CLOSURE OF THE ANTERIOR PERITONEUM AT THE TIME OF CESAREAN SECTION MAY REDUCE THE INCIDENCE OF POSTOPERATIVE DEVELOPMENT OF INCISIONAL ENDOMETRIOMA

S. Minaglia, C. Ballard, D.R. Mishell, Jr

USC-Keck School of Medicine, Los Angeles, CA

OBJECTIVE: Endometriomas developing in the scar of the skin incision performed for cesarean section have been well described.  The incidence of this postoperative lesion at a large hospital treating medically indigent individuals has apparently increased since closure of the anterior peritoneum is no longer performed at the time of cesarean section.

MATERIALS AND METHODS:  All patients diagnosed with incisional endometrioma at the time of surgical excision from 1975-2004 were identified from the surgical database. The medical records of 27 patients with this diagnosis who had surgical excision during 1995-2004 were reviewed. Data included patient age, type of incision at time of last cesarean section, presentation, preoperative assessment, time to diagnosis, size of mass, and management.  From 1975-1995, 4 patients with incisional endometrioma were identified from the same database.  Their medical records were no longer available for review.  Chi squared analysis was utilized where appropriate.

RESULTS: At this institution, closure of the anterior peritoneum at the time of cesarean section stopped being performed during 1991.  No other major changes in surgical technique were undertaken.  The 27 patients with endometrioma in the skin incision had a prior cesarean section performed through either a Pfannenstiel (n=21) or vertical (n=6) incision.  Time from the last cesarean section to diagnosis of skin endometrioma ranged from 6 months to 9 years with a mean time of 3.5 years.  Medical therapy with GNRH agonist, medroxyprogesterone acetate, or combination oral contraceptives had been attempted in 13 patients without change in lesion.  All patients were cured by surgical excision of the endometrioma. A total of 4878 cesarean sections between 1995-2004 were performed at this institution.  During the time 27 women (0.6%) were diagnosed with incisional endometrioma of the skin incision at the cesarean section scar.  Between 1975-1995, approximately 44,000 cesarean sections were performed at this institution and only 4 women presented with incisional endometrioma following a cesarean section for an estimated incidence of 0.01% (p<0.0001).

CONCLUSION: The incidence of incisional endometrioma following cesarean section increased from an estimated .01% to 0.6% during the period when routine closure of the anterior peritoneum at the time of cesarean section ended.  Closure of the anterior peritoneum at the time of cesarean section may markedly decrease the postoperative occurrence of an endometrioma in the skin incision scar.

Key Words: endometriosis, incisional endometrioma, surgical excision 

Disclosure – Nothing to disclose.