Symptomatology and Surgical Perspective of Scar Endometriosis

Scar endometriosis: symptomatology and surgical perspective

Key Points

Highlights:

• Scar endometriosis is a rare form of endometriosis due to direct inoculation of endometrial tissue, most commonly following cesarean section and uterine/pelvic surgical procedures.

Importance:

• The incidence of scar endometriosis is increasing because of increasing cesarean deliveries and laparoscopic procedures for pelvic endometriosis.
• Patients with scar endometriosis usually present with cyclical pain, purplish/brownish colored swelling or tender swelling at the site, bleeding from the swelling and dysmenorrhoea

What’s done here?

• A retrospective study conducted by Dr.Sumathy et al. in a group of 16 patients who underwent surgery for scar endometriosis.
• The aim is to describe the symptomatology of the lesions and to analyze the surgical aspect of the disease.

Key results:

• The mean age was 35.19 years (range 25–49), and the average interval from the index surgery to local pain was 4.56 years. 18.9% of patients had concurrent pelvic endometriosis.
• The symptoms were variable: scar site cyclical or noncyclical pain, purplish/brownish swelling or tender swelling at the scar site, bleeding from the swelling and dysmenorrhoea.
• Pain could be present also after menopause, usually without cyclicity. 
• While ultrasound can be used in the diagnosis of subcutaneous lesions and the differential diagnosis of other pathological conditions (for example an abdominal wall hernia), magnetic resonance imaging (MRI) is necessary to assess the extent of the lesions beyond the subcutaneous plan, to plan an appropriate surgical intervention.
• A wide surgical removal of the scar, with or without postoperative hormonal treatment, represent an effective treatment method, preventing recurrence of the lesions.

Lay Summary

Scar endometriosis is a rare condition that occurs as a consequence of iatrogenic implantation of endometrial tissue following cesarean section, vaginal delivery with episiotomy, laparotomy for hysterectomy, tubectomy, ectopic pregnancy surgeries, appendectomy, hernia repair sites; interestingly it can also occur in the needle tract after amniocentesis.

The incidence is increasing because of increasing number of cesarean deliveries and laparoscopic procedures performed for treatment of pelvic endometriosis.

Dr. Sumathy and colleagues conducted a retrospective study in a group of 16 patients who underwent surgery for scar endometriosis, to describe the symptomatology of the lesions and to analyze the surgical perspective of the disease.

The mean age of patients affected by scar endometriosis involved in the study was 35.19 years (range 25–49) and mean interval from the index surgery to local pain was 4.56 years.

Symptomatology was variable: patients manifested scar site cyclical pain, noncyclical pain, purplish/brownish colored swelling or tender swelling at the scar site, bleeding from the swelling and dysmenorrhoea. Pain could be present also after menopause, usually without cyclicity. 18.9% of patients had concurrent pelvic endometriosis. In all of the patients in this study, subcutaneous tissue involvement was detected; also, in a large proportion,  rectus sheath involvement was observed too.

Ultrasound can be used in the diagnosis of subcutaneous lesions and the differential diagnosis of other pathological conditions like an abdominal wall hernia, MRI is necessary to plan an appropriate surgical intervention.  "A wide local excision with or without reconstruction of the abdominal wall is the management of choice. Role of tumescent solution during surgery and postoperative medical management in reducing the recurrence needs further prospective studies" concluded the authors.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/28546671