Ultrasound-guided Spinal Needle Localization for Resection of Abdominal Wall Endometrioma

Abstract

A 47-year-old patient with 2 previous cesarean sections presented with 2 years of right lower quadrant spasm-inducing pain. The pain began with menses and lasted for 15 days each month. Magnetic resonance imaging revealed a 3.3 × 1.9 × 6.0-cm lesion in the medial aspect of the right rectus abdominis muscle, consistent with abdominal wall endometrioma (Fig. 1A). No fascial involvement was identified. At the time of surgery, intraoperative ultrasound was used to map the endometrioma (Fig. 1B). Under ultrasound guidance, the endometrioma borders were marked using 3.5-cm 20 gauge needles through the anterior abdominal wall (Fig. 2). During robotic-assisted excision of the endometrioma, the needles were intermittently advanced and withdrawn from the peritoneal cavity by the bedside assistant to delineate the limits of necessary dissection (Fig. 3). This technique contributed to efficient and complete excision. Postoperatively, the patient reported complete resolution of right lower quadrant pain. Final pathologic evaluation confirmed extensive endometriosis. Abdominal wall endometriosis (AWE) is most often found in previous abdominal surgical incisions. In women undergoing surgical excision of endometriosis, AWE was noted in 1.34% [1Khan Z Zanfagnin V El-Nashar SA Famuyide AO Daftary GS Hopkins MR. Risk factors, clinical presentation, and outcomes for abdominal wall endometriosis.J Minim Invasive Gynecol. 2017; 24: 478-484Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar]. The most common procedure before AWE is cesarean section with a higher risk reported with Pfannenstiel incision vs vertical midline incision [1Khan Z Zanfagnin V El-Nashar SA Famuyide AO Daftary GS Hopkins MR. Risk factors, clinical presentation, and outcomes for abdominal wall endometriosis.J Minim Invasive Gynecol. 2017; 24: 478-484Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 2Horton JD Dezee KJ Ahnfeldt EP Wagner M. Abdominal wall endometriosis: a surgeon's perspective and review of 445 cases.Am J Surg. 2008; 196: 207-212Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar, 3Zhang P Sun Y Zhang C et al.Cesarean scar endometriosis: presentation of 198 cases and literature review.BMC Womens Health. 2019; 19: 14Crossref PubMed Scopus (23) Google Scholar]. Cesarean scar endometriosis is likely secondary to direct implantation of endometrial tissue in the incision [2Horton JD Dezee KJ Ahnfeldt EP Wagner M. Abdominal wall endometriosis: a surgeon's perspective and review of 445 cases.Am J Surg. 2008; 196: 207-212Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar]. Surgical excision allows pathologic evaluation and therapeutic resection [4Karapolat B Kucuk H. A rare cause of abdominal pain: scar endometriosis.Emerg Med Int. 2019; 20192584652Crossref PubMed Google Scholar,5Behbehani S Magtibay P Chen L Wasson M. Clear cell carcinoma of the anterior abdominal wall secondary to iatrogenic endometriosis.J Minim Invasive Gynecol. 2020; 27: 1230-1231Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. Excision is often planned with preoperative ultrasound or magnetic resonance imaging. Previously reported surgical approaches to AWE include ablative techniques such as percutaneous cryoablation or ethanol injection [6Welch BT Ehman EC VanBuren WM et al.Percutaneous cryoablation of abdominal wall endometriosis: the Mayo Clinic approach.Abdom Radiol (NY). 2020; 45: 1813-1817Crossref PubMed Scopus (6) Google Scholar]. If AWE involves the fascia, surgical excision can still be performed by a minimally invasive approach with endoscopic mesh placement and fascial repair by general surgery. Intraoperative techniques to assist with excision include injecting the lesion with methylene blue or ultrasound-guided wire localization [7Lee MMH Robson NK Carpenter TT. Ultrasound-guided wired localisation for resection of impalpable anterior abdominal wall scar endometriomas.Gynecol Surg. 2012; 9: 103-105Crossref Scopus (2) Google Scholar,8Takmaz T Kiran G Ozcan P Sahin N Tanoglu B. Total surgical excision by ultrasound–guided wire localization for spontaneous abdominal-wall endometriosis.J Gynecol Surg. 2020; 36: 76-79Crossref Scopus (1) Google Scholar]. Ultrasound-guided localization with spinal needles is a simple, practical technique that can assist with complete excision of abdominal wall endometriomas.