Endometriosis is a common gynaecological condition that sometimes presents to general surgeons as a lump in the abdomen. It can pose a diagnostic dilemma and should be in the differential diagnosis of lumps in the abdomen in females. Diagnosis is usually made on histology. We discuss a case of recurrent abdominal wall endometriosis following caesarian section. The incidence, pathophysiology, course, diagnosis, treatment and prevention of this condition are also reviewed.

Case Report

Case 1

A 42 year old lady presented with a painful nodule on the lateral aspect of a pfannensteil incision two years after a caesarean section. This was initially thought to be a stitch granuloma. Two years following that, she underwent abdominal hysterectomy for adenomyosis through the same abdominal incision. Following hysterectomy, the abdominal wall nodule persisted and gradually enlarged in size. At presentation, there was a 2.5 cm firm discolored lump in the abdominal wall at right iliac fossa, fixed to underlying abdominal wall muscles and skin at the lateral aspect of the pfannensteil incision. A wide local excision was performed. The abdominal wall nodule was extraperitoneal. The adherent skin, subcutaneous fat, fascia and external oblique muscle were excised with a clear margin (1cm). The wound was closed primarily. The post operative recovery was uneventful and the patient remained disease free at 12 months after surgery. Pathological examination confirmed that it was endometriosis and the margins of excision were free of disease. She was given Danazol 100 mg twice daily for initial six months.

Case 2

A 32-year-old woman presented to the surgery clinic with the complaint of pain and swelling on the upper part of cesarean scar for the last 2 years. She had previously had two cesarean deliveries, 8 and 3 years ago. Examination revealed 2 x 2 cm mass at the upper part of cesarean scar. Fine needle aspiration cytology (FNAC) of the mass [Figure - 1] showed endometriosis and subsequently patient was referred in our unit. She was started on Danazol but as the response was partial, she subsequently underwent wide excision of the mass. Histopathology (HPE) of the excised mass confirmed the diagnosis of scar endometriosis [Figure - 2]. Postoperative period was uneventful and patient has been lost to follow-up since her discharge.

Case 3

A 33-year-old woman was seen in the surgery clinic with the complaint of swelling and pain at the upper part of cesarean scar for the last 10 years which was initially present at the time of menstrual cycle but later became continuous in nature. She had one prior cesarean delivery 14 years ago and tubal ligation 10 years ago. Examination revealed a 4 x 4 cm tender subcutaneous mass in the upper part of the midline vertical scar. The overlying skin was normal. Patient underwent excision of the mass under local anesthesia with a diagnosis of stitch granuloma. HPE revealed it to be a case of scar endometriosis and subsequently patient was referred to the gynae unit. As the excision was partial patient continued to be symptomatic. Treatment with Danazol 200 mg TDS for four months was unsuccessful. Wide excision of the mass was undertaken and the defect in the rectus sheath was closed by prosthetic mesh. Postoperative period was uneventful.