腹壁子宫内膜瘤模仿一个嵌顿性疝个案报告

1、Abdominal wall endometrioma mimicking an incarcerated hernia: a case report腹壁子宫内膜瘤模仿一个嵌顿性疝:个案报告Abstract: The case of a tender, isolated abdominal wall tumor within a Pfannenstiel incision文摘:招标的情况下,孤立的腹壁切口Pfannenstiel内肿瘤due to a seeding deposit of endometrial tissue secondary to a previous obstetric

2、operation由于播种存款的子宫内膜组织二次到前一个产科操作(caesarean section) in a 39-year-old female without previously reported pelvic endometriosis(剖腹产)在一个39岁的女性没有先前报道盆腔子宫内膜异位症is presented. The lesion clinically mimicked the appearance of an incarcerated incisional hernia提出了。病变临床上模仿像一个下狱切口疝at the outer corner of the heale

3、d Pfannenstiel incision. The preoperative differential diagnosis在转角的Pfannenstiel切口愈合。术前鉴别诊断的also included that of a locally forming post-operative tender granuloma and the remote pos-还包括一个局部成形手术后的温柔和远程pos -肉芽肿sibility of an incisional endometrioma (although no link to menstruation could be made). Lo

4、casibility的切口子宫腺肌瘤(尽管没有链接到月经可能)。轨迹malignancy was not taken as a serious possibility. Definitive diagnosis of the excised lesion恶性肿瘤是不作为一个严肃的可能性。切除病变的确诊was made at histology. The pre-operative diagnostic dilemma is presented, along with a shor是在组织学。术前诊断困境算法,结合一个肖review of the literature.回顾文献。Keywords

5、: endometrioma, seeding endometriosis, abdominal wall tumor关键词:子宫内膜异位症、子宫腺肌瘤,播种腹壁肿瘤Endometriosis is defined as the presence of normal endometrial mucosa abnormally子宫内膜异位症是定义为正常子宫内膜粘膜的存在异常implanted in locations other than the uterine cavity. The ectopic implants are located植入子宫腔以外的地点。异位移植的所在地in the m

6、inor pelvis, the ovaries, the fallopian tubes, and the uterosacral ligaments.在小骨盆、卵巢、输卵管、uterosacral韧带。More unusual implantation sites are the abdominal scars, scars of the perineum, the更不寻常的植入网站是腹部的疤痕,疤痕的会阴,navel, the spleen, the kidney, the gallbladder, the pleura, and the nasal mucosa. This肚脐,脾、肾

7、、胆囊、胸膜、鼻粘膜。这condition is not present before menarche, because the ectopic tissue possesses the same条件不存在初潮之前,因为异位组织具有相同的steroid and estrogen receptors as normal endometrium and is capable of responding类固醇和正常子宫内膜雌激素受体,可以应对to the normal cyclic hormonal milieu.正常的循环激素环境。1,21、2Endometriosis is the more

8、common cause of chronic pelvic pain in females. Its子宫内膜异位症是更常见的原因女性慢性骨盆疼痛。它的prevalence has been estimated to 1%2% of reproductive age females and is more患病率已估计1% - -2%的育龄女性,是更多的common (15%25%) among women with infertility problems.常见(15% - -25%)的女性中不育问题。11A 39-year-old female patient was referred to

9、 our Hospitals Emergency Surgical一个39岁的女性病人是指我们医院的紧急手术Department with a palpable tender mass at the left corner of a Pfannenstiel incision.部门,溢于言表投标质量在左边的角落里一个Pfannenstiel切口。Medical history revealed that this mass presented four months ago (2 cm diameter医学的历史显示,这个质量提出了四个月前(2厘米直径at the left end of he

10、r abdominal incision), and since then it exhibited interrupted在她的腹部切口的左端),从那时起,就表现出打断了abdominal tenderness, but with no identifiable pattern of exacerbation. During the腹部压痛,但没有可识别的模式的恶化。在last 4 months she received analgesics for intermittent pain management. She had a去年4月她收到了镇痛药在间歇性疼痛管理。她有一个typical

11、Pfannenstiel skin incision having healed normally after having a child birth典型的Pfannenstiel皮肤切口愈合通常有一个孩子出生后的4 years and 8 months before admission. Thus the patient was immediately admitted for further evaluation and treatment. The mass was immobile4年,前8个月入学。因此病人立即承认进行进一步的评估和治疗。质量是固定and clinically, a

12、side from the possibility of an incarcerated和临床,除了一个被监禁的可能性incisional hernia, one could also entertain the diagnosis切口疝,人们还可以娱乐的诊断of a locally forming tender granuloma or that of a seeding一个本地的形成肉芽肿或温柔播种deposit of ectopic endometrial tissue. There was no evidence异位子宫内膜组织存款。没有证据表明to support the possi

13、bility of a soft tissue neoplastic growth.支持的可能性,软组织肿瘤生长。No other pathologic findings were recorded. The patients没有其他病理结果都被记录下来。病人的laboratory results (general blood count and serum biochem -实验室结果(一般血细胞计数和血清总览-istry) were all within the normal range with no indication of手法)都在正常范围内,没有迹象an inflammatory

14、 response of significance. Plain chest and炎症反应的意义。胸部平片和abdominal X-rays failed to provide conclusive evidence of腹部x光没有提供确切的证据any pathology. Thus the patient was programmed without任何病理。因此病人编程没有further delay for an exploratory operation scheduled for the进一步的延迟为一个探索性操作安排的next available operation room.下

15、一个可用的操作空间。The abdominal skin was re-incised along the outer third腹部皮肤是沿着外三分之一重新雕刻of the previous incision and the subcutaneous layer was以前的切口和皮下层dissected free of the underlying abdominal musculature.切割自由底层腹部肌肉组织。Upon reaching the lower lateral border of the left rectus在到达下外侧边界的左腹直肌abdominus muscle,

16、 a hard mass was palpated. This massabdominus肌肉,硬质量是触诊。这个质量infiltrated the external oblique, the internal oblique, and the渗透到外斜肌,腹内斜肌,和transverse abdominus musculature and reached down to the横向abdominus肌肉组织,达成了preperitoneal fat layer. The mass was excised en-block withpreperitoneal脂肪层。大众是大块切除与a smal

17、l portion of surrounding abdominal wall musculature一小部分周围的腹壁肌肉组织( Figure 1). A small suction drain was placed preperitone-(图1)。一个小吸排水被放置preperitone -ally and the abdominal wall defect was closed in one layer盟友和腹壁缺陷被关闭在一个层using a non-absorbable monofilament suture followed by使用非吸收性单丝缝合线紧随其后the placem

18、ent of a synthetic non-absorbable mesh. The放置一个合成非吸收性网状。这个excised specimen was sent for histological examination. The histology report concerned a specimen 3.5 2.2 cm切除标本送组织学检查。有关样品的组织学报告3.52.2厘米in dimension containing f ibrous, adipose, and skeletal在维度包含f ibrous,脂肪,和骨骼muscular tissue. Within this t

19、issue specimen, multiple sites肌肉组织。在这个组织标本,多个网站of endometriosis were revealed. No findings of malignancy子宫内膜异位症的了。没有发现恶性肿瘤were reported.被报道。Discussion讨论The finding of ectopic endometrial tissue within the abdomi-这一发现的异位子宫内膜组织在abdomi -nal wall seems to occur among 0.03% to 1% of women whonal墙似乎发生在0.0

20、3%至1%的妇女have undergone prior gynecologic or obstetric surgery, and经历了之前的妇科或产科手术,然后呢has been noticed particularly after cesarean section.已经注意到特别是剖腹产后。363 - 6Its它的prevalence as an isolated abdominal wall mass is reported作为一个孤立的腹壁患病率质量报告in 4% of the endometrioma cases in another series.在4%的子宫内膜瘤病例在另一个系

21、列。77Other其他studies report an incidence of 1.04% in patients previously研究报告发生率为1.04%,患者以前operated on the uterus and 0.046% in those who underwent子宫手术,0.046%的人接受previous cesarean section.以前剖腹产。88Other authors have reported a其他作者报道了much higher incidence of about 0.2% of the cesarean sections更高的发病率约0.2%

22、的剖腹产performed.执行。99The literature seems to agree that the clinical appear -文献似乎一致认为,临床出现-ance of a triad consisting of periodic abdominal scar pain性质的一个三位一体组成的周期性腹部疤痕疼痛(associated with menses), a history of cesarean section, and(与月经有关),一个历史的,剖腹产an underlying tumor inside a surgical scar is more ofte

23、n一个潜在的肿瘤在手术疤痕更经常than not confirmed to be an endometrioma.比没有证实是一个子宫腺肌瘤。1010Moreover, the此外,presentation is atypical and thus the preoperative diagnosis演示是典型和因此术前诊断poses difficulties in differential diagnosis.在鉴别诊断带来困难。11,1211、12What most大多数authors agree about is the fact that definitive diagnosis ca

24、n作者都同意的事实是明确诊断可以only be established by pathologic analysis of the specimen.只有建立了病理标本的分析。In our case, the patient did not link the unsteady nature of在我们的案例中,病人没有链接不稳定的性质the periodic exacerbation of the pain followed by total pain周期性加重疼痛的后跟总疼痛remittance, with her menstruation. The clinical examination

25、汇款,她的月经。临床检查revealed a 2 cm hard, immobile, tender mass, which was defi -显示一个2厘米的硬的、稳定的、温柔的质量,这是挑战-nitely located within the abdominal wall musculature. Thus,nitely位于腹壁肌肉组织。因此,an all too familiar irreducible incisional hernia with bouts一个太熟悉的不可约切口疝与发作of incarceration was viewed as the most likely di

26、agnosis.监禁被视为最可能的诊断。The absence of specific intestinal symptoms allowed us to没有特定的肠道症状允许我们formulate an alternative diagnosis of the possible existence制定一个替代诊断可能存在of a post-operative incisional granuloma formation, attributed术后切口肉芽肿的形成,认为to the possible presence of underlying suture material or the对可

27、能存在的潜在的缝合材料或formation of an incisional endometrial tumor. Malignancy形成一个切口子宫内膜肿瘤。恶性肿瘤was unlikely, but a small soft tissue sarcoma could not be是不可能的,但一个小软组织肉瘤可以不readily ruled out. During operative dissection no hernia容易排除。在手术解剖没有疝was found and the operative diagnosis tilted towards the被发现和有效的诊断偏向了吗e

28、xistence of a hard granulomatous lesion forming from the肉芽肿病变存在困难的形成scar or fibrous tissue of the previous operation. The patients疤痕或纤维组织之前的操作。病人的post-operative course was uneventful and she was discharged手术后的课程是平凡的,她出院on the third post-operative day in excellent condition.在第三天的状况非常好。术后The histology

29、 report unveiled the true nature of the malady.组织学报告公布了真实自然的弊病。The patient was followed up 5 months post-operatively and was found well. No symptoms or clinical indications of病人手术后随访5个月,发现好。没有症状或临床的迹象relapse were evident.复发是很明显的。This case comes to add to the well-known need to elicit an这个案例涉及到增加知名需要

30、引出一个as accurate as possible history from the patient in which all尽可能精确的历史从病人中,所有pieces of information are pertinent, no matter how insignifi-的信息是相关的,无论多么insignifi -cant they may initially seem. The literature reports a limited不能他们可能一开始看起来。文献报道有限number of cases similar to this one. It seems that it is a rela-数量的类似的案件。看起来是一个决策tively rare finding, given the number of performed cesareantively罕见的发现,执行一定数量的剖腹产sections. Although endometri