Abdominal Wall Endometriosis Postcesarean Section: Diagnosis, Surgical Management, and Case Study of Extensive...

Endometriosis involves ectopic endometrial tissue outside the uterus, commonly in the pelvis but sometimes affecting organs like the urinary tract, gastrointestinal system, and respiratory tract. Abdominal wall endometriosis (AWE) is a rare subtype where endometrial tissue infiltrates the abdominal wall, often occurring secondarily in surgical scars, particularly after cesarean sections. Diagnosing AWE is difficult due to varied symptoms and locations, making imaging techniques such as ultrasound and MRI crucial for evaluation. Preoperative assessment is vital to determine the extent of tissue invasion, especially if large muscles, the peritoneum, or bowel are involved, which may require general surgical intervention.

A 43-year-old woman with a history of three cesarean sections presented with menorrhagia, chronic pelvic pain, and a palpable lump above her cesarean scar. Ultrasonography revealed a hypoechoic irregular mass measuring 39 × 34 mm in the linea alba above the cesarean scar, extending into the peritoneal cavity and adherent to the uterine body. Surgical wide excision of the mass was attempted, but due to its extension and severe adhesion to the uterus, complete excision with clear margins was not possible. So, a total hysterectomy with bilateral salpingo-oophorectomy was performed.

AWE mainly results from iatrogenic implantation of endometrial cells, particularly following cesarean sections, though lymphatic spread and metaplasia are also possible causes. It typically presents as a painful abdominal mass with symptoms like localized pain, swelling, bruising, bleeding, intermittent pelvic pain, and reduced fertility. Diagnosis is primarily made via abdominal and transvaginal ultrasound, with MRI used in uncertain cases. Medical treatments such as oral contraceptives, progesterone, danazol, and GnRH agonists offer only partial symptom relief without curing AWE. The definitive treatment is wide local surgical excision with at least 1 cm margins to prevent recurrence or rare malignant transformation. When the fascia and muscle are involved, or defects exceed 50 mm, fascia mobilization and polypropylene mesh placement may be necessary. In malignant or extensive cases, complete hysterectomy with bilateral salpingo-oophorectomy may be indicated. Preventive surgical measures during cesarean sections include gentle uterine handling, bleeding control, high-pressure saline irrigation before closure, avoiding dead spaces, use of wound protectors, thorough abdominal wall cleaning, specimen retrieval bags, and employing new needles and sutures to reduce AWE risk.

AWE is a rare condition with unclear causes, increasingly relevant due to rising cesarean and obstetric procedures. Diagnosis relies on clinical assessment, patient history, ultrasound, and MRI. The primary treatment is wide surgical excision, which may be more extensive for large or complex lesions, with careful follow-up to monitor for recurrence.