Abdominal Wall Endometrioma: A Case Report and Review of the Literature

Article Outline

• Abstract
• Endometrioma Formation
• Presenting Symptoms
• Clinical Findings
• Diagnostic Evaluation
• Treatment Options
• Perioperative Care
• Preoperative Nursing Assessment
• Preparation for Surgery
  • Patient Positioning
  • Induction of Anesthesia
• Surgical Procedure
• Postoperative care
• Summary
• Examination. Continuing Education Program
  • Abdominal Wall Endometrioma: A Case Report and Review of the Literature
    • Questions
• Learner Evaluation. Continuing Education Program
  • Abdominal Wall Endometrioma: A Case Report and Review of the Literature
    • Objectives
    • Content
• References
• Biography
• Copyright

Abstract 

Endometriosis is the presence of ectopic endometrial tissue that can respond to ovarian hormonal stimulation. Although it is uncommon, extrapelvic endometriosis can form a discrete mass known as an abdominal wall endometrioma. Endometriomas are thought to be caused by transfer of endometrial cells into a surgical wound, most often after a cesarean delivery. Endometriomas are diagnosed via ultrasound, computed tomography, magnetic resonance imaging, and ultrasound-guided fine needle aspiration. Treatment options can be medical, but surgical excision is the treatment of choice. Perioperative nursing care includes patient teaching, taking steps to prevent surgical site infection and inadvertent hypothermia, ensuring availability of supplies (eg, the graft for abdominal wall repair if needed), and postoperative pain management.

Key words: endometriosis, endometrioma, rectus abdominus, abdominal wall mass

A 38-year-old woman presented with complaints of pain and a mass in her left lateral abdominal wall. During clinical examination, the physician identified a painful and tender palpable mass in the lower third of the patient's left rectus abdominus muscle, about 10 cm above the incision of a previous cesarean procedure. The patient explained that the symptoms had appeared approximately 18 months previously, but, during the past eight months, the symptoms had become more intense, with redness, swelling, and pain. According to the patient, the intensity of pain increased mainly during her menses. The patient's medical history included three cesarean procedures, 10, nine, and six years ago, via a Pfannenstiel incision. No evidence of endometriosis was found during the cesarean procedures.

For diagnostic evaluation, the physician ordered abdominal ultrasonography and magnetic resonance imaging (MRI). The abdominal ultrasonography showed an hypoechogenic, heterogeneous lesion, 4.3 cm by 3.2 cm, within the left rectus abdominus muscle, without extension outside its sheath, and with sharp margins and increased vascularity. No necroses or calcifications were observed within this lesion. The abdominal MRI (Figure 1) showed a heterogeneous mass (5 cm in diameter) within its sheath in the lower part of the left rectus abdominus muscle.

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• Figure 1. 

  Abdominal magnetic resonance imaging scan showing a mass of approximately 5 cm in the abdominus muscle (marked by an ellipse).

The MRI also showed the presence of hemosiderin pigment. This abnormal microscopic pigment is composed of iron oxide that can accumulate in different organs because of various diseases; although iron is required by many of the chemical reactions in the body, it is toxic when not properly contained. The patient's clinical picture was compatible with the diagnosis of abdominal wall endometriosis. The physician then ordered an ultrasound-guided fine needle aspiration of the mass, which showed histologic and immunohistochemical evidence of endometriosis of the rectus abdominal muscle; the aspirate was negative for malignancy.

The patient, under general anesthesia, underwent wide local resection of the mass. During surgery, the surgeon removed the mass and the local abdominal wall en bloc because of the involvement of the rectus abdominus muscle sheath (Figure 2). The surgeon performed abdominal wall reconstruction by using a 10-cm by 15-cm silicone-polypropylene-microval dual mesh graft. The surgeon sent the mass for histologic examination, which revealed the presence of endometrioma (ie, multiple endometrial glands with variable focal cystic dilatation, surrounding specialized stroma, and dense fibrosis between the endometriotic foci) (Figure 3, Figure 4). No signs of cellular atypia were seen in the endometrial epithelium. Clusters of macrophages with cytoplasmic hemosiderin were identified. The patient's postoperative course was uneventful. Ten months after surgery, the patient was well and without symptoms.

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• Figure 2. 

  The mass after surgical resection (whitish mass in the center, surrounded by a reddish rim of normal adjacent tissue).

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• Figure 3. 

  Multiple endometrial glands with surrounding endometrial stroma (hematoxylin-eosin stain, magnification ×400).

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• Figure 4. 

  Endometrial gland with cystic dilatation (hematoxylin-eosin stain, magnification ×400).

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Endometrioma Formation 

Endometriosis is defined as the presence of ectopic endometrial tissue that can respond to ovarian hormonal stimulation.¹, ² Endometriosis is reported as being detected in 15% to 44% of laparoscopies and laparotomies performed on women in the reproductive age group.¹ Seventy-five percent of women with symptoms of endometriosis are between the ages of 25 and 45 years.² The term endometrioma is given to endometriosis when it forms a discrete mass.¹, ², ³ Endometriosis has been described in almost all body cavities and organs, including the central nervous system, lung, small and large bowel, gallbladder, kidney, extremities, perineum, and abdominal wall.², ³, ⁴

The presence of a mass of ectopic endometrial tissue within the abdominal wall (ie, endometrioma) is uncommon.³ Most often, abdominal wall endometriomas occur in women who have previously undergone abdominal or pelvic surgery, primarily cesarean delivery. The presence of abdominal wall endometrioma may pose diagnostic difficulties for clinicians.

Primary cutaneous endometriosis also has been documented.⁵ On histologic examination, endometriomas are characterized by two of the three following features:

Two theories have been proposed to explain endometrioma formation.¹, ³, ⁴ The metaplasia theory suggests that primitive mesenchymal cells undergo specialized differentiation metaplasia to form endometrial implants.³ The transport theory states that endometrial cells may be transported to distant locations and then form an endometrioma.³ The majority of abdominal wall endometriomas, including endometrioma within the rectus abdominal muscle, have been reported in and adjacent to cesarean procedure scars or along tracts that result from invasive abdominopelvic procedures (eg, needle amniocentesis, hypertonic saline solution abortion).³ Interestingly, although endometriomas occur most commonly after surgical procedures on the uterus and fallopian tubes, this phenomenon also has occurred after appendectomy, episiotomy, laparoscopic procedures, amniocentesis, and inguinal herniorrhaphy.², ⁷ The incidence of endometrioma associated with cesarean procedure incisions has been reported to be up to 1% (most commonly, 0.03% to 0.4%).¹, ⁷, ⁸, ⁹ The interval between the cesarean procedure and the diagnosis of abdominal wall endometriosis varies from several months up to 18 years.⁷, ¹⁰ This “late complication” of cesarean delivery is so rare that it is not usually discussed before surgery during the informed consent process. The etiology of these endometriomas is thought to be iatrogenic transfer of endometrial cells introduced into the surgical or procedural wound.³, ⁹ A minority of abdominal wall endometriomas are associated with the physiologic scar of the umbilicus, seeded with endometrial cells by way of the lymphatic or venous circulations.³ Rectus abdominis endometrioma, wherein the endometrioma is confined only within the rectus abdominis muscle, is rare and was first reported in 1993.³, ¹¹ Endometriomas that involved a combination of the rectus abdominis, subcutaneous tissues, and the abdominal wall also have been described.³

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Presenting Symptoms 

Abdominal wall endometriomas usually present as a tender or painful mass near an incisional scar, typically from a previous cesarean delivery.¹, ⁹ The pain or abdominal discomfort is usually cyclic and may correlate to the menstrual period.¹, ⁴, ⁹ Occasionally, abdominal wall endometriomas may present as a painless but gradually enlarging mass, which is first noted by the patient herself. Painless presentations may reflect endometriomal size or location in areas where expansion of the endometrioma does not impinge on other structures.³ The endometrioma in the patient described here was located within the body of the rectus abdominis muscle, which may have caused pain secondary to compressive phenomena within the confining rectus sheaths.

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Clinical Findings 

In patients with rectus abdominis endometrioma, clinical examination reveals a mass within the abdominal wall; this mass becomes more fixated when the patient elevates her head while in the supine position (ie, Fothergill sign). In contrast, intra-abdominal masses become less prominent with this maneuver. The differential diagnosis of a mass in a scar or generally within the abdominal wall includes abscess, incisional hernia, hematoma, lipoma, suture granuloma, sarcoma, endometrioma, desmoid tumor, lymphoma, or metastatic disease.¹, ⁶, ⁷, ⁹

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Diagnostic Evaluation 

Accurate preoperative diagnosis may be difficult and requires a high index of suspicion for the presence of endometrioma.⁹, ¹² Preoperative evaluation includes ultrasound, which is useful in determining whether the mass is cystic or solid; however, the echomorphological characteristics of endometrioma are not specific.¹, ⁴, ⁶ Color Doppler ultrasonography can improve the diagnostic accuracy of ultrasound examination.³ Computed tomography can accurately delineate the extent of the disease.¹³ Magnetic resonance imaging is highly sensitive in detecting very small masses and can achieve excellent differentiation of endometriomas from adjacent tissues.⁴, ¹³ Accurate preoperative diagnosis of abdominal wall endometriomas is possible by using fine-needle aspiration, often under ultrasound or computed tomographic guidance.⁴, ⁶, ¹⁴, ¹⁵

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Treatment Options 

Local excision is the treatment of choice.¹¹, ¹⁶ A frozen section could be used to accurately establish the diagnosis during surgery. To decrease the likelihood of recurrence, clear margins of at least 1 cm should be achieved.¹, ¹⁷, ¹⁸ Abdominal wall endometriomas are often densely adherent to the abdominal wall fascia so partial resection of the fascia may be required.⁹, ¹⁰ After the resection has been completed, reconstruction of the abdominal wall is usually achieved by using a mesh.¹⁶, ¹⁹ Surgery is indicated for recurrent lesions, in which case, every attempt should be made to ensure complete resection of the lesion with wide margins (ie, more than 1 cm).¹, ¹¹, ¹⁸

Medical treatment of endometrioma with danazol (ie, synthetic modified testosterone) and leuprolide (ie, gonadotropin-releasing hormone analog to reduce estradiol levels) has been tried as well. Unfortunately, these medications have shown limited success (eg, transient relief of symptoms) and some adverse effects (eg, amenorrhea, dyspareunia).³, ⁴, ⁶ Malignant transformation of an endometrioma to endometrial carcinoma has been reported in the literature.⁶, ⁷, ¹⁹, ²⁰, ²¹ Moreover, carcinoma or sarcoma of other types may also be present within abdominal wall endometrioma masses.²¹, ²² Fortunately, overall malignant transformation in endometriosis is rare, occurring in 0.3% to 1.0% of cases.⁷

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Perioperative Care 

The surgeon may obtain a history and perform a physical examination of the patient during the preoperative office visit and then have the documents delivered (eg, hand carried by the patient, sent via fax by an office staff member) to the preoperative area on the day of surgery. Alternatively, the surgeon may choose to obtain the history and perform the physical examination the morning of surgery. Patient education should begin when surgery is scheduled. The surgeon explains the indications for surgery, explains the risks and benefits of the procedure, and describes the surgical procedure and the required recovery period. After answering the patient's questions, the surgeon obtains verbal consent to perform the procedure. The patient may sign the actual informed consent form during the preoperative office visit or may be asked to sign it on the day of surgery.

The office nurse explains the anatomy and physiology of the pelvic organs and provides the patient with verbal and written information about the upcoming surgery. The nurse instructs the patient to remain NPO before surgery. The length of time required depends on the time the surgery is scheduled and surgeon preference. Typically, patients are instructed not to eat any food six hours before surgery but are told that clear liquids (eg, water, apple juice, black coffee) may be consumed up to two hours before surgery.²³ The nurse instructs the patient to shower on the morning of surgery to decrease skin microbial colony counts. The nurse also discusses preadmission diagnostic testing (eg, complete blood count, pregnancy test), work restrictions, and postoperative home care.

Typically, the anesthesia care provider calls the patient on the night before surgery to review the patient's medical history and discuss anesthetic options. The anesthesia care provider determines whether the patient should take any regularly scheduled medications, such as blood pressure, asthma, or diabetic medications. If necessary, the anesthesia care provider instructs the patient to take the medications with a sip of water on the morning of surgery and may instruct the patient to bring the medications to the hospital for administration after surgery if needed. If general anesthesia is selected, then the anesthesia care provider explains that the patient may experience a mild sore throat after surgery from the endotracheal tube.

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Preoperative Nursing Assessment 

After the patient's arrival in the surgical suite, the preoperative nurse identifies the patient verbally and by using the patient's medical record and identification bracelet. The nurse instructs the patient to change into a hospital gown and nonskid socks. When the patient is settled on the OR stretcher, the nurse helps her put on thromboembolic device hose and then provides the patient with warm blankets if desired. The nurse completes the patient's admission paperwork, including information about the patient's current medications and allergies (eg, to medications, latex, povidone-iodine, shellfish). The nurse performs a systems assessment, including the patient's physical condition and limitations; notes skin rashes, bruises, and lesions; and documents psychosocial, religious, and cultural considerations. The nurse determines whether the patient's lifestyle patterns (eg, tobacco, drug, or alcohol use; eating disorders; physical abuse) will affect the perioperative experience and assesses for the risk of malignant hyperthermia. He or she reviews the patient's understanding of pain management options and describes the zero to 10 pain rating scale. The nurse asks the patient what she feels would be a reasonable postoperative pain level (eg, 3 or 4 on a scale of 10 in which 10 is the worst possible pain).

The nurse may have the patient provide a urine specimen for a pregnancy test on the morning of surgery. After IV access has been obtained, the preoperative nurse administers prophylactic IV antibiotics as ordered by the surgeon and documents this and all assessment findings on the patient's record. The preoperative nurse then communicates any requirements or physical limitations that the patient may have to the circulating nurse during the hand-off communication.

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Preparation for Surgery 

The circulating nurse coordinates the room setup and equipment for the procedure. The circulating nurse and scrub person gather supplies in advance to ensure rapid availability, if required. The circulating nurse also oversees coordination of instrumentation. The nurse should be prepared for the possibility of the need for prosthetic material (ie, mesh), particularly if the defect formed by excision of the abdominal wall endometrioma is large. The nurse should ensure that a variety of sizes of the surgeon's preferred grafts are immediately available before the patient is taken into the OR. The circulating nurse also should have pulsed lavage supplies and equipment if preferred by the surgeon.

The circulating nurse visits the patient in the preoperative area to provide continuity between the preoperative and intraoperative phases of care. This provides the opportunity for introductions and questions, and allows the circulating nurse to review the patient's medical record because information obtained in the preoperative area may affect care provided in the OR. After reviewing the written history and physical examination performed by the physician, which should be present on the chart, noting previous surgical interventions and the presence or absence of metal implants, the circulating nurse reviews diagnostic tests and laboratory results to ensure that all are within normal limits. The circulating nurse receives a hand-off report from the preoperative nurse and reports any abnormalities to the surgeon, anesthesia care provider, and scrub person before surgery. The circulating nurse validates the patient's NPO status and that the informed consent form has been signed properly and witnessed before the patient receives preoperative sedation. The circulating nurse documents the information in the patient's medical record and develops a care plan specific to the patient and proposed procedure (Table 1).

TABLE 1. Nursing Care Plan for a Patient Undergoing Surgical Excision of an Abdominal Wall Endometrioma

The anesthesia care provider arrives in the preoperative area to meet the patient and review the anesthetic plan with the patient. After answering any questions the patient has, the anesthesia care provider obtains informed consent from the patient and then may administer a sedative if indicated to help lower the patient's anxiety level and promote relaxation. The circulating nurse and anesthesia care provider transport the patient to the OR and assist her onto the OR bed.

Patient Positioning 

After the patient assumes a supine position with good body alignment, the circulating nurse secures the safety strap just above the patient's knees and extends the patient's arms on padded arm boards in a less than 90-degree angle and secures them with palms up. The circulating nurse checks the patient's arm, elbow, and finger positions to prevent injury or ulnar nerve compression. The nurse may place pillows under the patient's legs to ease back strain and float the patient's heels off the bed surface. The nurse places warm blankets or an upper-body temperature-regulating blanket on the patient's chest and arms. The circulating nurse confirms the patient's position and then documents patient positioning and positioning aids on the OR record.

Induction of Anesthesia 

The circulating nurse remains at the patient's side to assist the anesthesia care provider with application of monitoring devices and induction of anesthesia, applying cricoid pressure if needed. General anesthesia frequently is the anesthesia of choice for this procedure. The nurse remains at the patient's side until the patient has reached the desired level of anesthesia, airway management and adequate ventilation have been achieved, and the anesthesia care provider has confirmed tube placement. The circulating nurse places the electrosurgical unit dispersive pad on a nonbony area of large muscle mass and exposes the surgical site. The circulating nurse cleanses the patient's skin and ensures that excess prep solution did not pool under the patient. The surgeon and scrub person then drape the patient according to recommended practices.

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Surgical Procedure 

The surgeon excises the abdominal wall endometrioma, ensuring a wide local excision with clear margins, which is key in preventing recurrence. The surgeon ensures that hemostasis has been achieved and begins the abdominal wall reconstruction. Some surgeons may use a dual-surface expanded polytetrafluoroethylene (ePTFE) patch graft to repair the fascial defect. This type of graft has two functionally different surfaces: a macroporous structure surface that encourages host tissue ingrowth and a closed structure surface that minimizes tissue attachment. The circulating nurse should understand the correct surface orientation of the graft to be able to direct the scrub person when he or she is handing the graft to the surgeon.

Dual-surface expanded ePTFE patch grafts come in different sizes but may be cut to fit.²⁴ The circulating nurse should have a variety of sizes available and should be prepared to pass a graft that is larger than the defect to the scrub person. The circulating nurse should ensure that extra gloves are on the sterile field for all scrubbed personnel, and the scrub person should assist everyone in changing gloves before handling the graft. The scrub person should provide the surgeon with fresh, sharp surgical instruments to trim the mesh. If the graft is cut too small, then excessive tension may be placed on the suture line, which may result in recurrence of the original, or development of an adjacent, tissue defect.

The scrub person should be prepared to hand the surgeon the graft in a specific direction to ensure proper placement. “Correct surface orientation is extremely important for the [dual-surface expanded ePTFE patch graft] to function as intended. The textured surface should be placed adjacent to those tissues where tissue ingrowth is desired (ie, peritoneal tissue). The other, smoother surface should be placed adjacent to those tissues where minimal tissue attachment is desired (ie, serosal surfaces). Improper positioning of the smoother, nontextured surface adjacent to fascial or subcutaneous tissue will result in minimal tissue attachment. Persistent seroma may result.”²⁴

The circulating nurse should ensure that the surgeon has only nonabsorbable, monofilament suture with a noncutting needle (eg, taper, piercing point) to secure the mesh in place. “Using absorbable sutures may lead to inadequate anchoring to the host tissue, which may require reoperation.”²⁴

When the repair is completed, the scrub person washes residual prep solution off the patient's skin and applies dressings according to surgeon preference. The circulating nurse removes the electrosurgical unit dispersive pad and inspects the site thoroughly to rule out skin breakdown and burns. The nurse places warm blankets on the patient. After the patient wakes from anesthesia, the patient may be able to move herself to the stretcher. If she is not alert enough to move, surgical team members move the patient by using a transfer device and proper body mechanics. The circulating nurse and anesthesia care provider transport the patient to the postanesthesia care unit (PACU). The circulating nurse then communicates any intraoperative specifics and patient requirements to the PACU nurse during the hand-off communication.

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Postoperative care 

The PACU nurse assesses and closely monitors the patient's respiratory, cardiac, vascular, and psychosocial status throughout her stay in the PACU. The PACU nurse also coordinates the patient's pain management and antiemetic control according to orders from the surgeon or anesthesia care provider. The patient remains in the PACU for one to two hours and then is transported to the phase two recovery area.

Typically, the patient remains in the hospital for two to three days. The discharge nurse provides the patient and her family members with oral and written discharge instructions (Patient Education Sheet). The nurse emphasizes that the patient may experience a sore throat from having had an endotracheal tube in place during surgery. The nurse instructs the patient to avoid lifting anything in excess of 5 kg (11 lb) until all incisions are healed, which usually is in approximately two months. Although recovery time varies, many patients return to sedentary employment in 10 to 15 days. The patient is discharged with oral analgesics, oral antibiotics, and possibly an antiemetic. The nurse explains that the patient should report

These problems should be reported to rule out postoperative complications, or the surgeon may determine that one or more medications should be substituted or discontinued.

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Summary 

Endometrioma should be considered in women of reproductive age who present with an abdominal mass and previous history of surgery, particularly cesarean delivery. Abdominal ultrasound and computed tomography or MRI may help in the differential diagnosis. Preoperative diagnosis can be established by using image-guided fine-needle aspiration. Wide local resection with clear margins (more than 1 cm) is the treatment of choice. Reconstruction of the abdominal wall is often necessary and may require the use of a mesh graft. Typically, patients recover uneventfully, remain asymptomatic, and are pleased with the results.

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Examination. Continuing Education Program 

Abdominal Wall Endometrioma: A Case Report and Review of the Literature 

PURPOSE/GOAL

To educate perioperative nurses about surgical treatment of patients with abdominal wall endometriomas.

OBJECTIVES

The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.

Questions 

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Learner Evaluation. Continuing Education Program 

Abdominal Wall Endometrioma: A Case Report and Review of the Literature 

This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate the items as described below.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

Content 

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References 

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