Subcutaneous Abdominal Wall Iatrogenic Endometriosis: A Case Report

Summary
A relatively healthy 37-year old woman was referred to the Obstetric and
Gynecology Clinic due to swelling in her lower abdomen which had become progressively
more uncomfortable over the past month. A preliminary diagnosis of borderline bilateral
ovarian cysts was made. An exploratory laparotomy was performed, revealing bilateral cystic
ovarian mass and a lower left abdominal subcutaneous mass. Histopathology results of both
ovarian cysts and subcutaneous mass confirmed the diagnosis of chocolate cysts and external
endometriosis.

Background
Endometriosis is defined as the presence of the endometrium outside the uterine
cavity accompanied by chronic inflammation. 1 Endometriosis typically presents as chronic
infertility and pain. Its incidence is reported to be approximately 10% of women of
reproductive age, with peak incidence in the period between 25 and 45 years of age. 2
Currently, endometriosis remains a “mysterious” disease with unclear pathophysiology.
Possible etiological factors include congenital, environmental, epigenetic, autoimmune and
allergic.1 Patients with endometriosis are also at greater risk of infertility, emergence of
fatigue, multisite pain, and other comorbidities. Debilitating pain and the associated
dysfunction of the body worsen the quality of life. In cases where there is no clear cause or
medication, the disease can be chronic and recurrent.3
We reported the case of a 37-year-old girl who presented with lower abdominal mass
progressing over a year. Contrary to the usual manifestation of chronic infertility and pain,
her sole symptom was abdominal swelling and discomfort over the past month.

Case Presentation
We report a rare case of a 37-year old woman seen in consultation for swelling in her
lower abdomen which had become progressively more uncomfortable over the past month.
She denied any post coital bleeding, vaginal bleeding and discharge. Patient’s menstrual
cycle was otherwise normal. She had her menarche at the age of 12. Her obstetric history
includes one vaginal birth and a caesarean section. She was on monthly injected
contraception. Patient’s vital signs were normal and she was afebrile. Her BMI was
normoweight (23.14 kg/m2). Physical examination revealed cystic abdominal mass, five
fingers above the umbilicus with limited mobility. Lab results showed mild anemia, with
hemoglobin of 10.6 mg/dL and elevated CA-125 of 204.1. To better characterize the lower
abdominal mass, non-contrast lower abdominal-pelvic MRI was performed. This
demonstrated pathological lesions on the right parametrium, relatively rounded shape, firm
borders, regular edges, with size of AP 9.9 x LL 15.3 x CC 11.7 cm and on the left lumbar
region, relatively rounded shape, firm borders, regular edges, size of AP 10.8 x LL 16.3 x CC
15.2 cm. Both lesions were hyperintense on T1W and were on T2W. It was unclear whether
both lesions originated from the ovaries. A preliminary diagnosis of borderline bilateral
ovarian cyst was made.

Treatment
We planned to perform a laparotomy unilateral salpingo-oophorectomy and
contralateral cystectomy, frozen section and complete surgical staging. An incision of linea
mediana until two fingers below the umbilicus was made. Accumulation of fluid inside the
peritoneal cavity was identified. 50 cc of ascites fluid was sent for frozen biopsy and no
malignant cells were identified. The uterus measured 6x6 cm, the posterior part had
adhesions with a mass and sigmoid colon, adhesiolysis was done. An impression of deep
infiltrating endometriosis was made. Bilateral fallopian has normal shape and size. The left
ovary appeared to be a cystic mass with solid parts measuring 15x15x10cm, forming
adhesions with the sigmoid Colon and pelvic wall, adhesiolysis was done. We decided to
decompress the mass and 1500 cc of brown slurry fluid came out, which concluded a
chocolate cyst. Left salphingo-oopherectomy was done and sent for frozen biopsy.
The right ovary appeared to be a cystic mass, measuring 10 x 10 x 8 cm, with
adhesions to the sigmoid Colon and pelvic wall, adhesiolysis was performed. We decided to
decompress the mass and 1200 cc of brown slurry fluid came out, concluding a chocolate
cyst. It was decided to perform a partial right oophorectectomy. Ovarian tissue was separated
from cyst tissue, cyst capsule was seen and sent for pathology. The remaining healthy right
ovary was sutured.
There were adhesions of the anterior uterine wall to the peritoneum, adhesiolysis was
done and an anterior wall uterine myoma was identified, measuring 1x1 cm. Myomectomy
was performed.
Identification and exploration of lower left abdominal mass revealed a subcutaneous
mass. It was decided to excise the subcutaneous mass measuring 3x4 cm lying on a fascial
base. The base of the tumor was sutured using an unlocked thread. The abdominal cavity was
washed with normal saline and abdominal wall was sutured in all layers. Post-operation
diagnosis was bilateral chocolate cyst, deep infiltrating endometriosis and grade 3-4 adhesion
post laparotomy left salphingo-oophorectomy, myomectomy, abdominal subcutaneous mass
excision, adhesiolysis. Patient was then closely observed at the ward and given intravenous
antibiotics and pain killers.

Figure 1. Surgical documentation. (a)

Outcome and Follow Up

Patient recovered well after the surgery. Histopathology results revealed the right
ovarian cyst capsule was an external endometriosis. The left ovary was confirmed to be a
chocolate cyst. The left fallopian tube was congested with blood vessels. The uterine myoma
was concordant for a leiomyoma. The subcutaneous tumour also appeared to be an external
endometriosis. Ascites fluid cytology was negative for malignant cells. The FNAB (Fine-
Needle aspiration biopsy) of the left inguinal skin region revealed no malignant cells,
consistent to a fibrotic tissue.
Discussion
The overall reported incidence for endometriosis is difficult to quantify, as most
women are asymptomatic. Furthermore, imaging modalities have low sensitivities for small
implants, thus making the gold standard diagnosis is laparoscopy, with or without biopsy for
histologic biopsy. Using this standard, the annual incidence of surgically diagnosed
endometriosis was 1.6 cases per 1000 women aged between 15 and 49 years. Among
asymptomatic women, the prevalence of endometriosis ranges from 6 to 11 percent,
depending on the population studied and mode of diagnosis.4
Endometriosis has a wide variety of presentations and comorbid conditions (Figure 2).
Endometriosis often presents with chronic pelvic pain (cyclical and non-cyclical), painful
periods (dysmenorrhea), painful sex (dyspareunia), and pain on defecation (dyschezia) and
urination (dysuria). Patients present with ranging severity, from mild to debilitating. Some
are asymptomatic, others have episodic pelvic pain, and still others experience constant pain
in multiple body regions. In accordance with other chronic pain conditions, women with
endometriosis often report experiencing fatigue and depression. 5 Infertility is significantly
more common in patients with endometriosis, with a doubled risk compared with women
without endometriosis. Endometriosis is discovered in 30-50% of women who present for
assisted reproductive treatment.6

Figure 2. Endometriosis manifestations and comorbid conditions.5

 Most endometriosis is found within the abdominal cavity, and it exists as three
subtypes: superficial peritoneal endometriosis (accounting for around 80% of endometriosis),
ovarian endometriosis (chocolate cysts or “endometrioma”), and deep endometriosis (Table
1).7 Deep infiltrating endometriosis (DIE) is the infiltrative form that involve vital structures
such as bowel, bladder, and ureters. Some define DIE as invasion of >5 mm. 4 Extra-
abdominal endometriosis is used to describe any endometriosis lesions found outside of the
abdomen (for example, thoracic endometriosis). Iatrogenic endometriosis describes
endometriosis thought to be arising from direct or indirect dissemination of endometrium
following surgery (for example, cesarean scar endometriosis). All forms of endometriosis can
be found together, not solely as separate entities. 7
Some individuals with abdominal pain can have anterior abdominal wall
endometriomas. Most of these lesions develop iatrogenically in the abdominal scar after
uterine surgery or cesarean delivery. Implants usually are found within the subcutaneous
layer, are palpable, and may involve the adjacent fascia. Less often, the rectus abdominis
muscle is infiltrated. In most instances, implants are surgically excised for pain relief and
diagnosis.4 In our case, endometriosis presents as chocolate cyst and deep infiltrating
endometriosis. The left lower abdominal subcutaneous mass could be classified as iatrogenic
endometriosis, as patient had a history of caesarean section.

Superficial Endometrium-like tissue lesions involving the peritoneal surface

peritoneal with multiple appearances
endometriosis
Ovarian Endometrium-like tissue lesions in the form of ovarian cysts
endometriosis containing endometrium-like tissue and dark blood-stained fluid
(endometrioma or “chocolate cysts”)
Deep endometriosis Endometrium-like tissue lesions extending on or infiltrating the
peritoneal surface (usually nodular, invading into adjacent
structures, and associated with fibrosis)
Extra-abdominal Endometrium-like tissue outside the abdominal cavity (for
endometriosis example, thoracic, umbilical, brain endometriosis)
Iatrogenic Direct or indirect dissemination of endometrium following surgery
endometriosis (for example, cesarean scar endometriosis)

Table 1. Endometriosis Nomenclature.7

 Women with endometriosis have a greater risk of presenting with other non-malignant
gynecologic diseases, including leiomyoma and adenomyosis. They are also at greater risk of
a subsequent diagnosis of malignancies, autoimmune diseases, early natural menopause, and
cerebrovascular and cardiovascular conditions. The hypothesized causal mechanisms for
endometriosis discussed below are all thought to be enhanced by and/or result in chronic
inflammation. Furthermore, endometriosis induced chronic inflammation and immune
dysregulation may also contribute to the endometriosis associated subsequent risk of each of
these comorbid conditions.5
Although the exact pathophysiology of this disease is still a mystery. The most likely
explanation is the reflux of endometrial tissue fragments/cells and protein rich fluid through
the fallopian tubes into the pelvis during menstruation. Additional postulated origins include
celomic metaplasia and lymphatic and vascular metastasis.5
Although endometriosis has a wide range of presentations, steps can be recommended
for decision making to approach a “working diagnosis” of probable endometriosis, implement
treatment to remediate endometriosis associated symptoms, and consider multi-specialty
collaboration for treatment. (Figure 3).5

Figure 3. Flowchart for approach to patient with suspected endometriosis.5

 Surgical excision is generally considered the optimal treatment for ovarian
endometriosis. Cystectomy, instead of drainage and coagulation, is the preferred surgical
approach as it reduces recurrence of endometrioma and endometriosis associated pain.
Cystectomy should be chosen with caution for women who desire fertility, as a risk of
fertility affecting diminished ovarian reserve exists, and a highly skilled conservative
approach should be applied to minimize ovarian damage. 8 For DIE, complete excision is
considered to be the treatment of choice with clinically and significant reductions of
symptoms.5
The clinical improvement using hormonal treatment observed for endometriotic
implants at other sites has not been observed for abdominal wall endometriosis. Treatment of
choice for abdominal wall endometriosis is considered to be wide surgical excision with at
least a 1cm margin with patch grafting of the defect.9

Conclusions
Endometriosis is a widely prevalent gynecologic disease with a variety of
presentations. Stigma around menstrual health and chronic pain remain a universal barrier to
healthcare access. Increasing gynecologic and obstetric surgery can further increase the
prevalence of iatrogenic endometriosis. Early diagnosis and prompt treatment can
significantly improve quality of life.

Learning points
1. Endometriosis might not present with chronic infertility and pain.
2. Most imaging modalities have low sensitivities for small endometriosis implants.
3. Consider diagnostic laparoscopy for patients with chronic pelvic pain.
4. Symptomatic patients with history of obstetric and gynaecologic surgery should be
assessed for iatrogenic endometriosis.

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