8168 Umbilical Endometriosis and Vaginal Stump Endometriosis Developing after Total Laparoscopic Hysterectomy

Abstract

<h3>Study Objective</h3> Even when endometriotic lesions in the pelvis are mild, they can survive in the vaginal stump and the trocar port-site after total laparoscopic hysterectomy. It is difficult to preoperatively assume the presence of fine lesions in the Douglas pouch when endometriosis is not detected elsewhere from imaging findings. Endometriotic lesions may survive in the vaginal stump, even in the absence of endometriosis in the uterus or adnexa. <h3>Design</h3> Case Presentation. <h3>Setting</h3> Yokohama City University. <h3>Patients or Participants</h3> A patient with less common/rare site endometriosis. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> A 40-year-old G0P0 presented with multiple uterine leiomyomas. Because of exacerbated hypermenorrhea, the patient underwent total laparoscopic hysterectomy and bilateral salpingectomy. Intraperitoneal findings included an approximately 1-cm endometriotic lesion in the peritoneum of the Douglas pouch, and partial adhesion of the rectum to the broad ligament. The vaginal canal was incised, and the uterus was transected, transvaginally morcellated and removed from the body cavity. Pathological examination revealed uterine leiomyoma, with no salpingeal abnormalities or endometriotic lesions. At 2 and 5 months postoperatively, the patient reported monthly genital bleeding; however, no apparent abnormalities were clinically observed. At 9 months postoperatively, the patient still experienced similar genital bleeding and noticed pain that occurred around the umbilicus simultaneously. Colposcopy revealed several red endometriosis-like lesions in the vaginal stump. The patient was eventually diagnosed with vaginal stump endometriosis. In addition, periodic pain appeared in the umbilical region as well, and the presence of endometriosis on umbilical port-site was suspected. Magnetic resonance imaging showed the umbilical trocar port-site endometriosis. Oral dienogest was started 11 months after surgery and maintained, and the patient's symptoms almost resolved after 5 months. <h3>Conclusion</h3> When patients complain of periodic genital bleeding or abdominal pain after total laparoscopic hysterectomy, vaginal stump and port-site endometriosis should be suspected. Vaginal stump endometriosis can be histologically diagnosed using colposcopy-guided biopsy, and dienogest may relieve symptoms.