Endometriosis is a condition defined by the presence of endometrial tissue, the tissue that normally lines the inside of the uterus, in locations outside the uterine cavity. Most often, these implants are found within the pelvis, affecting the ovaries, fallopian tubes, and pelvic lining. However, in rare cases, this tissue can be found in distant locations. One of the most specific and frequently misdiagnosed forms is abdominal wall endometriosis.
This condition, also known as scar endometriosis, occurs when endometrial tissue implants and grows within the layers of the abdominal wall, such as the skin, subcutaneous fat, or muscle. For the women who experience it, this condition is often a source of significant confusion and chronic pain. Many patients come to us after being misdiagnosed for years with conditions like hernias, abscesses, or suture granulomas.
About the abdominal wall
The abdominal wall is a complex organ that has several vital functions. These include protecting the abdominal organs, maintaining their anatomical position, increasing the pressure inside the abdomen, and expiring air. The abdominal wall has two muscle groups. These include two vertical muscles in the midline and three lateral flat muscles stacked upon each other. The rectus abdominis is an important vertical muscle that prevents herniation in the abdomen and stabilizes the pelvis during movement.
Prevalence of abdominal wall endometriosis
Abdominal wall endometriosis is rare. Research suggests its incidence to be between 0.03% to 1.5%. However, this may be an underestimate, and reported cases have been increasing with the rising number of Cesarean sections.
Get a Second Opinion
Our endometriosis specialists are dedicated to providing patients with expert care. Whether you have been diagnosed or are looking to find a doctor, they are ready to help.Our office is located on 872 Fifth Avenue New York, NY 10065.
You may call us at (212) 988-1444 or have your case reviewed by clicking here.
The cause how abdominal wall endometriosis occurs?
Unlike pelvic endometriosis, which has several complex theories regarding its origin, the cause of abdominal wall endometriosis is almost always direct iatrogenic transplantation. This means the tissue is accidentally transferred during a surgical procedure.
The vast majority of cases we see are directly linked to Cesarean section deliveries. During a C-section, the uterus is opened to deliver the baby. It is at this time, or during the subsequent suturing of the uterus and the abdominal wall layers, that endometrial cells can be inadvertently carried and deposited into the surgical incision.
Once these cells are in the abdominal wall, they establish a new blood supply and behave just as they would inside the uterus. They are living, hormone-responsive tissue. This means they are sensitive to the estrogen and progesterone that control your monthly menstrual cycle.
While C-sections account for the overwhelming majority of cases, we also see this condition arise in the scars from other gynecological surgeries. These can include laparoscopic port sites, hysterectomy incisions, and even incisions from ectopic pregnancy surgery. Any procedure that involves opening or instrumenting the uterus carries this small but real risk. This is not the result of a surgical error but rather an unfortunate complication related to the tenacious nature of endometrial cells.
Symptoms
Pain in the area where a prior Cesarean scar is present is one of the most common symptoms of abdominal wall endometriosis. Patients often complain of pain and a palpable mass at the site of the lesions. This pain is generally cyclic and is more intense during the first two days of menstruation. However, the pain may not always correlate with the menstrual cycle.
Skin changes such as discoloration or hyperpigmentation in the abdominal wall may also occur during menstruation. The collection of blood in the rectus abdominis muscle may also occur in some cases.
Diagnosis
Computerized tomography (CT), ultrasound, and magnetic resonance imaging (MRI) are useful to identify and assess the nature of abdominal wall endometriosis lesions.
Ultrasound is generally the first step in the diagnosis of this condition as it is the least expensive or invasive. If it is nondiagnostic, an MRI can better visualize smaller lesions. The lesions in the abdominal wall appear isoechoic or hyperechoic in most cases with peripheral vascularization. However, hypoechoic lesions can also occur. A CT scan, on the other hand, can help if the lesion involves the muscle or subcutaneous layer and can assist with surgical planning.
Doctors must exclude other conditions such as hernia, tumors in the abdomen, lipomas, and hematomas before confirming a diagnosis of abdominal wall endometriosis.
A biopsy and histological report can confirm a diagnosis of abdominal wall endometriosis.
Treatment
Treatment tends to be multidisciplinary depending on the severity of the AWE. At a minimum, surgery must be performed by a highly-skilled surgeon who will address the abdominal wall endometriosis and perform a concurrent laparoscopy. With AWE, there is a high likelihood of endometriosis in the abdominal cavity. Laparoscopic deep excision surgery combined with Aqua Blue Contrast (ABC)TM is the gold standard for the treatment of pelvic endometriosis.
A consultation with general surgery may be necessary in order to complete the reconstruction of the abdominal wall and prevent the formation of hernias.
Finally, hormonal treatment should be offered to minimize the risk of recurrence.
FAQS
How did I get endometriosis in my C-section scar?
You most likely developed this during your Cesarean section. It is a known, though uncommon, surgical complication. During the procedure, endometrial cells from inside the uterus were likely transferred accidentally. These cells then implanted into the layers of your skin, fat, or muscle. This is called iatrogenic transplantation. These cells then respond to your monthly hormones, causing cyclical pain and swelling at the scar.
Is abdominal wall endometriosis a type of cancer?
No, abdominal wall endometriosis is not cancer. It is a benign condition. The tissue is normal endometrial tissue; it is just in the wrong location. While it can be locally invasive and grow into muscle, it does not spread to distant organs like cancer does. There is an extremely rare association with malignancy, but this is not a common concern. The condition is treated definitively with surgery.
What are the main symptoms of abdominal wall endometriosis?
The main symptom is a painful lump in or near an old surgical scar. This lump typically follows a cyclical pattern of pain. It becomes tender, swollen, and more painful during your menstrual period. When your period ends, the pain and swelling usually decrease. Over time, the pain may become constant. In very rare cases, you might notice the skin over the lump bleeding during your period.
Get a Second Opinion
Our endometriosis specialists are dedicated to providing patients with expert care. Whether you have been diagnosed or are looking to find a doctor, they are ready to help.Our office is located on 872 Fifth Avenue New York, NY 10065.
You may call us at (646) 960-3080 or have your case reviewed by clicking here.
Dr. Seckin is an endometriosis specialist and women’s reproductive health advocate. He has been in private practice for over 30 years at Lenox Hill Hospital with a team of highly skilled personnel.
Dr. Seckin specializes in advanced laparoscopic procedures and is recognized for his expertise in complex cases of deep infiltrating endometriosis of the pelvis. He is particularly dedicated to performing fertility-preserving surgeries on cases involving the ovaries.
He has developed patented surgical techniques, most notably the “Aqua Blue Excision” technique for a better visualization of endometriosis lesions. His surgical techniques are based on precision and microsurgery, emphasizing organ and fertility preservation, and adhesion and pain prevention.
Dr. Seckin is considered a pioneer and advocate in the field of endometriosis.