Endometriosis post-operative scars

The defeat of postoperative scars refers to the most common localizations extra genital endometriosis. Thus, in 1934, N. Harbitz published 193 observations of endometriosis laparotomic scars. N. Wespi and M. KJetz-handler (1940) summarized 390 observations, of which 73 took place only in one clinic for 16 years. The authors noted that their information is not exhaustive and are concerned only with laparotomic scars. Not here included endometriosis scars on the perineum and vagina. In 1957, So Gottlieb submitted information on 100 patients with endometriosis, vaginal scarring after vaginal cesarean section.
We do not deal specifically with endometriosis this localization. Nevertheless, over the last 30 years endometriosis in laparotomic scars was observed in 49 patients. All of them were operated.
Endometriosis in the postoperative scars may be the only localization of the disease in women alone and combined with endometriosis, pelvic and abdominal cavity - other. The last option is more common after operations on pelvic organs.
The vast majority of patients endometriosis develops as a result of implantation of the pieces of the endometrium in the edges of the wound during obstetric and gynecological operations related to the opening of the uterus. Often this opportunity may arise during cesarean section, husking fibromatous sites, operation with regard to cystic forms of endometriosis, ovarian, entropically uterus, operations on the occasion of perforation of the uterus. More rarely it may take place after operations on other localizations intraperitonealno endometriosis (in the extension horn of the uterus, fallopian tubes, intestines, pozavcherashny localization and when adenomyosis of the uterus), after operations on the occasion of ectopic pregnancy and diseases of the fallopian tubes (pyosalpinx, hydrosalpinx). Endometriosis in abdominal scars may occur because of the growth of the endometrium in utero-brunetoochka fistula after cesarean section, from the stump of the uterus and fallopian tubes, as well as of the foci of endometriosis, pelvic (more often endometrioid ovarian cysts) and abdomen (endometriosis intestine). The defeat of the vaginal scarring, apparently, most often occurs as a result of germination endometrial from the bottom of the Department or of the isthmus of the uterus at the scar on the uterus and then into the vagina.
Endometriosis scars after episiotomy and perineostomy not difficult to explain implantation of the endometrium during labour (especially in the application of obstetrical forceps for manual separation of the placenta, tool or manual revision of the uterus) or in the early postpartum period.
Much less endometriosis scars develops after operations not connected with the sexual organs. So, the well-known observations of endometriosis scars after appendectomy, Greenacre, cholecystectomy, resection of the stomach and intestine, blending suprapubic fistula and other operations. We observed the development of endometriosis in the rumen after removal of fibroadenoma left breast and other ill - after cosmetic surgery on the face.
Most likely in such situations it seems hematogenous or lymphogenous entry elements of the endometrium in the field of postoperative scars. The rejection of the pieces of the endometrium and hit them in the flow of lymph and blood can help abortion, diagnostic curettage of the uterus, hydrotubation, childbirth and menstruation.
In addition, endometriosis scars after surgery, not connected with the sexual organs, can be the result of the inclusion of menstrual blood with particles endometrial hands of a surgeon, tools or gauze napkins. This option is available when the transaction is made in time and in the first days after month and part of menstrual blood retrograde tubal ligation gets to the pelvic organs, adjacent intestine and in utero-pryamokishechnye deepening.
It is considered that endometriosis scars develops earlier after obstetric and gynecological operations, and this happens in most patients within 1-3 years, and much later, after surgical interventions, not connected with the sexual organs. The earliest development of endometriosis in abdominal scars watched L. Kimball, W. Reeves (1957) in 2 patients after 4 and 6 months after surgery about perforation of the uterus, produced during curettage of the uterus in connection with the early postpartum bleeding.
A. Pfleiderer (1933) issued a statement about the development of endometriosis in abdominal scar through 24 years after surgery about appendiceal abscess.
In our observation (sick A., 40 years) endometriosis scar on the left breast developed in 3 months after the removal of pigment spots. In addition, the patient was adenomyosis of the uterus with a rather pronounced clinical manifestations.
The patient's Acting, 14 years old, endometriosis in the rumen has evolved over 5 months after surgery about endometrioid cysts right ovary.
We saw patients with endometriosis abdominal scar developed 26 years after appendectomy produced in the age of 9. The features of this observation was the fact that such a late development of endometriosis in the postoperative scars in the available literature could not be found. In addition, endometriosis have developed never veremeeva women who are not undergoing any vaginal and uterine manipulations and operations.
Returning to the question of the dependence of time of development of endometriosis on the nature of the operations (earlier after obstetric and gynecological operations and later after surgical interventions, not connected with the sexual organs), it should be noted that a similar dependence is observed not in all patients. Literature data and our observations indicate its absence at least 1/3 of the patients. Apparently, is not only the nature of the operation (for sexual or other bodies), but hormones, and changes in the immune system in the body of patients during surgery and subsequent time.
It would seem, diagnosis of endometriosis post-operative scars should not cause difficulties. Yet the disease is often mistaken for inflammatory infiltrate, and spend a long time resolving treatment, including thermal treatments, from which the pain worsens. In some patients with paroxysmal pain resulting from involvement in the process of peritoneal mistaken for disadvantaged ventral hernia.
As a rule, patients complain of the occasional pain in the postoperative scar before and during menstruation. Pain may be different in intensity: from dull aching to painful "pinging". Sometimes the pain take paroxysmal character and may be accompanied by nausea and vomiting. The clinical picture resembles a strangulated hernia and occurs when endometriosis captures the entire thickness of the abdominal wall, including the peritoneum. At the end of menstruation pain subside. Apart from the pain, many patients noted the appearance of dark brown or bloody discharge from the scar during menstruation. Allocation stain the underwear. The more intense the highlight, the less pain, and Vice versa.
In the period of strengthening the pain in the scar felt tight painful nodules or cysts education in size from a pea to cherries and larger. One of our patients conglomerate nodes of endometriosis in the thickness of the front abdominal wall represented the mass 11X8X6 see he Developed 16 years after the resection of the small intestine. The color of these formations varies from blue to brown. Especially well they are visible during menstruation. In this period of pin holes allocated blood or brown liquid. Skin and scar tissue around the hole and on the sites can be pigmented (brown color).
In addition to these complaints, some patients noted the appearance of local itching in the area of the scar. Quite often, there is high humidity of a skin in the nodes of endometriosis scars.
Of the 49 patients operated by us for endometriosis post-operative scars, 42, was identified genital endometriosis and 6 set the intestinal damage. In 12 patients endometriosis developed after cesarean delivery, 8 - after appendectomy, 4 - after operations about ectopic pregnancy, 3 - after Greenacre, 9 - after removal of the "chocolate" ovarian cyst, 5 - after supracervical amputation of uterus, 1 - after removal of fibroadenoma of the breast, 1 - after the surgery about perforation of duodenal ulcer, 1-after resection of the small intestine, in 5 after surgery about perforation of the uterus during abortion.