Materials and Methods

Following approval by the University of Pittsburgh Institutional Review Board, a retrospective review was performed of all hospital and office charts of patients treated for AWE at the University of Pittsburgh Medical Center between March 2001 and April 2013. Cases were identified by International Classification of Diseases , ninth revision, codes and confirmed via pathological specimen diagnosis ( Figure 1 ). Cases were excluded if endometriosis was limited to the peritoneal layer alone.

Histology of an abdominal wall endometrioma

In this microscopic view of an excised abdominal wall endometrioma, endometrial glands ( dotted arrow ) are inappropriately adjacent to skeletal muscle ( dashed arrow ) and adipose cells ( solid arrow ).

Ecker. Abdominal wall endometriosis: a 12 year experience. Am J Obstet Gynecol 2014 .

Chart review extracted the following data: age at the time of excision, gravity/parity, race, body mass index (BMI), prior medical and surgical history, time to presentation/excision, specialty of primary surgeon, and incision type (open vs laparoscopic) as well as location and tissue layers involved.

Statistical analysis was performed using SPSS version 20 (IBM, Armonk, NY). Continuous data are reported as mean and SD when normally distributed, and as median and interquartile range (IQR) when not normally distributed. The comparisons of normally distributed, continuous data were made with a Student t test and an analysis of variance. The nonnormally distributed, continuous data were analyzed with Mann-Whitney U tests. The categorical data were analyzed with χ ² and Fisher exact tests and are presented as counts and percentages.

Results

A search based on the International Classification of Diseases , ninth revision, identified 98 potential subjects of which 90 records were available for review. An additional 25 subjects were excluded for either lack of pathologically confirmed endometriosis or endometriosis limited to the peritoneal cavity. Ultimately, 65 subjects who underwent the excision of pathologically confirmed AWE by a variety of subspecialty surgeons at our institution between March 2001 and April 2013 were analyzed. The mean patient age at the time of excision was 35 ± 8 years but ranged from 21 to 52 years. The majority were overweight or obese (70.8%), white (75.4%), and multiparous (87.3%). Additional patient characteristics are presented in Table 1 . The majority presented with complaints of abdominal pain (73.8%) and/or a mass (63.1%). Other associated symptoms included dysmenorrhea, pelvic pain, dyspareunia, and bowel or bladder symptoms ( Table 1 ). Two patients (3.1%) were asymptomatic and were incidentally diagnosed at the time of an unrelated surgery. A total of 30.8% of the patients were on pain medications at the time of presentation.

In our patient population, 81.5% reported a surgical history that included at least 1 cesarean section ( Table 1 ). Interestingly, 6 patients (9.2%) had no prior surgical history, and the lesions in these cases were in the groin (n = 2) or umbilicus (n = 4). Five patients with a prior AWE excision (7.7%) underwent a second excision during the study period. The time from the initial relevant surgery of any kind to excision ranged from 1 to 32 years (median, 7.0 years; IQR, 4–11.5) and time from the most recent surgery ranged from 1 to 32 years (median, 4.0; IQR, 3–7). Both time intervals were recorded because it is impossible to determine which surgery was the potential inciting event. There was no difference in time from the initial surgery or most recent relevant surgery to excision (suggesting a delay in treatment) if the patient presented with abdominal pain alone ( P = .59, P = .19).

The majority of patients with a prior cesarean section had pain at or near their prior incision (32.7% right lower quadrant, 32.7% left lower quadrant, and 16.3% nonspecific scar pain). Women with a prior cesarean section were significantly more likely than women without cesarean to have incisional lesions at the following locations: right (36.5% vs 8.3%), left (46.2% vs 0%), midline (11.5% vs 0%), ( P < .001), but women without cesarean sections were more likely to have lesions at the umbilicus ( Table 2 ). Nulliparous women also had higher rates of umbilical pain and lesions ( Table 3 ).

For our purposes, skin was considered the deepest layer involved because of the presumed inoculation from the peritoneum directed outward. However, for completeness, the statistical analysis was also conducted with the peritoneal layer considered the deepest layer to ensure no false-negative findings. We were unable to show that an increasing number of cesarean sections influenced the depth of involvement ( P = .418) or decreased the time to excision from either the initial or most recent relevant surgery ( P = .543 and P = .075). Women without a prior cesarean section were more likely to have only skin involvement (16.7% vs 0%, P = .027), which correlates with their increased rates of umbilical involvement.

Our institution has no standardized protocol for preoperative diagnostic testing in these cases. Imaging varied by provider and 20% of patients (n = 13) had no preoperative imaging. Studies performed included abdominal and/or pelvic ultrasound, computed tomography, magnetic resonance imaging, and fine-needle aspiration ( Table 1 ). Two providers utilized preoperative wire localization of the lesion in a total of 4 cases. Obesity was the only patient characteristic that predicted whether imaging was obtained but only for pelvic ultrasound (32% vs 10%, P = .03). Pelvic ultrasounds were ordered by all gynecological oncologists, 20.5% of gynecologists, and none of the general or plastic surgeons. We did not find a difference in imaging based on parity ( P = .978).

The majority of AWE excisions were performed via open incision (75.4%; Table 4 ). The surgical approach utilized was not associated with the location of the lesion ( P = .198) or the depth of invasion ( P = .978). Gynecologists, including minimally invasive subspecialists, reproductive endocrinologists, and gynecological oncologists, performed 77% of the surgeries ( Table 4 ). One hundred percent of the cases performed by plastic surgeons involved the skin layer, but only 18.2% performed by general surgeons and 0% by gynecologists involved the skin ( P = .018). We did not appreciate any differences when comparing the surgeon type to the presenting complaint, surgical approach, and/or time from first and most recent relevant surgery (data not shown).

Table 4

Surgical characteristics at time of AWE excision ^a

Characteristic	n (%)
Surgical approach
Laparoscopic	5 (7.7)
Open	49 (75.4)
Combined	11 (16.9)
Primary surgeon
General gynecologist	44 (72.1)
Gynecologic oncologist	3 (4.9)
General surgeon	11 (18)
Plastic surgeon	3 (4.9)
Layers excised b
Skin	12 (18.8)
Subcutaneous/adipose	62 (96.9)
Fascia	43 (67.2)
Muscle	11 (17.2)
Peritoneum	13 (20.3)
Location of excised tissue
Lateral incision, right	20 (31.3)
Lateral incision, left	24 (37.5)
Incision, midline	6 (9.4)
Incision, nonspecific	3 (4.7)
Groin	2 (3.1)
Umbilicus	9 (14.1)

AWE , abdominal wall endometriosis.

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