Views
3 years ago

Endometrioma of the abdominal wall: a case report

Endometrioma of the abdominal wall: a case report

สงขลานครินทร์เวชสารEndometrioma of the abdominal wallปีที่ 25 ฉบับที่ 4 ก.ค.-ส.ค. 2550 334 ศักดิ์ชาย เรืองสิน, ปราโมทย์ ทานอุทิศ, วิญญู มิตรานันท์บทคัดย่อ:รายงานผู ้ป่วยก้อนเยื ่อบุมดลูกต่างที ่ผนังหน้าท้อง 1 ราย ผู ้ป่วยหญิง อายุ 34 ปี มาโรงพยาบาลด้วยอาการปวดท้องด้านล่างเรื ้อรังนาน 2 ปี ตรวจร่างกายพบก้อนที ่คลำได้ไม่ชัดเจน และมีอาการเจ็บที ่ผนังหน้าท้อง ภาพถ่ายรังสีคอมพิวเตอร์แสดงก้อนเนื ้อนอกทึบแสงที่กลางผนังหน้าท้องตรงตำแหน่งกล้ามเนื้อ rectus abdominis ผู้ป่วยได้รับการผ่าตัดเอาก้อนเนื้อออกพร้อมกับเนื้อเยื่อที่ดีโดยรอบกว้าง 1 ซม. และซ่อมผนังหน้าท้องด้วยวัสดุสังเคราะห์ โดยไม่มีภาวะแทรกซ้อนหลังการผ่าตัด รายงานผลพยาธิวิทยายืนยันภาวะเยื ่อบุมดลูกต่างที ่ ผู ้ป่วยมาติดตามอาการหลังการผ่าตัด 5 เดือนตามนัด และไม่พบภาวะการกลับเป็นซ้ำคำสำคัญ: ภาวะเยื ่อบุมดลูกต่างที ่, ผนังหน้าท้อง, ก้อนเยื ่อบุมดลูกต่างที ่IntroductionEndometriosis is defined as growth of the endometrialgland and stroma outside the uterine cavity, which can respondto ovarian hormonal stimulation. Endometrioma is a wellcircumscribed mass of endometriosis. Abdominal wall endometriomasusually occurs as a secondary process involving asurgical scar. Since the diagnosis of scar endometrioma israrely established prior to surgery, endometriosis should beincluded in the differential diagnosis of masses on the abdominalwall. We herein report a recent case of abdominal wallendometriosis (AWE) from southern Thailand as a reminderto the general surgeon to be attentive in the diagnosis of atriskpatients.A previous ultrasonograph had shown a rather definedfusiform hypoechoic mass in the area of the lower rectus muscle,normal uterus and adnexa. Computed tomography revealed anenhancing isodense mass (2.6 x 3.7 x 8 cm) at the midlinerightrectus abdominis muscle. The subcutaneous fat wasinvaded, and the peritoneum was also involved (Figure 1).The patient was treated with a mesh grafting repairfollowing a wide radical resection with a 1 cm margin. Therewere no postoperative complications. The histological examinationconfirmed endometriosis. After the surgery, the patienthave no medical treatment. The patient is now on regularfollow-up and five months after the operation is doing wellwithout any recurrence.Case reportA 34-year-old woman presented with a two-yearhistory of lower abdominal pain that had become progressivelyworse over the preceding six months. The pain wascyclical beginning few days prior to menses. She had undergonea caesarean section at full term five years previously.The physical examination revealed a well healed lowermidline scar. There was no discoloration of the skin. Therewas some induration in the lower abdominal area, with an illdefined mass; which was fixed, of hard consistency and mildtenderness. A clinical diagnosis of abdominal wall tumor wasconsidered.Endometrioma of the abdominal wallFigure 1 Computed tomography scan of the abdominal wallendometrioma

Songkla Med J Endometrioma of the abdominal wallVol. 25 No. 4 Jul.-Aug. 2007335Ruangsin S, Tanutit P, Mitarnun W.DiscussionThe most common site of endometriosis is the pelvis,followed by the ovaries, pouch of Douglas, uterine ligament,rectovaginal septum, uterine cervix, and inguinal hernial sac.The extrapelvic sites include the rectosigmoid, ileum, appendix,lungs, gallbladder, bowel, kidneys, central nervous system,extremities, perineum, and abdominal wall. 1-2 Postoperativeendometriomas occurs most commonly after surgical procedureson the uterus and fallopian tubes. Several pathophysiologicaltheories for endometriosis have been suggested. Themost likely explanation is iatrogenic implantation of endometrialtissue during surgery, particularly caesarean sections.The incidence of endometriosis after caesarean section rangesfrom 0.03% to 0.45%. 2 Primary cutaneous endometriosishas also been documented at sites such as the umbilicus, vulva,perineum, groin, and extremities. It may also occur followinglymphatic or vascular transplantation or metaplasia. 3The clinical presentation of AWE is a tender mass withinor adjacent to a surgical scar. The pain is usually intermittentand associated with the patient's menstrual cycle but may beconstant in nature. The overlying skin may be hyperpigmenteddue to deposition of hemosiderin. The interval fromoriginal surgery to onset of symptoms has been recorded asanywhere from six months to 20 years. A gynecological examinationis recommended because a concomitant pelvic endometriosismay be encountered in patients with AWE. Thedifferential diagnosis for abdominal wall endometrioma mayinclude desmoid tumor, hernia, suture granuloma, hematoma,cyst, abscess, sarcoma and/or metastatic carcinoma.An ultrasonographic examination can determine the sizeof the lesion, help determine if the nature of mass is cystic orsolid, and help to exclude underlying intra-abdominal pathologicalfactors. The sonographic appearance of endometriomais nonspecific and may change during the course of the menstrualcycle. A CT usually appears as a circumscribed solid ormixed mass, enhanced by contrast, and may show hemorrhage.The MRI shows a low signal within the mass. 4 Thedifferent imagings are nonspecific but useful in determiningthe extent of the disease, and assisting in the planning ofoperative resection. Fine-needle aspiration may be used todiagnose endometrioma in isolated cases but should be usedonly with caution as needle tract endometriosis has beenreported. 1The treatment of choice is wide excision with a 0.5 to1 cm margin. Care must be taken not to rupture the mass toavoid reimplantation of microscopic remnants of endometrialtissue. Complete excision may necessitate a synthetic meshplacement or tissue transfer for abdominal wall closure.Recurrences have been associated with larger and deeper lesionsthat were difficult to remove completely. Medical managementwith hormonal therapy may produce only temporaryalleviation of symptoms, with extreme adverse effects followedby recurrence after the cessation of drugs. Surgeons shouldalso be aware that endometrial carcinomas have been reported.ConclusionEndometriosis of the abdominal wall is a rare conditionand unfamiliar to most general surgeons. Clinical presentationsand imaging study may not be sufficient for diagnosis, sincethe condition is often diagnosed only upon postoperativehistological examination. Wide excision is the treatment ofchoice for abdominal wall endometrioma.References1. Blanco RG, Parithivel VS, Shah AK, Gumbs MA, ScheinM, Gerst PH. Abdominal wall endometriomas. Am J Surg2003;185:596-8.2. Zhao X, Lang J, Leng J, Liu Z, Sun D, Zhu L. Abdominalwall endometriomas. Int J Gynaecol Obstet 2005;90:218-22.3. Kocakusak A, Arpinar E, Arikan S, Demirbag N, TarlaciA, Kabaca C. Abdominal wall endometriosis: a diagnosticdilemma for surgeons. Med Prine Pract 2005;14:434-7.4. Teh J, Leung J, Dhar S, Athanasou NA. Abdominal wallendometriosis: comparative imaging on power dopplerultrasound and MRI. Clin Radiol Extra 2004;59:74-7.

The Abdominal Wall And Hernias
Abdominal Wall & Diaphragmatic Hernias - Dr Jonathan Leith
Mycotic Abdominal Aneurysm - WVU School of Medicine
Untitled - International Journal of Case Reports and Images (IJCRI)
Untitled - International Journal of Case Reports and Images (IJCRI)
International Journal of Case Reports and Images (IJCRI)
300. Case Study report 4.1 - Book - Aga Khan Development Network
Abdominal Wall Endometrioma: A Case Report and Review ... - AORN
Abdominal Wall Endometrioma - Balkan Medical Journal
Desmoid tumors of the abdominal wall: A case report
Endometriosis of the abdominal wall - Rjme.ro
Interesting Case Series Abdominal Wall Reconstruction - ePlasty
abdominal wall, umbilicus, peritoneum, mesenteries, omentum
Suture granuloma of the abdominal wall with intra-abdominal ...
7. Anterior abdominal wall
Abdominal aortic aneurysms: case report
Axial Muscles of the Abdominal Wall, and Thorax∗ - Connexions
Evaluation of Abdominal Wall Integrity After Using the ... - ESPRS
Chapter 69: Abdominal Wall Reconstruction - Gregory Dumanian ...
Clinical anatomy of the anterior abdominal wall in - Ohio University ...
Sonography in Identification of Abdominal Wall Lesions Presenting ...
Malignant granular cell tumor of the abdominal wall - Siapec
atypical incarcerated abdominal wall hernia mimicking acute ...
Clinical anatomy of the anterior abdominal wall in its relation to hernia.
ABDOMINAL TUBERCULOSIS: REVIEW OF 78 CASES
Cosmetic Special Topic Abdominoplasty and Abdominal Wall ...
Abdominal wall actinomycosis simulating a malignant neoplasm ...