Medical case presentation on a rare topic- Caesarean scar endometriosis.

1. Wide excision of Scar
Endometriosis in a case of Previous
Caesarean Section.
DR. MUKULIKA SHARMA
JR III, DEPT OF OBGY
KEM HOSPITAL
DR. ADITI PHULPAGAR
HOU, DEPT. OF OBGY
KEM HOSPITAL
DR. GAURAV DESAI
AP, DEPT. OF OBGY
KEM HOSPITAL
DR. SALONI
ZUNZUNWALA
SR, DEPT. OF OBGY
KEM HOSPITAL

2. INTRODUCTION
Endometriosis is a common benign gynecologic disease during the
reproductive age due to ectopic proliferation of endometrial tissue under the
influence of feminine hormones outside the uterine cavity. Its symptoms
include menstrual pain, pelvic pain, dyspareunia, and infertility.
Usually endometriosis develops in the uterine adnexa, but sometimes it
occurs in an extrapelvic location such as the intestine, lung, liver, pleura, and
skin.
Cutaneous involvement is less than 1% of all cases of endometriosis, and in
most cases of such involvement it is found on obstetric and gynecologic
surgical sites of the abdomen or perineum following hysterectomy,
hysterotomy, Cesarean section, perineotomy, or laparoscopy.

3. CASE REPORT
History & Clinical findings:
A 28-year-old female presented with-
•Dull aching pain In lower abdomen (on & off) since 3 months
•Swelling over previous caesarean scar site since 3 months
•Irregular menstrual cycles since 3 months
She had a history of 2 Caesarean Sections between 2014-2016.
Medical history included Pulmonary Kochs, treated with AKT in 2014.
Patient BMI: 22 kg/m2
Local examination- 6*7cm tender, firm, ballotable mass over the left side of
suture line, arising from anterior abdominal wall.

4. Investigations:
•USG Local- A well defined heterogeneously hyperechoic
lobulated lesion measuring 6.3*4.4*7cm in the left rectus muscle
underlying the LSCS scar site. There are multiple cystic areas in
the periphery of the lesion with central echogenic areas and mild
vascularity suggesting of Scar Endometriosis.
•USG guided FNAC- revealed endometrial lining cells.
•All routine blood investigations were within normal limits.

5. Treatment:
Wide excision of Scar endometriosis tissue with bilateral Tubal ligation was done
under Spinal Anaesthesia.
7*5*3cm mass involving the subcutaneous tissue, rectus muscle, rectus sheath
and peritoneum was excised. Omentum
was adherent to the mass and
to anterior uterine surface. Adhesiolysis was done.
Mini abdomino-plasty performed and rectus
sheath reconstructed with non-absorbable
Ethilon no. 1 using continuous interlocking sutures.
Post-operatively patient was given i.v. antibiotics,
abdominal binder, stool softeners, cough
suppressants & 3 doses of Inj Leuprolide.

9. ■Scar endometriosis is a rare entity. Incidence estimated to be only 0.03% to
0.15% of all cases of endometriosis.
■Most generally accepted theory is the iatrogenic transplantation of
endometrial implants to the wound edge during an abdominal or pelvic
surgery. Spontaneous endometriomas may occur due to lymphatic or
hematogenous spread.
■Risk factors- Hysterectomy, C-section before onset of labour or
Hysterotomy before 22weeks, heavy menstrual blood flow, alcohol
consumption, Pfannenstiel vs Midline scar.
■Common clinical symptoms and signs are swelling, tenderness on local
site, and cyclic pain.
DISCUSSION

10. ■Differential diagnoses- incisional hernia, primary or metastatic tumor,
lymphoma, sarcoma, lipoma, abscess, sebaceous cyst, neuroma and
suture granuloma.
■Diagnostic tools include ultrasound, computed tomography, magnetic
resonance imaging, fine needle aspiration biopsy, and serum CA-125.
■Medications- combined oral contraceptive, progesterones, danazol,
gonadotropin-releasing hormone agonists, aromatase inhibitors, and
androgens can be used for decidualization, atrophy of endometrial
tissue, and relieving pain.
■Gold-standard: Wide excision + Reconstruction (Mini-Abdominoplasty),
with/without mesh placement.

11. ■Delayed excision- Mild symptoms & patient plans to conceive future
pregnancy.
■Wound complications such as dehiscence, hematoma, seroma, and
hypertrophic scar; asymmetry of the abdominal wall or dog-ear deformities
could also occur.
■Preventive measures- Used sponge/mop to be discarded, different sutures
for uterus & abdominal wall, saline irrigation before abdominal closure,
sucking out & washing endometriomas before ovarian cystectomy.
■Follow up- Chances of recurrence & need for re-excision, Possibility of
malignancy & rapid fatality, concomitant pelvic endometriosis.

12. CONCLUSION
•Cutaneous Caesarean section scar endometriosis may be caused
by Iatrogenic inoculation of endometrium into the surgical
wound.
•It is currently regarded as a rare entity. However, in the light of
rising C-section, it may become more common.
•So, it is highly recommended that during obstetrical &
gynecological operations, precautions should be practiced.

13. REFERENCES
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