Large Intramuscular Abdominal Wall Endometriosis: Clinical, Imaging, and Intraoperative Insights

Background: Intramuscular abdominal wall endometriosis (AWE) refers to the ectopic implantation of functional endometrial tissue within the musculature of the abdominal wall.It is typically associated with chronic symptoms, most notably cyclical lower abdominal pain.Although uncommon, AWE is often linked to surgical interventions involving obstetric or gynecologic procedures, where endometrial cells may be inadvertently introduced into the incision site.Case description: This report discusses a 30-year-old woman who presented with a cyclically enlarging bluish mass adjacent to her previous cesarean section scar.Radiological evaluation identified multiple cystic lesions consistent with the imaging profile of scar endometriosis, extending from the intramuscular layer to the peritoneal surface.The patient underwent extensive surgical excision of the mass, and due to a significant fascial defect, polypropylene mesh was placed to reinforce the abdominal wall.Histopathological analysis confirmed the diagnosis of extrapelvic endometriosis.Postoperatively, the patient reported substantial symptom resolution.Clinical discussion: A history of prior abdominal surgeries, particularly cesarean sections, is recognized as a contributing factor to the development of AWE.The lesion typically enlarges during menstruation and presents with associated symptoms.Abdominal wall endometriosis can manifest from as early as 12 months to as late as 21 years postoperatively, often mimicking conditions such as hernias or neoplasms, necessitating thorough clinical evaluation.In this case, ultrasonography and magnetic resonance imaging (MRI) were utilized for diagnostic assessment.Definitive treatment involved wide excision of the lesion with placement of a polypropylene mesh to reinforce the abdominal fascia and reduce the risk of postoperative herniation.To minimize recurrence, the patient received leuprolide acetate 3.75 mg administered at 4-week intervals.Conclusion: Clinicians should maintain a high index of suspicion for endometriosis in women of reproductive age presenting with cyclic pain, palpable abdominal nodules, or bluish discoloration near a cesarean scar or previous obstetric-gynecologic surgical site.This case illustrates the complexity of managing intramuscular and intrafascial AWE, particularly when associated with extensive fascial defects, which may predispose to hernia development and mesh-related complications.These considerations underscore the necessity of a multidisciplinary approachintegrating detailed clinical assessment, appropriate imaging modalities, and comprehensive surgical planning-to achieve effective and safe management of this challenging condition.