Monday, December 19, 2016

Endometriosis of the Cesarean Section scar

A young lady and mother of a child complained of pain in the right side of lower abdomen for more than 7 years. Apparently, it began about 1 year after the cesarean section delivery of her child. It has nothing to do with the timing of food, and her bowel and bladder habits were normal.
She was examined by many experts and her ultrasonogram of abdomen was showing a cyst in the ovary (Right). She was examined by me. I inquired about the suture materials used during the previous cesarean se4ction. I presumed it to be due to the use of non-absorbable suture material, like polypropelene, the knot of which sometimes gives rise to pain. However, as she could not exactly say about the use of the suture material, I too suspected it to be due to the ovarian cyst.
English: localisation of endometriosis Deutsch...
English: localisation of endometriosis Deutsch: Lokalisation der Endometriose (Photo credit: Wikipedia)
The cyst along with the innocent appendix was removed in a higher centre. But, she continued to experience the same pain and approached me again. This time, I could make out a tender sub-cutaneous nodule in the right lower abdominal wall. Again, I thought it to be a foreign body granuloma arising out of use of some non-absorbable suture material. Ultrasound was ordered for the abdominal wall. It suggested that there is a well defined solid sub-cutaneous nodule. I thought it to be some benign tumour of the fascia or again foreign body granuloma. The nodule was subjected to FNAC examination. It came out to be non-specific inflammation. It was presumed to be a foreign body granuloma.
It was planned for excisional biopsy. Intra-operatively, it was found that the nodule was a part and partial of the rectus sheath. The nodule was excised and fascial defect repaired. The HP study came out to be endometriosis.
Though, endometriosis is rare after a cesarean section, is a reality. This happens due to implantation of endometrial tissue from uterus during the cesarean section. Typically, endometriosis becomes painful, towards the time of periods, but this feature was not there in the present case.
Hence, painful and tender sub-cutaneous nodule in the scar of previous cesarean section should be suspected to be endometriosis.  


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