Management of a large umbilical endometrioma

A 39-year-old G1A1 presented with severe umbilical pain and dysmenorrhea. Initially isolated to menses, the pain became constant, debilitating, and sharp, with cyclic bleeding. Physical examination revealed a 4×6cm firm, tender mass (Figure 1). Imaging confirmed a corresponding umbilical mass (Figure 2) and an ovarian endometrioma. A joint surgery with gynecology and general surgery was planned. Following laparoscopic management of Stage 4 endometriosis, an elliptical incision was made around the umbilical mass, which was elevated off the posterior fascia (Figure 3). Healthy subcutaneous fat was identified circumferentially. The laterally preserved anterior sheath was mobilized to reapproximate the midline using figure-of-eight 0 monofilament delayed absorbable sutures (Figure 4, A–C), with size 2-0 braided absorbable suture for subcutaneous closure. No mesh was required. At follow-up, the patient had a well-healed incision with no pain or hernia (Figure 4, D). Pathology confirmed an abdominal wall endometrioma (Figure 5). Figure 2Ultrasound imaging of umbilical endometrioma in relation to tissue planes Show full caption Warshafsky. Management of a large umbilical endometrioma. Am J Obstet Gynecol 2023. View Large Image Figure Viewer Download Hi-res image Figure 3Excision of umbilical endometrioma specimen Show full caption A, Excision of endometrioma to level of posterior sheath. B, Complete specimen removed. Warshafsky. Management of a large umbilical endometrioma. Am J Obstet Gynecol 2023. View Large Image Figure Viewer Download Hi-res image Figure 4Mobilization of abdominal wall structures to facilitate closure after specimen excision Show full caption A, Abdominal wall after specimen excision, demonstrating layers of anterior fascia, muscles, posterior sheath. B, Actively mobilizing tissues into midline. C, Deep monofilament absorbable sutures reapproximating midline. D, Abdominal wall 6 weeks postoperatively. Warshafsky. Management of a large umbilical endometrioma. Am J Obstet Gynecol 2023. View Large Image Figure Viewer Download Hi-res image Figure 5Histologic examination of excised specimen confirming endometriosis Show full caption Endometrial glands (double asterisks) and surrounding stroma (asterisk) involving the deep dermis. Arrow indicates lesional tissue with cautery artifact at deep margin. Warshafsky. Management of a large umbilical endometrioma. Am J Obstet Gynecol 2023. View Large Image Figure Viewer Download Hi-res image Warshafsky. Management of a large umbilical endometrioma. Am J Obstet Gynecol 2023. A, Excision of endometrioma to level of posterior sheath. B, Complete specimen removed. Warshafsky. Management of a large umbilical endometrioma. Am J Obstet Gynecol 2023. A, Abdominal wall after specimen excision, demonstrating layers of anterior fascia, muscles, posterior sheath. B, Actively mobilizing tissues into midline. C, Deep monofilament absorbable sutures reapproximating midline. D, Abdominal wall 6 weeks postoperatively. Warshafsky. Management of a large umbilical endometrioma. Am J Obstet Gynecol 2023. Endometrial glands (double asterisks) and surrounding stroma (asterisk) involving the deep dermis. Arrow indicates lesional tissue with cautery artifact at deep margin. Warshafsky. Management of a large umbilical endometrioma. Am J Obstet Gynecol 2023.