Parulekar SV

An abdominal wall mass is usually a general surgical problem. It is not very often that a gynecologist has to address one. However one has to be conversant with the differential diagnosis, so that one does not miss a gynecological cause of such a presentation. Such a lump can be secondary to trauma, infection, neoplasia, or defects in the abdominal wall. Trauma would result in formation of a hematoma. Infections include abscesses – either confined to the abdominal wall or due to communication with an underlying bowel disease adherent to the abdominal wall. A suture granuloma and an injection granuloma are examples of iatrogenic conditions that belong to the infective category. Neoplasms form a large percentage of such masses. Benign neoplasms found in the anterior abdominal wall include a fibroma, lipoma, fibrolipoma, rhabdomyoma, leiomyoma, angioma, neurofibroma, and peripheral nerve tumor. Desmoid tumor is a benign tumor in that it does not metastasize, but it is locally aggressive, and tends to recur after excision. Malignant tumors in the abdominal wall include metastatic disease, lymphoma, and rhabdomyosarcoma. Abdominal wall hernia may occur at different sites. When it becomes irreducible, it may mimic many other conditions producing abdominal wall lumps. Endometriosis is a unique gynecological condition that can be found in the anterior abdominal wall. A hematoma is an acute condition that usually follows trauma. The presence of a coagulopathy predisposes to it. Iatrogenic hematomas follow abdominal surgery, when the hemostasis has not been adequate. It may be found in any layer of the abdominal wall, the subcutaneous tissue and the rectus sheath being the most common ones. It is acute, painful, and associated with features of concealed blood loss. An abscess is another acute painful condition with features of an acute inflammation. Suture granulomas are not very large, usually superficial and easy to diagnose. Injection granulomas are not very common, because the anterior abdominal wall is not a common site for administration of injections. A prior history of an administration of an injection is helpful in making a diagnosis. Benign connective tissue tumors can be found in the anterior abdominal wall as commonly as anywhere else in the body. They have features of such tumors elsewhere. They may be difficult to differentiate from other lesions when they are deep seated. A desmoid tumor tends to arise during a pregnancy or in the scar of a cesarean section. It can occur after trauma or surgery other than a cesarean section too, and with estrogen therapy. It develops from fascia, muscle or aponeuroses. It is locally infiltrative and hence of relative fixity. If the patient has undergone an excision of a tumor at that site and presents with a recurrence, it is more likely to be a desmoid tumor than any other tumor. Breast cancer the most common cancer in a woman that spreads to the abdominal wall, while in a man it is a melanoma. About ten percent of all malignant tumors develop superficial soft tissue metastases. Lymphomas are also known to be found in the anterior abdominal wall. Iatrogenic spread of this type is seen following implantation of malignant cells during abdominopelvic surgery for a malignancy. Anterior abdominal wall hernias can be diagnosed easily when they are reducible – by both expansile impulse on coughing and reducibility. When irreducible, past history of reducibility helps in diagnosis. If not, they mimic benign tumors and need help with imaging techniques for diagnosis. Obstructed and strangulated hernias need urgent surgical care. Clinical history, associate intestinal obstruction, local acute condition and general toxicity, along with imaging clinch the diagnosis. Abdominal wall endometriosis is a condition that can be diagnosed clinical with almost 100% accuracy. It usually follows a cesarean section or a hysterotomy, sometimes any other operation in which the endometrium has been opened. It may be associated with mullerian duct anomalies of obstructive type, associated with intraabdominal and pelvic endometriosis. The lesions may be superficial or deep, usually fixed due to local infiltration and inflammation leading to fibrosis. The lesions are painful with menstruation. They enlarge and become tender during menstruation. A hemogram helps suspect inflammatory conditions. Imaging techniques like ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI) are extremely useful in making a diagnosis. In this issue, we have two interesting cases, one of a rectus sheath leiomyoma, and the other of extensive endometriosis. I hope the readers enjoy reading about those.