Spontaneous abdominal wall endometrioma: A case report

Abstract

Introduction: The abdominal wall is the commonest site of extra pelvic endometriosis (endometrioma), defined as the presence of functional endometrial gland and stroma outside the uterine cavity. Spontaneous abdominal wall endometriosis (AWE) represents an ectopic functional endometrial tissue situated superficial to peritoneum in a scar less abdomen. Spontaneous AWE is rare, accounting for 20% of all abdominal wall endometriosis. It is unfamiliar to general surgeons because of a large number of potential pitfalls in its diagnosis.

Clinical presentation and intervention: We report a case of spontaneous abdominal wall endometriosis (endometrioma) presenting to our general surgery clinic with a painful nodular mass in hypogastric area below umbilicus. The initial diagnosis was a desmoid tumour of the anterior abdominal wall. Pain was a remarkable complaint in our patient. Abdominal wall endometrioma was diagnosed by histopathology postoperatively. Excision planned, during operation, one mass was spotted and excised within healthy limits. Histopathology revealed: endometrial glands surrounded by mantle of endometrial stroma, few scattered hemosiderin laden macrophages and fibrous scar tissues. Our patient had no previous scar. She was discharged from hospital on 5th postoperative day uneventfully. (On account of uncontrolled DM and Hypertension). One year of follow up after the surgery, she is free from disease and no recurrence has been observed.

Discussion: Endometriosis is characterised by the presence of endometrial glands and stroma outside the uterine cavity with the maximum prevalence reported in the 4th decade of life. Most cases of spontaneous endometriosis occur in a scar less abdomen. Multiple imaging techniques have been used and described for its diagnosis. The alleged aetiopathogenesis of spontaneous endometrioma is still debatable. It is usually diagnosed by the histopathology and the preferential treatment in cases of endometrioma is total excision of the mass. The hormonal therapy can be added to surgical excision if there is proven pelvic endometriosis. The surgical excision should be wide enough to prevent its recurrence.

Conclusion: Spontaneous abdominal wall endometriosis is an extremely rare gynaecological entity, accounts for 18-20% of all abdominal wall endometriosis. The diagnosis of abdominal wall endometrioma is hardly established prior to surgery. The triad: mass, pain and cyclic symptom aids in diagnosis, unfortunately cyclic symptom is not present in all cases (as in our case). Spontaneous abdominal wall endometrioma is usually diagnosed by high index of clinical suspicion and histopathology. The results of imaging techniques are nonspecific. It may pose a diagnostic dilemma due to its rarity and atypical presentation. The preferential treatment of choice is wide excision.

Keywords: Abdominal wall; Endometrioma; Hormone therapy; Mass lesion; Spontaneous endometriosis; Wide excision.

Fig. 1

Endometrioma in parietal wall of abdomen.

Fig. 2

Resected endometrioma: cut surface consists of dense tan-white, rubbery tissue with focal haemorrhage and multiple cystic spaces.

Fig. 3

Haematoxylin and Eosin Stain 10× (Low Power): Endometrial glands surrounded by endometrial stroma embedded in dense abdominal fibrous tissues.

Fig. 4

Endometrial stroma and endometrial glands with signs of intra-glandular haemorrhage. Occasional haemosiderophages seen. Haematoxylin Eosin stain. Magnification: 40× (High Power).

Fig. 5

Scanner view: Endometrial glands and stroma embdded in dense fibrous tissue (Haematoxylin and Eosin Stain).