Bijapur S*, Panchbudhe S**, Parulekar SV***.
(* Third Year Resident, ** Assistant Professor, *** Professor and Head, Department of Obstetrics and Gynecology, Seth G S Medical College & K E M Hospital, Mumbai, India.)
Cesarean scar endometriosis is a rare presentation of extra pelvic endometriosis. Usually, it presents as a triad of underlying mass at the incision site, cyclical menstrual scar site pain and history of previous gynecological or obstetric surgery leading to the diagnosis. We report our experience in managing cesarean scar endometriosis and highlight the diagnosis and treatment options.
Endometriosis at the site of previous surgery scar is increasing now-a-days, mainly due to increased rate of cesarean sections. Cesarean scar endometriosis (CSE) is an unusual manifestation of extra pelvic endometriosis, reported to be 0.03 – 0.45% in women undergoing cesarean sections. Endometrial cells are implanted directly into the surgical site and can progress to endometriosis in optimal conditions. Here we discuss a case of scar endometriosis developing in the scar of previous cesarean section, 2 years after the primary surgery.
A 36 year old woman, married for 18 years, para 1 living 1, with previous lower segment cesarean section (LSCS), presented to the outpatient department with complaints of lump and pain over the scar of previous LSCS for 1 year, the pain being dull aching and increasing during menstruation. She had undergone LSCS 2 years back, in view of meconium stained amniotic fluid. Operative notes showed that the procedure was uneventful. Thea patient also gave history of undergoing diagnostic hystero-laparoscopy 3 years back in view of primary infertility. Operative notes were not available. Her general and systemic examination findings were normal. On local examination, a healthy Pfannenstiel scar of LSCS was noted. There was a firm, minimally tender lump of around 2x3 cm close to the left angle of the Pfannenstiel scar, which was subcutaneous in origin. There was another 2X2 cm mass on the right side near the end of the scar. On speculum examination, her cervix and vagina were healthy, and bimanually uterus was anteverted, normal sized, with clear fornices. Ultrasonography done showed features suggestive of scar endometriosis, around 2.6X2 cm in the subcutaneous plane at the scar site in lower abdomen. Her investigations for fitness for anesthesia showed normal results. She was posted for excision of scar endometriosis.
Transverse incision was taken over the skin near the previous Pfannensteil scar and subcutaneous tissue reached. A firm, nodular mass of around 3X2 cm found near upper margin of left side of the incision. It was excised en-mass by sharp and blunt dissection, along with a small part of surrounding normal tissue to ensure complete removal and sent for histopathological examination. The mass extended into the rectus sheath, hence part of rectus sheath was also excised. Similar procedure was repeated on right side for nodule of 2X2 cm, found near the right end of scar. The cut section of the mass showed chocolate colored fluid. The defect in the rectus sheath was closed with a polypropylene mesh of 6X2 cm with intermittent sutures of No. 1-0 polypropylene and then subcutaneous tissue and skin were closed. Postoperative course was uneventful. Histopathology report was suggestive of endometriosis. The patient was offered injection leuprolide depot for 6 months for ovarian axis suppression.
Figure 1. Clinical appearance of the lesion. The extent of the endometriosis is shown by arrows.
Figure 2. Intraoperative appearance of the lesion.
Figure 3. Polypropylene mesh is being sutured to the edges of the defect in the rectus sheath.
Endometriosis is defined as occurrence of functioning endometrial tissue, including glands and stroma outside the uterine cavity. It is most commonly seen on peritoneum, surface lining of the pelvic cavity, ovaries, posterior cul-de-sac, and uterosacral ligaments. In very few cases, implants of endometriosis can occur outside the pelvis, called as extra pelvic endometriosis. It is mainly seen in women of reproductive age.
The pathogenesis of scar endometriosis is believed to be the result of mechanical iatrogenic implantation, by direct inoculation of the abdominal fascia and/or subcutaneous tissue with endometrial cells during surgical procedures like cesarean sections, hysterectomies, tubal ligations, ovarian cystectomies and amniocenteses, which, stimulated by estrogen, become active and expand. The most prominent risk factor for the presence of endometriosis in scar tissue is previous history of obstetric surgical procedures.
The presence of hormone-sensitive tissue under the skin explains the clinical features including cyclic pain, swelling and blood-like brown leakage during menstruation (found only during surical excision, since the lesion usually does not communicate with outside). Pain, either cyclical or noncyclical, is the most common major symptom, reported by more than 80% of patients. With respect to imaging, ultrasound is the most reliable imaging tool for the diagnosis of CSE, providing a differential diagnosis of incisional hernia, abscess, hematoma, cyst or lipoma in most cases. It can also help reveal deep infiltration guiding the surgical excision. Computed tomography or magnetic resonance imaging are rarely needed. Fine needle aspiration cytology (FNAC) is a cost-effective, and accurate diagnosis tool to be included in the diagnostic tests.
Therapeutic management is essentially based on wide surgical excision, with clear margins and reconstruction of affected tissue and is the one overly recommended. Medical treatment with hormone suppression has been tried but recurrence is common. Recently, there have been reports of the use of the gonadotrophin agonist (leuprolide acetate), found to provide only prompt improvement in symptoms with no change in the lesion size. Follow up of endometriosis patients is important because of the chances of recurrence and possibility of malignancy. Using a good technique and taking proper care while performing a cesarean section may help prevent scar endometriosis.
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Bijapur S, Panchbudhe S, Parulekar SV. Cesarean Scar Endometriosis. JPGO 2019. Vol 6 No. 2. Available from: https://www.jpgo.org/2019/01/cesarean-scar-endometriosis.html