± SD or median (range), as appropriate. Abbreviations: AWE, abdominal wall endometriosis; SD, standard deviation. After adjustment for potential confounders, multivariable logistic regression showed that the diagnosing department was independently associated with correct preoperative diagnosis. Evaluation by general surgeons (reference group) was associated with a 28‐fold higher likelihood of misdiagnosis compared with the specialized endometriosis center (odds ratio [OR] 28.01, 95% confidence interval [CI]: 2.74–286.47, P  = 0.005). No significant associations were found for imaging modality, number of previous cesarean deliveries, or patient age (Table  4 ). Regression model for correct diagnosis at admission. Note : Reference category: Diagnosis by specialized endometriosis center. Abbreviations: CD, cesarean delivery; CI, confidence interval. When examining the correlation between lesion size and the need for mesh, we found that the predicted probability of mesh use increases sharply between lesion sizes of 3–5 cm, reaching near certainty for lesions larger than 5 cm. As for lesion sizes smaller than 3 cm, the probability of mesh use remains very low. However, between 3 and 5 cm, the probability increasing from about 10% at 3 cm to 90% at 5 cm (Figure  2 ). Predicted probability of mesh use based on lesion size. This figure shows the probability of requiring mesh placement based on lesion size. The probability increases significantly for lesions measuring between 3 and 5 cm, approaching near certainty for lesions larger than 5 cm.

In this study we showed the impact of specialized endometriosis center on the accurate diagnosis of AWE. Our primary finding was that correct diagnosis rates were significantly higher in the specialized endometriosis center compared to diagnoses made by general surgery specialists (96.3% vs 42.1%, P  < 0.001) with no difference in complication rates. Regression model revealed that the type of department at the time of admission increased the likelihood of misdiagnosis in case of the general surgery department by 28 times (28.01 95% CI: 2.74–286.47, P  = 0.005). No statistically significant effect was found for the type of imaging prior to surgery, the number of previous CD, or the patient's age. The diagnostic approach was naturally biased due to the common diagnoses that general surgeons typically encounter compared to specialized gynecologists. To arrive at the diagnosis of AWE from an “abdominal wall mass,” the patient's history and physical examination should be specifically focused. Questions about pain in the lesion during menstruation, along with other symptoms of endometriosis, such as dysmenorrhea, dyspareunia, dyschezia, bowel and urinary symptoms, could potentially lead to the correct diagnosis. 5 Once the differential diagnosis includes endometriosis, the imaging is more targeted. As seen in the results, the general surgeons opted more often for CT or MRI, which are their central tools, whereas the specialized gynecologist used gynecologic US and abdominal wall US which are more specific for diagnosis of AWE and MRI not as first option. 18 The correct diagnosis and referral to the correct center is important also for providing the patient with the appropriate surgical technique. While a skilled general surgeon may excise an abdominal wall mass, the surgical approach to endometriosis aims to achieve adequate surgical margins. 2 , 4 Beyond accurate diagnosis and achieving clear surgical margins, referral to an endometriosis allows for holistic evaluation of associated symptoms that may indicate concomitant pelvic endometriosis. In cases where pelvic endometriosis coexists, reported in up to 16.7% of patients, 12 the removal of the pelvic disease will not be addressed by general surgeons. This may result in partial treatment and suboptimal outcomes, potentially requiring further surgical intervention in the future. This comprehensive approach ensures that concurrent lesions are addressed surgically if needed, reducing the likelihood of incomplete treatment and the need for additional surgeries. Constant follow‐up provided by specialized centers also aids in monitoring for recurrence and managing long‐term outcomes, further support the centralized care. In terms of secondary outcomes, our study found no significant differences between the groups in lesion size and surgical complications but found that the need for mesh increased in patients with lesion sizes between 3 and 5 cm. The observation regarding mesh use was added because the need for multidisciplinary approach for cases involving larger lesions. Lesions measuring 3–5 cm or more often require collaboration between specialized gynecologists and general surgeons to ensure appropriate placement of mesh for abdominal wall reconstruction. This multidisciplinary coordination can ensures optimal surgical outcomes. In the literature, the consideration of mesh placement for lesions measuring 3–4 cm is based largely on expert opinion. 8 , 19 , 20 This consideration is important because a combined surgical approach involving general surgeons, will be needed in those cases. In our study since the opening of the specialized center, there has been an increase in the rate of accurate preoperative diagnoses (79.3%), shows the positive influence of centralized expertise in reducing misdiagnoses, facilitating better treatment planning. The establishment of a specialized endometriosis center has improved diagnostic accuracy and raised general practitioners' awareness of AWE. Referrals have increased, showing greater recognition of the value of the center in specialized care. Previously, diagnostic delays for endometriosis varied widely, often taking eight to 12 years and one third of the women had consulted general practitioners six or more times for dysmenorrhea before receiving a diagnosis. 21 Although US was frequently utilized to investigate symptoms, it was ineffective in diagnosing the majority of cases. 22 Recent data show a reduction in diagnostic delay for endometriosis, likely due to improved guidelines and greater advocacy. However, delays persist, emphasizing the need for earlier diagnosis and timely specialized care to reduce the impact of untreated disease. 23 , 24 A strength of our study is the comparison between a specialized endometriosis center and general surgery specialists. To the best of our knowledge, no previous studies have addressed this specific question, allowing us to examine the impact of specialized care on diagnostic accuracy. Additionally, our 15‐year study period enables a broad analysis of trends before and after the establishment of the specialized center. The inclusion of histologically confirmed cases ensures diagnostic reliability, and the use of advanced imaging modalities, such as US, enhances the accuracy of preoperative assessments. Despite these positive findings, our study had several limitations. The retrospective single‐center design may have introduced selection bias, and the relatively small sample size limits the generalizability of the results. In addition, only surgically treated and histologically confirmed cases were included, therefore, patients with suspected or misdiagnosed AWE who were not referred for surgery were not captured. Group allocation was based on the treating department rather than random assignment, which may reflect referral bias. Furthermore, changes over time, including the establishment of the specialized endometriosis center, may have influenced referral patterns and diagnostic practices. Residual confounding due to unmeasured variables cannot be excluded. Future prospective studies with larger cohorts are needed to confirm these findings and further explore long‐term outcomes. In conclusion, management by specialized endometriosis surgeons was associated with significantly higher diagnostic accuracy of AWE compared with general surgical teams. These findings support early referral of patients with suspected AWE to experienced endometriosis units.

Abdominal wall endometriosis (AWE) occurs when endometrial glands and stroma are present within the abdominal wall, 1 most commonly at the site of a prior surgical incision, such as after a cesarean section or other gynecologic surgery 2 and can be located in the umbilicus, groin or anterior abdominal wall. 3 , 4 The condition is thought to arise from the accidental transfer of endometrial cells to the surgical site during the procedure, where they can later implant and proliferate. 5 The true prevalence of AWE is estimated to range from 0.03% to 3.5%, indicating it is relatively uncommon. 5 , 6 , 7 Symptoms of AWE typically include cyclic pain, a palpable mass, and sometimes skin discoloration, all of which tend to correspond with the menstrual cycle. 1 , 8 , 9 While these features can suggest a diagnosis, identifying AWE is not always straightforward and requires specialist intervention. AWE can easily be confused with other conditions, including hernias, hematomas, or even malignancies, especially in non‐specialized practices. 10 , 11 In specialized endometriosis settings, diagnosis may be more straightforward due to expertise based on history and clinical examination, but definitive diagnosis is made through histopathologic analysis after surgical excision. 12 Imaging modalities such as ultrasound (US) and magnetic resonance imaging (MRI) can play a crucial role in preoperative diagnosis and may reduce the misdiagnosed cases. US often serves as the first imaging approach and may show isoechoic or hyperechoic masses with peripheral vascular patterns with high sensitivity. 13 MRI is particularly beneficial due to its high soft tissue contrast, often revealing hyperintense lesions on T2‐weighted images with cystic or hemorrhagic components 14 , 15 MRI sensitivity is up to 90% and specificity 85%–95% for detecting soft tissue lesions. 16 The primary treatment for AWE is surgical excision of the lesion. Cryoablation has also been shown to be an effective and safe treatment for AWE. 17 Complete removal of the ectopic endometrial tissue is crucial to alleviate symptoms and prevent recurrence. Given the complexity of the condition and its potential to mimic other abdominal wall pathologies, it is particularly important that diagnosis and treatment are handled by specialists in the field of endometriosis for optimal outcome and minimizing unneeded complications. In this study, we aimed to assess the importance of a specialized endometriosis center in improving preoperative diagnostic accuracy. The purpose of this study was to compare the preoperative accuracy in the diagnosis of AWE using clinical data and imaging between the specialized endometriosis center and those made by general surgery specialists.

None declared.

This retrospective cohort study included patients with a histologic diagnosis of AWE who underwent surgical intervention from 2007 through 2022. All patients with positive histology of endometriosis in the registry of the pathology department were reviewed. Inclusion criteria were women over the age of 18 years old, who had positive histology of AWE. The study group was stratified into patients managed by the endometriosis center and those treated in the general surgery department, based on clinical and imaging data. All eligible patients identified from the pathology registry were included in the analysis, and no cases were lost or excluded due to missing data. The primary outcome was the rate of misdiagnosed AWE prior to surgery. The secondary outcomes include the correlation between lesion size and the need for mesh and complication rates between the two groups. The changes observed since the establishment of the specialized endometriosis center are also included. A multidisciplinary endometriosis clinic was established in our center in 2012. Surgical procedures in the specialized endometriosis center were performed by a gynecologic surgeon with formal fellowship training and expertise in endometriosis surgery. At our clinic, a multidisciplinary approach is employed to ensure comprehensive care for patients with suspected or confirmed endometriosis, including AWE who are referred by their gynecologist to the specialized clinic. The protocol integrates clinical evaluation, imaging (US or MRI), and individualized treatment plans. Initial evaluation of the patient includes a thorough clinical assessment performed by an endometriosis specialist. US evaluation in the specialized endometriosis center was performed by a gynecologist with expertise (subspeciality) in endometriosis US, in addition to abdominal wall US performed by a radiologist. If further evaluation is needed, MRI is used. Following this assessment a multidisciplinary team of gynecologists, radiologists and, when necessary, general surgeons (when there is need for mesh with involvement of the rectus sheath) review each case and plan surgical steps. Surgical excision is performed by two endometriosis specialists from the unit. Operative steps include making a skin incision over the lesion, excising it en bloc with clear margins, and reconstructing the defect layer‐by‐layer, using mesh if needed for larger defects. All excised specimens were routinely sent for histopathologic confirmation. Patients were referred to the general surgery department from outpatient clinics for the evaluation and treatment of suspected abdominal lesions. The initial evaluation included a thorough clinical assessment conducted by a specialist in general surgery, without gynecologic involvement. The evaluation consisted of a physical examination and imaging, typically abdominal wall sonography performed by a radiologist. Based on the findings, one of the general surgeon team reviewed each case and developed a surgical plan. Surgical excision was performed by one of approximately 20 general surgery specialists, without a dedicated surgeon, and histopathologic confirmation was obtained whenever a lesion was excised. Patients were followed postoperatively for symptom resolution and recurrence, with imaging as needed. Those operated on in the general surgery department were referred to the endometriosis unit for long‐term follow‐up after histopathologic confirmation. Data were obtained from the electronic medical records of the Obstetrics and Gynecology department at a tertiary medical center. Data from both groups were collected by three investigators using a standardized data extraction protocol. The collected information included patient demographics and medical history, encompassing age, underlying conditions, smoking status, gravidity, parity, history of prior cesarean delivery, abdominal, and laparoscopic surgeries. All complications were documented. Preoperative clinical parameters, including infertility, abdominal pain, dysmenorrhea, dyspareunia, and urinary or bowel symptoms, were recorded. Urinary symptoms included dysuria, urgency, frequency, incontinence and bowel symptoms included dyschezia, constipation, and diarrhea. Data from physical examinations and sonographic findings were also captured. For each case, operative details, histologic findings, complications and improvement following resection were thoroughly documented. For the purpose of the study, data were compared between patients who were diagnosed under specialized endometriosis clinic and diagnosis under the general surgery specialists. A multivariable regression model was performed based on significant parameters from the univariate model and relevant clinical parameters, as detailed in the statistical analysis section. This study was conducted according to good clinical practice guidelines and was approved by the Meir Medical Center Institutional Review Board. Due to the retrospective nature of the study, waiver for informed consent was accepted based on the nature of the study. Patient characteristics were compared between the groups. All statistical analyses were conducted using SPSS. Data are presented as numbers and percentages for categorical variables, and as means and standard deviations (SDs) for continuous variables. The categorical variables were compared between the two groups using chi‐square or Fisher exact tests. Continuous and ordinal variables were compared between groups using independent samples t ‐test or Mann–Whitney test. Multivariable logistic regression was used to study the association between correct diagnosis and diagnosing department, while controlling for potential confounders: age, history of previous cesarean delivery (CD) and imaging prior to surgery. Using logistic regression analysis, lesion size was entered as the independent variable and the use of mesh as the dependent variable. The model calculates the probability that mesh will be needed based on lesion size. All statistical tests were two‐sided and a P value less than 0.05 was considered statistically significant. All statistical analyses were performed using IBM SPSS (version 27, IBM Corporation, Armonk, New York).