Small Bowel Obstruction Caused by Ileal Endometriosis with Appendiceal and Lymph Node Involvement Treated with Single-Incision Laparoscopic Surgery: A Case Report and Review of the Literature

Abstract

BACKGROUND Endometriosis is an ectopic proliferation of endometrial glands and interstitium outside the uterus. It usually affects the organs surrounding the uterus, and less often, involvement of extrapelvic organs, such as the intestines and urinary tract, is observed. CASE REPORT A 40-year-old woman had been experiencing intermittent right lower abdominal pain for years, which worsened months earlier. The patient was admitted for the worst pain ever accompanying nausea and vomiting. Contrast-enhanced computed tomography revealed a heterogeneously enhanced lesion that measured approximately 50×25×35 mm, and a caliber change of the ileum at the same site with dilated small bowel proximal to the caliber change were observed. Colonoscopy revealed that the ileocecal valve and the lumen of the terminal ileum protruded inward, suggesting an extramural compression by the lesion. Since the patient showed no improvement following conservative therapy, bowel resection through a single-incision laparoscopic surgery was successfully performed. Histopathological exploration showed patchy infiltration of endometrium-like tissues in the muscularis propria and subserosa layers of the ileum and appendix. Moreover, nearby lymph nodes resected for their firmness showed similar findings. CONCLUSIONS We report a case of recurrent intestinal obstruction due to ileal and appendiceal endometriosis with lymph node involvement, which was successfully treated by single-incision laparoscopic surgery. Careful follow-up is important because the prognosis for the intestinal endometriosis with lymph node involvement is still unclear.

Figure 1.

(A, B) Contrast-enhanced computed tomography (CT) findings. Abdominal contrast-enhanced CT revealed a heterogeneously enhanced lesion with cystic content, which measured approximately 50×25×35 mm (arrowhead). The caliber change of the ileum at the same site and dilated small bowel proximal to the caliber change were observed. No dilated lymph nodes were found. A polycystic lesion was found in the right ovary, confirming the previously diagnosed right chocolate cyst (arrow head). No other intrapelvic lesion or ascites was detected.

Figure 2.

Colonoscopy findings. Colonoscopy showed no epithelial lesion in the terminal ileum and the cecum, but the ileocecal valve and the lumen of the terminal ileum seemed to be rather protruded inward, suggesting compression by the extramural lesion. The appendiceal orifice could not be discerned.

Figure 3.

Intraoperative findings. The right ovary was enlarged. No other abnormalities were observed in the pelvis (A). The lesion responsible for the bowel obstruction was located at the terminal ileum, forming a solid mass (B). The small white lesion was attached to the serosa (C), which was resected together with the mass. The abdominal scar was minimal and aesthetically satisfactory (D).

Figure 4.

Macroscopic findings of the resected specimen. The resected specimen showed a solid mass that involved the terminal ileum and appendix. The lumen was clear, with no epithelial lesion (A). Histopathology revealed patchy distribution that showed infiltration of endometrial tissues (B).

Figure 5.

Histopathological findings. In the ileum (A, B) and appendix (C, D), gland formation having similarity with tissues of the endometrial glands and interstitium in the muscularis propria and subserosa was observed. The white scar on the serosa of the ileum (E, F) and the picked-up lymph nodes (G) showed similar findings (hematoxylin and eosin staining: A, C, E: ×20; B, D, F, G: ×100).