A multiparous obese patient with prior abdominal surgeries complained of cyclic abdominal pain located near the surgical scar. A 1 cm lesion was identified on imaging. Computed tomography–guided needle localization was performed immediately before surgery. This allowed for complete excision of the abdominal wall endometrioma and resolution of the cyclic, focal abdominal pain.
Problem: obese patient with suspected abdominal wall endometrioma, difficult to localize on physical examination
A 27 year old obese (37.2 kg/m 2 ) multiparous woman presented with left lower quadrant pain, localized to her Pfannenstiel cesarean incision. Her general surgeon ruled out hernia with a computed tomography (CT) scan, but our team noted that her area of pain localized to an area described on the scan as a small density, probable artifact. Based on her clinical presentation, endometriosis of the abdominal wall was suspected; however, we did not suspect she had intraperitoneal disease based on her prior surgery (performed by M.T.S.). A follow-up pelvic magnetic resonance imaging with contrast demonstrated a 1.1 cm nodular soft tissue mass within the anterior abdominal wall involving the left lateral rectus muscle, consistent with an endometrioma ( Figure 1 ).
Our solution
The nodular focus was difficult to localize on physical examination because its small size and the patient’s habitus. As such, we determined that localization was necessary for targeted surgical excision, and Interventional Radiology was consulted for needle biopsy localization under CT-guidance.
On the day of surgery, with CT-guidance, 2 Kopans breast lesion localization needles, 15 cm in length (Cook, Inc, Bloomington, IN) were inserted around the nodule from angled and near perpendicular approaches and localization wires deployed. Completion CT scans confirmed the wires to be adjacent to the nodule ( Figure 2 ).
