Clinico-pathological assessment of post-cesarean section abdominal wall endometriosis

A study of 30 women who had their post-cesarean section abdominal wall endometriomas (AWE) surgically removed found that the main symptom for detection and for surgery in two-thirds of cases was cyclic pain, whereas 13.3% of patients had no symptoms.

Abdulkarim Hasan, MD

The average patient age was 35 years (range 25 to 55 years) in the cohort study in the Annals of Medicine and Surgery. On average, the interval between prior cesarean section and appearance of symptoms was 55.2 months and the mean size of the excised mass was 42 mm.

Principal investigator Abdulkarim Hasan, MD, a consultant and lecturer of pathology at Al-Azhar University in Cairo, Egypt, said, “The rate of cesarean sections has been increasing steadily in our country and has reached an alarming level in recent years.”

In addition, the prevalence of cesarean section-associated complications, including AWE, increases with each additional operation, Hasan told Contemporary OB/GYN.

All study patients were diagnosed, treated and followed for 2 to 8 years at Al-Azhar Hospital between January 2012 and November 2018. Surgical excision of AWE was performed by either a general surgeon or a gynecologist and most patients were not preoperatively examined by the pathologist.

For the study period, the incidence of AWE among patients with previous cesarean delivery was 0.21%.

The study found that preoperative AWE via fine-needle aspiration (FNA) cytology was performed in only 10% of cases, which helped exclude other potential pathologies.

One surprise study finding was that one patient experienced AWE 10 years after a previous cesarean section.

The mean excised mass size of 42 mm in the study was also much larger than the average size in previous similar pee-reviewed studies, “suggestive of late diagnosis,” Hasan said. But no recurrence occurred for excised masses with surgical margins less than 9 mm.

“Wide surgical excision with a margin of less than 1 cm could be acceptable, especially in cases of weak abdominal wall,” Hasan said.

The clinical-pathological agreement value for detection of the nature of the abdominal wall mass was 93.4%.

“Only AWE with high suspicion of another serious pathology should undergo preoperative cytological biopsy to exclude alternative diagnosis, but this procedure might exacerbate lesions progression, so good correlation between the surgical history and the ultrasonographic findings is crucial for preoperative diagnosis,” Hasan said.

To reduce the severity of post-cesarean section AWE, Hasan recommends that patients commit to regular follow up, have an early and accurate diagnosis, a preoperative radiological diagnosis rather than interventional tools, and a postoperative histopathology examination.

Similarly, to reduce the incidence of complications from the surgical removal of AWE, the authors advocate minimizing contact of swabs for cleaning the endometrial cavity within the scar site and removing the swabs quickly from the operation area. Also, avoid using the same suture material for closure of the uterus, saline wash the scar site before closing and suture the scar site thoroughly. “These steps may assist in preventing the growth of endometriotic tissue from the scar tissue,” Hasan said.

For future studies, Hasan advocates gene expression profiling of endometriosis and histological assessment of endometriotic fibrosis. He also supports evaluating the surgical margins for AWE in a larger number of cases for adopting generalized surgical recommendations.

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Hasan reports no relevant financial disclosures.

Hasan A, Deyab A, Monazea K, et al. Clinico-pathological assessment of surgically removed abdominal wall endometriomas following cesarean section. Ann Med Surg. 2021 Jan 21;62:219-224; doi:10.1016/j.amsu.2021.01.029