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CASE REPORT
Year : 2018  |  Volume : 17  |  Issue : 3  |  Page : 204-206

Use of radioguided surgery in abdominal wall endometriosis: An innovative approach


Department of Surgery, Woman Health Investigation Group, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil

Date of Web Publication21-Jun-2018

Correspondence Address:
Hakayna Calegaro Salgado
San Sebastian Avenue, 740/503, Juiz de Fora, Minas Gerais
Brazil
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DOI: 10.4103/wjnm.WJNM_47_17

PMID: 30034288

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   Abstract 


Endometriosis is characterized by the presence of endometrial glands and stroma outside the uterine cavity. The occurrence of endometriosis in the anterior abdominal wall is often associated with previous cesarean section, once the spread of endometrial cells during the surgical procedure is a biologically fact possible. A 43-year-old patient, with cesarean section history and pelvic endometriosis diagnosed for over 10 years, presented with progressive abdominal pain. Tests showed cystic image with 1.6 cm of diameter and debris, located in mid-lower portion of the rectus abdominis left, suggesting abdominal wall endometriosis. This abdominal wall lesion was not identifiable in the clinical examination (impalpable), which is why we opted for the use of preoperative marking technique with radioisotope called Radioguided Occult Lesion Localization (ROLL). The use of ROLL in this case allowed rapid surgical identification of endometriotic lesion and its complete excision.

Keywords: Abdominal wall, endometriosis, technetium Tc 99m aggregated albumin


How to cite this article:
Vitral GS, Salgado HC, Rangel JM. Use of radioguided surgery in abdominal wall endometriosis: An innovative approach. World J Nucl Med 2018;17:204-6

How to cite this URL:
Vitral GS, Salgado HC, Rangel JM. Use of radioguided surgery in abdominal wall endometriosis: An innovative approach. World J Nucl Med [serial online] 2018 [cited 2021 Aug 3];17:204-6. Available from: http://www.wjnm.org/text.asp?2018/17/3/204/234890




   Introduction Top


Endometriosis is characterized by the presence of endometrial glands and stroma outside the uterine cavity.[1],[2] Its prevalence in the female population, according to the literature, reaches rates ranging from 5% to 15% and affects mainly women aged around 35 years.[3],[4]

It affects mainly the pelvic area, confined to serous peritoneal surfaces and intra-abdominal organs such as the ovaries, fallopian tubes, peritoneum, and rectovaginal septum.[5],[6] The extrapelvic endometriosis is considered a rare entity and is described cases with involvement of the bladder, bowel, and omentum, for example.[3],[6] There are also reported cases in scar tissue from previous abdominal incisions, including laparoscopy holding local, hernias repair, and laparotomy, collectively named abdominal wall endometriosis.[1],[5]

Many theories attempt to explain its pathogenesis, including, retrograde menstruation, lymphatic and vascular dissemination, metaplasia, and mechanical implementation.[4]

The occurrence of endometriosis in the anterior abdominal wall is often associated with previous cesarean section, once the spread of endometrial cells during the surgical procedure is a biologically fact possible. This is an opportunity for the inoculation of endometrial cells in the peritoneum and abdominal wall.[1],[2]


   Case Report Top


A 43-year-old patient, with surgical birth history (cesarean section) and pelvic endometriosis diagnosed for over 10 years, presented with progressive abdominal pain, despite being in use of levonorgestrel-releasing system (MIRENA ). Magnetic resonance image and ultrasound showed a cystic image with 1.6 cm of diameter and debris, located in mid-lower portion of the rectus abdominis left, suggesting abdominal wall endometriosis [Figure 1].
Figure 1: Abdominal wall ultrasound with hypoechoic image suggestive of endometriosis cyst

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This abdominal wall injury was not identifiable in the clinical examination (impalpable). After signature a postinformed and explained term of acceptance by the patient, we opted for the use of preoperative marking technique with radioisotope called Radioguided Occult Lesion Localization (ROLL ) [Figure 2]. With the help of the portable gamma probe, was obtained proper identification of endometriotic lesions, allowing for complete excision [Figure 3]. Pathological study of the surgical specimen confirmed abdominal wall endometriosis [Figure 4].
Figure 2: Scintigraphy after labeling with radioisotope guided by ultrasound

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Figure 3: Node location the endometrioma with the help of portable gamma probe

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Figure 4: Gland with endometrial stromal pattern (H and E, ×100)

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   Discussion Top


Endometriosis is considered as a condition devoid of cure. However, there are several types of treatment aimed at reducing their symptoms, especially pain, but also the improvement of fertility and sex life.[7]

One of therapeutic approaches for endometriosis is surgical excision of endometriomas either by laparoscopy or laparotomy.[8]

Women with abdominal wall endometriosis may experience cyclical abdominal pain, a palpable mass, no specific pelvic pain, dysmenorrhea, dyspareunia, irregular menstrual cycles, and infertility.[1],[4]

Considering its low frequency and the lack of familiarity with the subject, the diagnosis of abdominal wall endometriosis can be a problem, especially in cases of impalpable or subclinical lesions. Images of ultrasound and magnetic resonance are useful in the identification, characterization, and location of the wall endometriomas.[2]

The ROLL technique, used in mastology, is an approach for the localization and resection of nonpalpable breast lesions. It is based on intratumoral injection, under stereotactic or under the guidance of ultrasound, of a small amount of a radiopharmaceutical (Tc99) associated with a macroaggregated albumin. The drug's deposit works, then, as a marker of nonpalpable lesions. A gamma radiation detector probe is used during surgery to guide the excision of the marked area.[9],[10]

Due the ROLL's ability to mark subclinical breast lesions, we found ourselves faced with the possibility of using this technique as a way to help to identify, during the surgery, the suspicious lesion of impalpable endometrioma of the abdominal wall.

The use of ROLL in this case allowed rapid identification of endometriotic lesion and its complete excision.


   Conclusion Top


The difficulty of locating and addressing the impalpable endometriomas of abdominal wall is a promising new indication for the use of ROLL technique. In addition to increasing surgical precision, can positively impact the operative time and morbidity of the same, with its proven efficacy and safety in other surgeries.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Ecker AM, Donnellan NM, Shepherd JP, Lee TT. Abdominal wall endometriosis: 12 years of experience at a large academic institution. Am J Obstet Gynecol 2014;211:363.e1-5.  Back to cited text no. 1
    
2.
García-Gavilán Mdel C, Fernández-Pérez F, Hinojosa-Guadix J, González-Bárcenas ML. Rectus abdominal endometriosis on cesarean scar. Gastroenterol Hepatol 2016;39:341-3.  Back to cited text no. 2
    
3.
Mistrangelo M, Gilbo N, Cassoni P, Micalef S, Faletti R, Miglietta C, et al. Surgical scar endometriosis. Surg Today 2014;44:767-72.  Back to cited text no. 3
[PUBMED]    
4.
Tse SY, Chiu TW, Burd A. Scar endometriosis: A case report and review of the literature. Surg Pract 2011;15:57-60.  Back to cited text no. 4
    
5.
Ijichi S, Mori T, Suganuma I, Yamamoto T, Matsushima H, Ito F, et al. Clear cell carcinoma arising from cesarean section scar endometriosis: case report and review of the literature. Case Rep Obstet Gynecol 2014;2014:642483.  Back to cited text no. 5
[PUBMED]    
6.
Ramesh B, Chaithra TM, Gupta P, Prasanna G. Anterior abdominal wall scar endometriosis: An enigma. J Obstet Gynaecol India 2016;66 Suppl 2:636-8.  Back to cited text no. 6
    
7.
Fritzer N, Hudelist G. Love is a pain? Quality of sex life after surgical resection of endometriosis: A review. Eur J Obstet Gynecol Reprod Biol 2017;209:72-6.  Back to cited text no. 7
[PUBMED]    
8.
Yeung PP Jr., Logan I, Gavard JA. Deep retraction pockets, endometriosis, and quality of life. Front Public Health 2016;4:85.  Back to cited text no. 8
    
9.
Lovrics PJ, Cornacchi SD, Vora R, Goldsmith CH, Kahnamoui K. Systematic review of radioguided surgery for non-palpable breast cancer. Eur J Surg Oncol 2011;37:388-97.  Back to cited text no. 9
[PUBMED]    
10.
Zurrida S, Galimberti V, Monti S, Luini A. Radioguided localization of occult breast lesions. Breast 1998;7:11-3.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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