A bizarre surgical aftermath of caesarean scar endometriosis

A 32-year-old multiparous female patient came to our gynaecology OPD with complaints of a painful lump over the previous caesarean scar. She had a history of two caesarean sections previously in 2012 & 2015. The last Caesarean section was done electively along with copper T insertion in 2015. In the postoperative period, she had a superficial surgical site infection which was managed successfully with antibiotics and re-suturing done on day 8 postoperative period and rest were uneventful. On per abdominal examination seen, a hyperpigmented hard indurated tender mass of 6*4cm present in the right side of scar site with 2mm orifice and chocolate brown fluid seen oozing from the orifice on pressing. Ultrasound showed a hypoechoic mass of 4*6 cm in the subcutaneous plan of the abdominal wall extending up to the anterior uterine wall with minimal vascularity. Possibility of scar endometriosis was given. Contrast-enhanced computed tomography showed defined Solid soft tissue mass of size 2*8.3*3.4 cm (CC*AP*TR) seen in the deep subcutaneous plan of the anterior abdominal wall in the hypogastric region extending to deep musculature of rectus abdominis. Rectus muscle and anterior rectus sheath closed with loop ethilon and 15*15cm trulene mesh placed as only mesh fixed with 2-0 prolene and another drain placed. The patient made a good recovery following the surgery. Histopathology report consistent with scar endometriosis showing foci of endometrial tissues consisting of cystic endometrial glands surrounded by endometrial stroma.