Abdominal wall endometriosis: pathogenesis, diagnosis, and update on minimally invasive treatment options: a narrative review

Introduction

Abdominal wall endometriosis (AWE) is a rare presentation of extrapelvic endometriosis, characterized by the presence of endometrial-like tissue on the abdominal wall. According to various reports, the incidence of AWE ranges from 0.03% to 3.5% (1-3).

AWE primarily develops through tissue trauma mechanisms, often associated with prior abdominal or pelvic surgeries, particularly cesarean births, with an incidence of 0.03% to 1.3% among women undergoing such procedures (4). Although, most associated with a prior surgical incision, AWE can occur spontaneously without a prior surgery as in one third of cases of umbilical endometriosis (5).

In cases of prior surgeries, the proposed mechanism involves the translocation of endometrial cells to the abdominal wall during these procedures, although this does not explain the cases of spontaneous presentation.

Piriyev et al. proposed a classification that categorizes the condition based on localization, depth of infiltration, and nodule size. Localization is divided into cesarean scar (CS), accessory trocar (T), pure/primary umbilical endometriosis with no previous surgery (U1), umbilical endometriosis with a history of previous surgery (U2), and other locations (O). The depth of infiltration is classified as epifascial (subcutaneous ± fascia), subfascial (rectus muscle ± fascia), and total infiltration, which includes the subcutaneous tissue, fascia, and rectus muscle. Nodule size is categorized as less than 3 cm or equal to or greater than 3 cm (6).

This condition usually presents with cyclic and non-cyclic pain and a palpable mass. However, diagnosis can be challenging and delayed due to its varied presentation. Imaging studies utilized for diagnosis include ultrasound (US) and magnetic resonance imaging (MRI), with histopathological confirmation being the gold standard. Given the increasing rates of cesarean deliveries worldwide, the incidence of AWE is a growing concern, underscoring the need for greater awareness and effective management strategies (7).

The mainstay of treatment has traditionally been wide local surgical excision via open surgical approach. However, newer treatments are emerging, including percutaneous cryoablation, radiofrequency ablation (RFA), microwave ablation (MWA) and high-intensity focused ultrasound (HIFU) and sclerotherapy with ethanol and other agents. These minimally invasive techniques offer promising alternatives to conventional surgery, potentially reducing complications and recovery times.

This narrative review aims to synthesize current knowledge on the pathogenesis, diagnosis, and treatment options for AWE, identifying gaps in the literature and guiding future research and clinical practice. We present this article in accordance with the Narrative Review reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-24-33/rc).

Methods

A comprehensive literature search was conducted to identify relevant studies on AWE using PubMed database. The search covered articles published from 2008 to 2024. Both Medical Subject Headings (MeSH) and free text search terms were utilized to ensure a thorough search. The search terms included “abdominal wall endometriosis”, “AWE”, “pathogenesis”, “diagnosis”, “treatment”, “surgical excision”, “radiofrequency ablation”, “microwave ablation”, “high-intensity focused ultrasound (HIFU)”, “sclerotherapy” and “cryoablation”. The full search strategy for each database is detailed in Table 1.

Our inclusion criteria comprised articles published in English that focused on clinical, pathogenetic, and therapeutic aspects of AWE. We included randomized controlled trials (RCTs), cohort studies, case-control studies, case series, case reports and systematic reviews. Our exclusion criteria included articles published in languages other than English, as well as editorials, commentaries, or letters.

Results

Presentation

Patients with AWE often report a palpable, painful mass that coincides with the location of a prior surgical scar. The mass may become more painful and noticeable during menses due to hormonal influences on the endometrial tissue (3,4,8).

Additionally, some cases describe the presence of a mass with discharge or bleeding that coincides with hormonal changes (9).

Sites of occurrence

• Cesarean birth scar (CS): most AWE cases are associated with a prior cesarean birth scar (3,4);
• Laparoscopic accessory trocar port sites;
• Pure/primary umbilical endometriosis with no previous surgery: there are cases where AWE develops spontaneously, without any prior surgical intervention. This suggests that other mechanisms, such as hematogenous or lymphatic spread of endometrial cells, might play a role (6,10);
• Umbilical endometriosis with a history of previous surgery;
• Other abdominal or vaginal surgeries: AWE can also occur at other surgical sites, leading to the implantation of endometrial cells during the procedure (11).

Differential diagnosis

AWE is a complex diagnosis, and other conditions need to be considered as differentials, including:

• Hernias: due to the presence of a mass and pain, AWE can be mistaken for incisional or umbilical hernias (12);
• Hematomas: post-surgical hematomas can present similarly with pain and a palpable mass at the surgical site (12);
• Tumors: both benign and malignant tumors of the abdominal wall must be considered, especially if the mass is rapidly growing or associated with systemic symptoms (13,14).

Risk factors

Several risk factors have been suggested for AWE, including:

• Cesarean birth as the most significant risk factor. The risk has not been shown to have relation to the number of cesarean sections (6).
• Other surgeries: including gynecologic abdominal, vaginal, and laparoscopic procedures (15). These surgeries pose a risk of transplantation and implantation of endometrial cells to the surgical site.
• Obesity: higher body mass index (BMI) has been associated with increased risk of AWE in some studies, the suggested mechanism is due to technical challenges in optimal surgical closure, which could lead to endometrial cells being implanted in the abdominal wall (4,15). Although this was not confirmed by other authors where no association was found between higher BMI and AWE occurrence (6).

Pathogenesis of AWE

Iatrogenic mechanism

The most widely accepted theory is that AWE occurs due to the direct implantation of endometrial cells into the abdominal wall during surgical procedures such as cesarean births and hysterectomies. The mechanical disruption during these surgeries could lead to endometrial tissue being inadvertently transplanted to the incision site. During the healing process, the environment can be conducive for endometrial cells to implant and proliferate, leading to the development of endometriotic lesions in the abdominal wall (3,8,16). This theory does not account for the spontaneous presentation of AWE.

Hematogenous or lymphatic spread

One proposed mechanism for the spontaneous development of AWE is the hematogenous or lymphatic spread of endometrial cells. This theory suggests that endometrial cells can enter the blood or lymphatic circulation and subsequently implant in distant sites, including the abdominal wall. These ectopic cells then proliferate and form endometriotic lesions under the influence of hormonal changes (17).

Coelomic metaplasia

Another theory is coelomic metaplasia, which proposes that the peritoneal lining or mesothelial cells can transform into endometrial-like cells under certain conditions. This metaplastic transformation can be induced by chronic inflammation, hormonal changes, or genetic predisposition, leading to the development of endometriotic lesions in the abdominal wall. This theory also accounts for the potential malignant transformation of AWE (13,14,18).

Hormonal factors

Estrogen stimulation is important in the growth and development of endometrial cells in AWE. These ectopic cells express estrogen receptors, which mediate their responsiveness to hormonal changes. Similar to other phenotypes of the disease, there is evidence of genetic and epigenetic changes that contribute to the pathogenesis of AWE (19).

Diagnosis

The diagnosis of AWE is based on clinical suspicion, followed by imaging studies, and confirmed by histopathology. The most common imaging modalities utilized are US and MRI (3). A definitive diagnosis is made by histopathology.

Treatment

Surgical excision

Currently, the standard treatment for AWE is wide excision of the lesion through an open surgical approach with at least 1 cm margins. However, since most cases involve lesions located above the fascia, the procedure does not typically require a full laparotomy. Instead, a more localized incision is sufficient to ensure complete excision of the affected tissue laparotomy. This procedure has high cure rates of up to 95%. In the rare instances where larger excisions are required, a multidisciplinary approach is recommended involving gynecology, plastic surgery, or general surgery for abdominal wall reconstruction with or without mesh placement (8,20).

Outcomes

Surgical excision is considered a highly effective procedure, providing 85–95% symptom relief. However, it is an invasive approach with high rates of postoperative pain. The length of hospital stay varies depending on the extent of the lesion and the required excision and repair, including mesh placement for larger lesions (>3–4 cm). Benedetto [2022] reported a mean hospitalization time of 16 hours, ranging from 3 to 36 hours, with most patients typically staying in the hospital for 1–2 days. Other studies have described hospital stays of up to 5 days for larger excisions (1,21,22). Due to the invasive nature of the procedure, recovery times range from 4 to 6 weeks.

Complications related to wide surgical excision include infection in 5–10%, hernia formation with 2–5%, and adhesions in 3–8% of cases (1,3,23).

The reported recurrence rates vary greatly with different studies and reports but generally fall within the range of 1.25% to 10%, with positive surgical margins being a significant risk factor for recurrence (3,6,21,24-27).

There are a couple of video case reports of minimally invasive techniques used to excise AWE, including conventional laparoscopy and robotic-assisted excision with the use of US (28-30). However, there have not been case series or larger studies evaluating these approaches.

Minimally invasive interventional procedures

There has been a focus on developing other interventions to treat AWE that offer less morbidity, faster recovery, and fewer complications. These include percutaneous image-guided cryoablation, RFA, MWA, US-guided HIFU, and sclerotherapy.

Histopathologic confirmation is recommended if nonsurgical treatment is chosen, typically via fine-needle aspiration (FNA) cytological analysis, to avoid missing benign or malignant tumors (12). Table 2 contains a summarized comparison between treatment modalities.

Percutaneous cryoablation

This minimally invasive technique uses extreme cold to destroy endometriotic tissue, involving cryoprobes inserted under imaging guidance [US or computed tomography (CT)]. The procedure lasts 1–2 hours and is considered safe with low complication risks. Common adverse effects include minor localized pain, swelling, and bruising (16,19,31,32,34).

Outcomes

Cryoablation effectively reduces pain and lesion size in 80–90% of patients. Rare complications include infection, bleeding, and damage to adjacent structures (33,35). The recurrence rate ranges from 10–15%, making it a viable alternative to surgical excision for patients with AWE (36,37).

RFA

RFA uses heat generated by radio waves to destroy endometriotic tissue. The procedure, which lasts about 1–2 hours, involves a needle-like probe inserted into the lesion, guided by imaging (US or CT). Patients are monitored post-procedure and usually discharged the same day (38,39).

Outcomes

RFA is safe, with minor localized pain, swelling, and bruising being the most common adverse effects. Studies show RFA reduces pain and lesion size in 80–90% of patients, with recurrence rates of 5–10% (27,38,40,41). Rare complications include infection, bleeding, and damage to adjacent structures.

MWA

MWA uses microwave energy to generate heat and destroy endometriotic tissue. The procedure lasts 1–2 hours and is guided by imaging techniques (US or CT). Patients are typically discharged the same day after monitoring (38,42,43).

Outcomes

MWA is effective in reducing pain and lesion size in 85–95% of patients. It is considered safe, with minimal complications such as localized pain and swelling. Recurrence rates are relatively low, at 5–10% (15,43).

HIFU

HIFU is a non-invasive technique that uses focused US waves to generate heat and ablate endometriotic tissue. The procedure is performed under imaging guidance, typically using US or MRI, to precisely target the lesion without damaging surrounding tissues (44).

Outcomes

HIFU is generally safe, with the procedure typically lasting 1–2 hours. Patients are monitored for a short period post-procedure to check for immediate complications and are usually discharged on the same day. Potential complications are rare and include localized pain and skin burns (1–5%). It effectively reduces pain and lesion size in 80–90% of cases, with low recurrence rates of 5–10% (16,19).

Sclerotherapy

Sclerotherapy involves the injection of a sclerosing agent, most commonly ethanol or other agents like lauromacrogol (polidocanol), directly into the endometriotic lesion to induce fibrosis and shrink the tissue. The procedure is performed under imaging guidance to ensure accurate targeting of the lesion (23,45-47).

Outcomes

Sclerotherapy is minimally invasive and can be an effective alternative to surgical excision, particularly for small lesions Minor complications include pain and inflammation at the injection site (1–3%). It has been effective in reducing pain and size of lesions in 75–85% of cases, with recurrence rates described as 5–15% (23,45).

Discussion

The findings of this review highlight the evolving landscape of treatment options for AWE, underscoring the transition from traditional invasive surgical approaches to minimally invasive techniques. This shift reflects broader trends in medical practice toward patient-focused outcomes.

Implications for clinical practice

Surgical excision via laparotomy has long been the standard treatment for AWE due to its high efficacy and substantial symptom relief. However, the invasive nature of this approach and its associated complications have prompted the exploration of alternative treatments. Minimally invasive techniques such as cryoablation, RFA, MWA, HIFU, and sclerotherapy offer promising alternatives. These methods not only provide effective symptom management but also reduce the risks and recovery times associated with more invasive surgeries.

The success rates of these minimally invasive procedures, as documented in recent studies, suggest that they can be viable first-line treatments or adjuncts to surgery, particularly for patients for whom open surgery poses significant risks (e.g., patients with comorbidities such as obesity, diabetes, multiple surgeries, recurrent AWE or who desire to avoid open surgery). For instance, cryoablation and HIFU have shown high efficacy in reducing pain and lesion size, with manageable recurrence rates and fewer complications than open surgery (21,48). These techniques can significantly benefit patients by offering quicker recovery and less postoperative discomfort.

Policy development and implementation

The findings from this review suggest a need for updated clinical guidelines that incorporate minimally invasive treatments for AWE. Another important step would be to create standardized protocols for the use of minimally invasive techniques in treating AWE that would allow reproducibility.

Lastly, encouraging a multidisciplinary approach involving gynecologists, radiologists, and surgeons is fundamental to optimize patient outcomes.

Quality of evidence

The evidence base for the treatment of AWE is primarily composed of case reports, case series, and retrospective reviews, which can be explained in part due to the rarity of the condition and the diversity of proposed non-surgical interventions. There are no RCTs specifically evaluating the treatment modalities for AWE, which limits the strength of the recommendations that can be made. The reliance on non-randomized studies introduces potential biases and variability in the reported outcomes.

This narrative review is subject to several limitations, including the previously mentioned quality of the evidence. The included studies vary in their design, patient populations, and outcome measures, making direct comparisons challenging. Many studies included in this review have short follow-up periods, which may not capture the long-term recurrence rates and complications. Additionally, the lack of standardized outcomes complicates the aggregation and comparison of data. Different studies use varying criteria for measuring outcomes such as symptom relief and lesion size reduction, which complicates the aggregation and comparison of data.

Prevention

Prevention of AWE is also a critical consideration, particularly through efforts to reduce the rate of cesarean births. Given the strong association between cesarean births and AWE, strategies to minimize unnecessary cesarean procedures could significantly lower the incidence of AWE. This approach aligns with broader public health goals to promote safer childbirth practices and reduce surgical risks. In the case of laparoscopic trocar site AWE, there are general guidelines that should be followed to prevent its occurrence. These include routinely retrieving endometriotic specimens in laparoscopic retrieval bags, thoroughly washing the abdomen while the trocars are still in place, and removing instruments within the sheath to prevent contamination (11,49).

Future research directions

Despite the promising outcomes associated with minimally invasive treatments, there remains a need for long-term studies to fully establish their efficacy and safety profiles. Future research should focus on large-scale, RCTs comparing these techniques to traditional surgical excision. Additionally, studies should aim to refine these procedures, optimize patient selection criteria, and develop standardized protocols to ensure consistent and reproducible outcomes.

Understanding the pathogenesis of spontaneous AWE cases remains another critical area for research. Unraveling the mechanisms behind hematogenous or lymphatic spread and coelomic metaplasia could provide insights into preventive strategies and novel therapeutic targets. Moreover, exploring the genetic and epigenetic factors involved in AWE could pave the way for personalized medicine approaches, tailoring treatments to individual patient profiles based on their genetic predispositions.

Conclusions

The management of AWE is undergoing a significant transformation, driven by the application of minimally invasive treatments. These emerging techniques offer substantial benefits over traditional surgery, aligning with the overarching goals of modern medicine to minimize patient morbidity and enhance recovery. However, the dissemination and integration of these methods into standard practice require robust evidence from comprehensive clinical studies. Continued research and innovation are essential to fully realize the potential of these treatments, improve patient outcomes, and refine clinical guidelines for AWE management.

The management of AWE has evolved significantly, moving from traditional invasive surgical methods to a variety of minimally invasive techniques. This narrative review highlights that while surgical excision remains a highly effective treatment with a cure rate of up to 95%, it is associated with significant morbidity, long recovery times, and potential complications. Minimally invasive options such as percutaneous cryoablation, RFA, MWA, HIFU, and sclerotherapy have emerged as effective alternatives that offer shorter recovery times and fewer complications. Health professionals should consider these less invasive options for appropriate patients, balancing the benefits of symptom relief and lesion reduction with the potential risks and recovery implications.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-24-33/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-24-33/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-24-33/coif). E.M. serves as an unpaid editorial board member of Annals of Laparoscopic and Endoscopic Surgery from November 2022 to October 2024. E.M. has grants/contracts with Abbvie, Myovant, Dotlab, and Organon. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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