A case report on scar site endometriosis

Sangeetha V1 /Preethika A2/ Shanthi P3/ PreethiB4

Department of Obstetrics and Gynaecology,Sree Balaji Medical College and Hospital
1
Sangeetha V, Post Graduate Department of OBG , Sree Balaji Medical College and
Hospital , Chennai , India.
2
Preethika A , Assistant professor , Department of OBG , Sree Balaji Medical College and
Hospital , Chennai , India.
3
Shanthi P , Professor , Department of OBG , Sree Balaji Medical College and Hospital ,
Chennai , India.
4
Preethi B , Associate professor , Department of OBG , Sree Balaji Medical College and
Hospital , Chennai , India.
Email-drsangeethaobg2012@gmail.com
Abstract
The development of functioning endometrial tissue in the abdominal wall after a cesarean birth is
an uncommon case phenomenon known as scar endometriosis. Aside from the pelvis,
endometriosis most often manifests in the bladder, gastrointestinal system, and, most notably,
after obstetric surgical procedures. Here we present a case of caesarean scar endometriosis in a
pregnant woman of 30 years of age. The patient has a history of type 1 diabetes mellitus, is now
taking insulin and oral hypoglycaemic medications, and is being treated for hypothyroidism. She
said that the region around her prior cesarean scar was swollen and painful on a periodic
basis.USG showed ill defined heterogeneous hypo-echoic subcutaneous mass lesion
approximately measuring 3*2*3cms over the right lateral one third of the caesarean scar
site.MRI report showing a well defined hypointense lesion in the anterior abdominal wall in
theprevious caesarean scar site suggestive of scarendometriosis. Total of three masses were
removed, and scar endometriosis was verified by histology.
Keywords:Cutaneous endometriosis, Endometriosis, Incisional endometriosis, Painful scar, Scar
endometriosis,Post-operative scar.

Introduction condition that may develop at the site of an

abdominal wall incision.
Karl Von Rokitansky first described
endometriosisin the year 1860. This Case presentation
hormone-dependent disorder is characterized
A 30 year old women, Para 2 Live 2,
by the location of the endometrial glands
Previous 2LSCS came to the OPD on 27
outside of the uterus. Women of
May 2024 withcomplaints of pain in the
childbearing age seem to experience this
previous Lscs scar siteduring her cycles.She
more often.Between 0.03% and 1.7% is the
had undergone Lscs 6 yearsback. She
prevalence. Metastasis into cancer is
complained of pain in the scar site on and
uncommon. Scar endometriosis is a frequent
off for 1 yearduring her cycles. Period endometriosis has beenincreasing together
discomfort, she said, intensified across the with the increase of CS incidence. The
right lateral third of her cesarean incidence of endometriosis in womenof
scar.Ultrasound revealed a poorly defined, reproductive age is reported to be around 5–
heterogeneous, hypoechoic mass lesion 15% . AWE (Abdominal wall endometriosis)
under the skin, with dimensions of around
that develops at the site of the surgical
3*2*3 cm. She came with the MRI report
incision after obstetric or gynaecological
showing T2hypointense lesion noted in the
surgeries, including CS (Caesarean section),
anteriorabdominal wall at the scar site
is called scar or incisional endometriosis.
measuring2.5*1.9*1.8cm with no diffuse
The incidence ofAWE after CS is 0.03–1%
restriction.Throughout, she had regular
of women that underwent obstetric or
periods and described experiencing
gynaecological surgeries.
discomfort at the surgery site. She has been
married for ten years, and her first kid is a Usually there is delay in diagnosing AWE,
girl who is now nine years old. Due to her the most common clinical symptoms and
obvious diabetes, she had a caesarean signs areswelling, tenderness on local site,
section during her birth. Given her history and cyclic pain. The most accepted cause is
with LSCS, she has decided to choose to mechanicaliatrogenic implantation.
have the procedure again for her second Endometrial cells are inoculated directly into
child, a girl, who is now six years old. Both the surgical area and canprogress to
are live and healthy.Patienthas not endometriosis in optimal conditions. The
undergone sterilisation. most common treatment options for
scarendometriosis include medical therapy
On examination, a soft non tender
and surgery. We present a case of incisional
nodularswelling was noted measuring
scarendometriosis and followed by
2*1cms just lateralto the midline. The
management and discussion regarding this
patient had uncontrolledblood sugars with
rare case
RBS of 318mg/dl, which wasinitially
managed with careful glycaemic Intra operative images
monitoringand titrating the insulin
levels.She was on Dethroner 100mcg for the
past 5years. Her TSH levels were in a
normal range.
Patient was taken up for endometrial scar
excision on 28 May 2024, intraoperatively
theendometriotic nodule was densely
adherent tothe rectus sheath and the anterior
wall of theuterus, the same released with
1cm free margin.
Endometriosis scars were shown by
histopathology. Highlights areas of
endometrial gland and stroma. Figure 1. Per-operative photograph showing
endometriotic tissue was noted on the
Endometriosis is a common gynaecological subcutaneous plane involving the outer layer of
condition where the endometrial glands and rectus sheath
stromalstructures are found outside the
uterus. Recently, the occurrence of scar
Endometriosis is a common gynaecological diminished natural killer cell immunity
condition that affects the female of causes decreased clearance of endometrial
reproductive age group. cells from the peritoneum [8]. Most of the
Physicalexamination revealed a well- studies have shown left sided predisposition
healedcaesarian scar, with a nonmobile, of iatrogenic endometrioma as seen in our
nodular,moderately pigmented area at its case.
lateralborder (Figure 1). Exquisite point
tendernessto palpation over the nodular area The usual time interval between surgical
was noted.A preliminary diagnosis of procedure and the development of
neuroma wasentertained, and the patient was endometrioma is 3 months to 10 years [9].
taken to theoperating room for exploration Scar endometriosis has been found to occur
of theabdominal wound and possible in surgical procedures like episiotomy,
neuromaexcision. Scar endometriosis hysterectomy, hysterotomy, ectopic
involving the abdominal wall is a pregnancy, laparoscopic gynaecologic
distinctly rare entity, and presents in surgeries, tubal ligation, and
females who have undergone prior caesareansection. Though they may occur as
abdominal or pelvic surgery [1,6]. a consequence of hysterectomy for ovarian
Various theories have been postulated malignancies like ovarian carcinomas, they
regarding the development of scar usually do not occur in no obstetric cyst
endometriosis.Endometriosis is defined as surgeries done during pregnancy [10,11]. In
the presence or growth of ectopic our case, the prior surgical procedure was a
endometrial tissue [2]. Affecting an caesarean section
estimated 89 million women of reproductive
age worldwide, endometriosis occurs in 5%
to 10% of all women, often resulting in
debilitating pain and infertility. Although
most frequently found in the pelvis, reports
citing extrapelvic endometrial locations
range from the lungs to the extremities [3].
Incisional or scar endometriosis has also
been described, however, with a much rarer
incidence (fewer than 1% of affected
patients) [4]. This entity can result in Figure 2. Photograph showing endometriotic
unnecessary procedures, delayed or tissue with chocolate coloured fluid in cross
misdiagnosis, and can cause emotional and section of the specimen.
physical distress to the patient. The present
study describes a case of scar endometriosis,
and reviews the literature to elucidate
physical signs and symptoms that may lead
to earlier diagnosis and prompt treatment.

The most accepted theory is the transport

theory which explains that iatrogenic
implantation of hormone sensitive
endometrial tissue to the edge of wound
during the abdominal or pelvic surgery
followed by hormone mediated changes in
Figure 3. Photograph showing the resected
those implanted tissue causes endometriosis
specimen.
[5,7]. Another hypothesis explains that
Endometriosis is defined by occurrence of These glands are surrounded by stromal
endometrial-like epithelium and stroma cells and hemosiderin laden macrophages.
outside the uterine cavity. This condition is The histopathologic image is shown in
commonly seen in females of reproductive Figure 4. Hence the final diagnosis was
age. Grossly, endometriosis may present as made as an endometriosis of the previous
small, dark red, black or bluish cysts or LSCS scar.In case of inconclusive or
nodules on the surface of peritoneal and doubtful ultrasonography reports, CT/MRI
pelvic organs. Histologically, endometriosis facilitates the diagnosis [12]. CT/MRI
is characterized by the ectopic presence of facilitates the diagnosis in case of large
endometrial-like glands, spindled masses, as they provide the relationship of
endometrial stroma and hemosiderin mass with the surrounding structures [2].
deposition either within the macrophages or Histopathologic studies after the excision is
in the stroma (Figure 2 and Figure 3). In the definitive and confirmatory diagnostic
many cases, this diagnostic triad is not tool. Presence of endometrial glands and
present, or the glands and stroma may be stroma embedded within fibroblasts,
obscured by haemorrhage, foamy cells and collagen fibers and skeletal muscle cells,
hemosiderin-laden macrophages. When this with or without hemosiderin laden
occurs, the diagnosis may be suggested but macrophages makes the diagnosis of scar
histological confirmation may not be endometriosis [13]. Management can be
possible. medical or surgical. It is found that the use
of NSAIDS, progesterone, oral
Histopathology images contraceptive pills, GnRH agonist, and
danazol is not much effective, and gives
only partial relief without curing the lesion
[2]. Compliance to these therapies is also
minimum due to various side effects like
amenorrhea, depression, weight gain,
hirsutism, bone pain, acne, and muscle
cramps. They are also not much used
because of recurrence of the symptoms after
cessation of therapy [14]. Reports have
suggested the intralesional injection of
gorsereline prior to surgical excision
benefits in reduction of lesion size [15]. The
treatment of choice of scar endometriosis is
wide local excision of the lesion with at least
Figure 4. Photograph showing 1 cm margin, in order to prevent recurrence
histopathologic slide of resected specimen [16]. The fascial defect may need closure
showing endometrial glands lined by benign with synthetic mesh, if it is found to involve
endometrial cells. the underlying sheath [17]. Clinicians ought
to be aware of malignant changes that may
Ultrasonography reveals a solid,
occur in long standing recurrent
hypoechoic, inhomogeneous echo texture
endometriosis [18]. The risk of malignant
with internal scattered hyperechoic echoes,
change in caesarean scar is rare, and only
and speculated margins infiltrating the
0.31 % of pfannenstiel incision patients are
surrounding tissue.
reported to have malignant transformation
[19].
The occurrence of this rare entity can be fluctuations in the size of the endometrial
prevented through surgical efforts aimed at implants and the level of discomfort.
minimizing the transfer of the endometrial Endometrial glands and stromal cells outside
tissue into the subcutaneous area. Thorough of the uterus are histologically required for
washing of the wound with saline prior to the diagnosis of endometriosis.
closure, and replacement of the gloves into a
Surgical excision and hormone suppression
new pair of it Fig. 4. Photograph showing
are also part of the management plan.
histopathologic slide of resected specimen
showing endometrial glands lined by benign A temporary alleviation of symptoms may
endometrial cells should be practiced in be achieved with the use of oral
order to avoid the implantation of the contraceptives, progestogens, and
endometrial tissue in the anterior abdominal androgenic drugs. Hormonal suppression is
wall. Repairing of the peritoneum at the time thought to be only partly successful, and the
of caesarean section has also been final therapy is surgical scar removal.
recommended as a preventive measure of
this rare entity [20]. Scar endometriosis has many possible
causes, such as metastases, hematomas,
Post operative period incisional hernias, dermoid tumours, and
suture granulomas.
A course of IV antibiotics were given. The
patient was monitored with cog since they Between 0.3% to 1% of cases have
had type 1 diabetes mellitus and their sugar malignant transformation.
levels are uncontrolled. Physician opinion
The preferred method of therapy is a wide
obtained andinsulin levels titrated.
local excision leaving at least a 1 cm margin
Thromboprophylaxis wascovered with
of freedom. Very seldom does it happen
enoxaparin 0.4ml for 3days. Post operatively
again.
suture removal was doneon POD 12. The
patient was reviewed after 2weeks. Some research suggests that irrigating the
abdominal incision with a high-get NaCl
Discussion (normal saline) solution after surgery may
Rarely does a woman of childbearing age help reduce the risk of scar endometriosis.
get scar endometriosis. Surgical operations When preparing for surgical procedures
involving the uterus or fallopian tubes are (hysterectomy, laparoscopy, caesarean
the most prevalent causes of scar delivery), it is important to keep in mind the
endometriosis. possibility of endometrial cell contamination
of adjacent tissues. Because of the potential
About 0.03% to 0.4% of endometriosis role it may play in the development of scar
instances occur at scar sites. The iatrogenic endometriosis, it is recommended that
transfer of endometrial implants to the patients have cesarean sections without
wound edge during abdominal and pelvic brushing the uterus with gauze.
surgery is the most commonly accepted idea
about the etiology of scar endometriosis, There was no sign of recurrence throughout
although many other hypotheses have been her follow-up, and her menstrual cycle was
advanced. normal and free of dysmenorrhea.

Scar endometriosis may be difficult to Acknowledgements

diagnose. During menstruation, classical
We would like to thank our patient and
endometriosis is characterized by cyclical
colleague in treating this case.
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