Scar endometriosis developing after an umbilical hernia repair with mesh.

Abstract: A 44-year-old female was initially evaluated for a 3-cm umbilical hernia, which developed after a laparoscopic myomectomy performed seven years prior. The umbilical hernia was repaired using a synthetic mesh. Eight months after the umbilical hernia repair, the patient returned with chronic pain in a 3-cm raised mass originating from the umbilical hernia repair incision. The mass and mesh were surgically removed. The umbilical fascial defect was repaired with a primary fascia-to-fascia closure and the umbilicus was reconstructed from adjacent skin. The mass was found histologically to be endometriosis and fascial scarring with a foreign body reaction to synthetic mesh. Umbilical endometriosis developed either from peritoneal endometrial seeding from a laparoscopic myomectomy or from metaplasia of multipotential cells, which developed into endometriosis due to inflammatory stimulation by the synthetic mesh. Synthetic mesh probably should be avoided in the surgical repair of a laparoscopically caused umbilical hernia in a premenopausal female especially if there is a history of pelvic endometriosis.

Key Words: foreign body reaction, scar endometriosis, umbilical hernia repair

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Endometriosis is present in 7 to 10% of women and is a difficult disease to treat during the reproductive years. (1) Endometriosis is defined as the presence of ectopic functional endometrial tissue outside of the uterine cavity. The most common locations are in the pelvis involving the ovaries, fallopian tubes, posterior cul-de-sac, uterine ligaments, rectovaginal septum and surrounding pelvic peritoneum. Endometriosis has been described in almost every area of the female body. The most common extrapelvic appearance of endometriosis occurs in scars following a variety of obstetric and gynecologic surgery. (2) Umbilical endometriosis has been reported spontaneously or after various surgical procedures. (3) We are reporting the unusual development of umbilical endometriosis after an umbilical hernia repair with mesh.

Case Report

The patient was a 44-year-old black female who was referred for repair of an umbilical hernia. The umbilical hernia developed through a previous trocar site used seven years prior for a laparoscopic myomectomy to remove a uterine fibroid. During the umbilical exploration, a 3-cm umbilical defect was found. The defect was repaired with a polypropylene mesh.

Nine months after the umbilical hernia repair, the patient returned with chronic pain in a 3-cm raised mass originating from the previous hernia repair incision (Fig. 1). The patient retrospectively related to having the symptom of increased cyclic pain in the umbilical mass with menstruation, which is characteristic of endometriosis. The preoperative diagnosis was a large keloid, which developed from the previous umbilical surgical procedure. The patient was returned to the operating room where the mass was excised and the mesh was removed. The hernia was repaired primarily without mesh, and reconstruction of the umbilicus followed. The pathology report revealed endometriosis, fascial scarring and foreign body reaction to synthetic mesh (Fig. 2). The patient recovered and returned to work several weeks later without pain.

Discussion

Cutaneous endometriosis may occur spontaneously in the physiologic scar of the umbilicus. (3) Umbilical endometriosis may also develop in the surgical scar after abdominal procedures. (4) Several cases have been reported of umbilical endometriosis occurring after laparoscopic surgical procedures where a trocar was placed through the umbilicus. (5-8) As the use of laparoscopic techniques in surgery becomes more frequent, the development of endometriosis in laparoscopic trocar sites through the umbilicus will probably increase, particularly when used in women with pelvic endometriosis. (8) Umbilical hernias occur after laparoscopic surgery if the abdominal wall fascia is not carefully closed. Mesh has been used frequently in umbilical hernia repairs if the fascial defect is greater than 2 cm. The use of mesh in this patient, with the concomitant inflammatory foreign body reaction, may have lead to the development of an umbilical endometrioma.

[FIGURE 1 OMITTED]

There are two main theories extant in the literature which attempt to explain the origin of scar endometriosis. (4) The transport theory posits retrograde regurgitation of endometrial cells through the fallopian tubes, vascular or lymphatic spread, or direct implantation in surgical scars. The metaplasia theory holds that cells which have retained primitive multipotential are located in extra-uterine sites. These cells can undergo metaplasia under the proper stimulus to produce endometriosis, according to the theory. (4)

[FIGURE 2 OMITTED]

Umbilical endometriosis in this patient could have occurred by either method. Endometrial cells could have been transported to the umbilicus at the time of a laparoscopic myomectomy seven years before the umbilical hernia repair. The placement of mesh in the umbilical hernia defect and the subsequent inflammatory foreign body reaction may have stimulated multipotential cells in the umbilicus to undergo metaplasia into endometrial cells. It has been suggested previously (9) that chronic inflammation may stimulate the development of endometrioid tissue in the kidney through metaplasia of renal tissue. Inflammation and fibrosis are characteristically found histologically in the vicinity of cutaneous endometriosis. (4,10)

Clinical diagnosis of scar endometriosis can be made by a careful history and physical examination. If women of reproductive age relate symptoms of increased cyclic or noncyclic pain, bleeding, or increase in the size of scar tissue at the time of menstruation, scar endometriosis should be suspected. Diagnostic tests such as computed tomography, (11) magnetic resonance imaging, (7,12) ultrasound, (13) and fine needle biopsy (14) have been used with varying degrees of success and accuracy to establish the diagnosis of scar endometriosis.

Medical management of scar endometriosis has been reported, but recurrence on cessation of therapy is almost inevitable. (2.15-7) Surgical resection is the treatment of choice for scar endometriosis because it provides simultaneous diagnosis and therapy. Excision of the mass should be complete, with margins wide enough to prevent recurrence. Mesh, such as was initially used in this patient, should be completely removed. The use of mesh in umbilical hernia repairs in patients with a previous history of endometriosis probably should be avoided due to the inflammatory foreign body reaction. The umbilical hernia should be repaired with a tissue-to-tissue repair. The umbilicus should be reconstructed if enough skin is available.

The more I want to get something done, the less I call it work.
--Richard Bach

Accepted January 8, 2004.

Copyright [c] 2004 by The Southern Medical Association

0038-4348/04/9705-0532

References

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RELATED ARTICLE: Key Points

* Umbilical endometriosis may occur spontaneously, or following surgical procedures involving the umbilicus.

* Umbilical endometriosis may develop from peritoneal endometrial seeding or from metaplasia of multipotential cells which can develop into endometriosis due to inflammatory stimulation.

* Synthetic mesh probably should be avoided in surgical repair of a laparoscopically-caused umbilical hernia in a premenopausal female with a history of pelvic endometriosis.

James Majeski, MD, PHD, and James Craggie, MD

Reprint requests to James Majeski, MD, PhD, 900 Bowman Road, Suite 100, Mt. Pleasant, SC 29464.