Umbilical Mass Due to Endometriosis: A Rare Localization
Hüseyin Bilge1, Ömer Başol1 and Hakan
Akelma2*
1Gazi Yaşargil
Training and Research Hospital, General Surgery Clinic, Diyarbakir, Turkey
2Gazi Yaşargil
Training and Research Hospital, Anesthesiology and Reanimation Clinic,
Diyarbakir, Turkey
*Corresponding author: Hakan Akelma, Department of Anesthesiology, Gazi Yaşargil Training and Research
Hospital, Anesthesiology and Reanimation Clinic, Diyarbakir 21010, Turkey. Tel:
+90-4122580071; Fax: +90-4122230067; Email: hakanakelma@hotmail.com
Received Date: 13 August, 2019; Accepted
Date: 26 August, 2019; Published Date: 30 August, 2019
Citation:
Bilge H,
Başol Ö, Akelma H
(2019) Umbilical
Mass Due to Endometriosis: A Rare Localization. J Surg 4: 1246. DOI:
10.29011/2575-9760.001246
Objective:
Endometriosis is rarely seen in the anterior abdominal wall. Cyclic pain and
previous gynecological operations help us in preoperative diagnosis. Although
it is most frequently seen in the phannensteil incision line, it may be
atypically located far from the incision. Here, we describe atypical localized
endometriosis operated for umbilical mass in our clinic.
Case Presentation:
The patient who was 45-year-old, gravida three, parity three, had a history of
myomectomy four years ago due to a phannensteil incision for myoma uteri. The
patient's USG showed an echogenicity of approximately 22×14 mm in size under
the skin. The operation was performed to exclude the mass in the umbilical
region. Histopathological diagnosis of the mass was reported as findings
consistent with endometriosis.
Conclusion:
The history of the patient's gynecological operation is typical. However,
localizations outside the incision line are atypical. It should be kept in mind
that endometriosis may occur even in patients with cyclic pain and previous
gynecological surgery.
Keywords: Abdominal wall endometriosis; Atypical location; Umbilical
mass
1. Introduction
Endometriosis
is a disease caused by the presence of functional endometrial tissue outside
the anatomical location of the uterus. It is located in the sacrouterine
ligaments, rectovaginal septum and pelvic peritoneum, which are the most common
ovaries [1-3]. The majority of cases of
extrapelvic endometriosis are scar endometriosis after hysterectomy, cesarean
section and episiotomy [4,5]. Rarely, cases of
endometriosis after amniocentesis and laparoscopic procedures have been
reported, as well [6,7]. Anterior abdominal wall
endometriosis presents with various presentation and treatment methods.
Considering the increase in cesarean rates, it is thought that these cases will
be encountered more. In the literature, diagnosis and treatment have been
emphasized more, but there are not many recommendations for preventive measures
[8]. Firstly, in 1975, it was reported that
endometriosis foci may be present in or around the incision scar in patients
undergoing cesarean or gynecologic surgery [9].
It is reported that in 0.03-0.4% of the cases, it can be seen around the
incision scar or the abdominal wall [3,10]. In
this study, a case who was operated due to a mass in the umbilical region but
whose histopathological diagnosis was reported as endometriosis is presented.
2. Case Report
A
45-year-old patient with a gravity three and parity three had complaint of
swelling in the navel for three years. However, he was admitted to the General
Surgery Outpatient Clinic of our hospital with complaints of increased swelling
in the navel and growing cyclic pain for 6 months. He had a history of
laparoscopic cholecystectomy 5 years ago and myomectomy for myoma uteri 4 years
ago. Physical examination of the patient revealed a 2 cm mass in the umbilical
region (Figure 1).
The
patient's ultrasound showed a reduced echogenic tissue of approximately 22×14
mm under the skin. Excisional biopsy was planned. The patient received 3mL (15
mg) of Havy Marcaine (MARCAINE®
SPINAL HEAVY ampoule containing 0.5% injection solution, Astra Zeneca İlaç San.ve Tic. Ltd. Şti.). The patient underwent spinal
anesthesia and after adequate block formation, a 7-8 cm longitudinal incision
was performed to excise the mass in the umbilical region (Figure 2). The patient was taken to PACU (Postoperative Care
Unit) postoperatively and anesthesia follow-up started. There were no problems.
The patient followed in clinic was discharged on the first postoperative day. Polyclinic
was recommended and the sutures were removed on the 10th postoperative day.
There were no complications. Histopathological diagnosis of the mass was
reported as consistent with endometriosis.
3. Discussion
We
know that endometriosis affects approximately 15-44% of women of reproductive
age today [3]. Dysmenorrhea, dyspareunia and
infertility are the most common symptoms of endometriosis [3,11,12]. Abdominal wall endometriosis is very rare.
The most common cases present to the physician with complaints of abdominal
wall mass and abdominal pain [10,11]. Although
endometriosis is a gynecological problem, especially as in this case, most of
the patients usually apply to general surgery because of differential diagnoses
such as hernia, abscess and malignancy. Most of the cases are young and they
present with the complaint of a painful and tender mass which occurs cyclically
a few years after the surgery. In our case, the menstrual cycle increased and
the mass was enlarged. Although history and physical examination support the
diagnosis, the definitive diagnosis is made only by histopathological
examination [10-12].
Although
endometriosis has been reported to occur after pelvic surgeries such as
caesarean section, hysterectomy and myomectomy as in this case, it may develop
spontaneously, as well. As in this case, abdominal wall endometriosis may not
always accompany pelvic endometriosis, especially pelvic endometriosis is known
to occur in only 13-24% of cases with abdominal wall endometriosis [3,13]. It is accepted that abdominal anterior wall
endometriosis is caused by iatrogenic auto-transplantation of endometrial cells
during surgery [12]. It can also be seen in
lymphatic and hematologic spread. In differential diagnosis, neuroma, hernia,
hematoma, lymphadenopathy, lymphoma, desmoid tumors and sarcomas in the
abdominal wall should be taken into consideration [3,10,11].
Although imaging methods such as ultrasonography, computed tomography and
magnetic resonance imaging are not diagnostic, they give detailed information
about the location, size and density of the mass [3,10,14].
Since ultrasound is both radiation-free and cost-effective in these cases, it
should be the first choice in imaging, but computed tomography and magnetic
resonance imaging may be more useful for surgical planning. Incisional biopsy
should not be performed because it may cause endometriosis to spread [2,3].
Surgical
excision is an effective treatment in abdominal wall endometriosis. Preference
of the most comfortable anesthesia for the patient during surgery is very
important in reducing postoperative complications, early mobilization and early
oral start. In this case, surgeon and anesthesiologist compliance is also
prominent. Therefore, we preferred spinal anesthesia, which is a regional
anesthesia method, because this patient was suitable.
To
prevent recurrence, the mass should be totally removed with at least 1 cm of
intact tissue [3,9,12]. If residual tissue is
not left postoperatively, no additional treatment is needed [14]. Medical treatment (combined oral contraceptives,
progestins, danazol, gestrinone, GnRH analogs and anastrazole) for atrophy of
ectopic endometrial tissue is preferred primarily in patients with pelvic
endometriosis. Non-steroid anti-inflammatory agents can be used for symptomatic
treatment [9,11,12]. In conclusion, gynecologic
operations should be questioned well in female patients presenting with
abdominal wall mass and endometriosis should be considered. Imaging methods
should be used for differential diagnosis. In the treatment, surgical excision
should be performed with 1 cm intact tissue as in our case.
Sources of Funding
This
case report had no involvement sponsors.
Conflict of Interest
The
authors have no conflict of interests to declare.
Ethical Approval
This
case report is exempt from ethical approval by our institution.
Consent
Written
informed consent was obtained from the patient for publication of this case
report and accompanying images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal on request.
Acknowledgements
None to declare.
Figure 1: Preoperative appearance of the mass.
Figure 2: Mass removed with umbilicus.
- Tarım
E, Bağış T, Tarım A ve ark (2002) Inguinal
endometriozis: bir olgu sunumu. Türkiye Klinikleri J Obstetrics Gynecology 12: 184-185.
- Dwivedi AJ, Agrawal SN, Silva YJ (2002) Abdominal wall endometriomas. Dig Dis Sci 47: 456-461.
- Blanco RG,
Parithivel VS, Shah AK, Gumbs MA, Schein M, et al. (2003) Abdominal wall
endometriomas. The American Journal of Surgery 185: 596-598.
- Chatterjee SK (1980) Scar endometriosis: a clinicopathologic study of 17 cases. Obstetrics and Gynecology 56: 81-84.
- Wolf GC, Singh KB (1989) Cesarean scar endometriosis: a review. Obstetrics and Gynecology Survey 44: 89-95.
- Hughes
ML, Bartholomew D, Paluzzi M (1997) Abdominal wall endometriosis after
amniocentesis: a case report. The Journal of
Reproductive Medicine 42: 597-599.
- Healy
JT, Wilkinson NW, Sawyer M (1995) Abdominal wall endometrioma in a laparoscopic
trocar tract: a case report. The American
Surgeon 61: 962-963.
- Teng CC, Yang HM, Chen KF, Yang CJ, Chen LS, et al. (2008) Abdominal wall endometriosis an overlooked but possibly preventable complication.Taiwanese Journal of Obstetrics and Gynecology 47: 42-48.
- Aimakhu
VE (1975) Anterior abdominal wall endometriosis complicating a uteroabdominal sinus
following classical cesarean section. International
Surgery 60: 103-104.
- Singh KK, Lessells AM, Adam DJ, Jordan C, Miles WF, et al. (1995) Presentation of endometriosis to general surgeon: a 10-year experience. BJ Surgery 82: 1349-1351.
- Nirula R, Greaney GC (2000) Incisional endometriosis: An underappreciated diagnosis in general surgery. Journal of the American College of Surgeons 190: 404-407.
- Ideyi SC, Schein M, Niazi M, Gerst PH (2003) Spontaneous endometriosis of the abdominal wall. Digestive Surgery 20: 246-248.
- Horton JD, Dezee KJ, Ahnfeldt EP, Wagner M (2008) Abdominal wall endometriosis: a surgeon’s perspective and review of 445 cases. The American Journal of Surgery 196: 207-212.
- Erdem M,
Erdem A, Göl K ve ark (1992) Sezaryen skar endometriozis:
Vaka takdimi. Türkiye Klinikleri J Obstetrics Gynecology 2: 15-16.