Left-sided lower abdominal wall mass, thought to be an endometrioma.
An 8 cm intramuscular left-sided abdominal wall mass.
Radical excision of left-sided abdominal wall mass endometrioma, with Flex HD allograft ultra-thick construction using a total 10 x 16 cm for a total of 160 cm2 allograft repair of the abdominal wall.
The patient had an 8 cm soft tissue mass between the anterior rectus sheath and left rectus musculature intertwined with the muscle fascicles and the inferior epigastric artery and vein complex. This required a radical excision to achieve margins to make sure that this does not recur rapidly. It had grown after a C-section, the patient developed an area that was painful and firm.
INDICATIONS FOR PROCEDURE:
An ultrasound directed biopsy was suggestive of an endometrioma. Patient was referred to our office by Dr. for the evaluation and management of this problem.
PROCEDURE IN DETAIL:
The patient received perioperative antibiotics consisting of Ancef. She voided. Sequential pneumatics were placed on her lower extremities. She received 2500 units of Fragmin subcu preop for VTE prophylaxis. The site was marked with her help in the preoperative holding area. She was identified, brought to the operating room and placed supine on the operating room table.
A time-out was done and then a general anesthetic was induced. Her anterior abdominal wall was prepared and draped, 0.25 percent Marcaine with epinephrine was infused through her old C-section scar and a transverse skin incision was made encompassing the previous scar using the scar as the entrance point. Skin flaps were raised superiorly. I could feel the mass through the left side of the rectus sheath and then a Pfannenstiel style incision was performed on the left side distal to the palpable mass and the entire rectus sheath involved with the palpable mass as well as the fascicles of her rectus muscle on the left side and the inferior epigastric pedicle were taken en bloc, resected and sent to pathology.
We asked if the pathologist could evaluate this mass to make sure there was not any invasive component and looks to be an endometrioma based on his evaluation. We treated as an invasive tumor since it can recur if we do not get good margins. The entire lesion was removed en bloc. The posterior rectus sheath was left intact as was the peritoneum below the semilunar line.
A 10 x 16 thick Flex HD mesh was then cut into 2 parts and a sandwich repair was created by placing this Flex HD below the rectus musculature on the left side and bringing it using horizontal mattress 0 Vicryl sutures through the remaining rectus sheath laterally and through the external oblique fascia laterally and the rectus sheath medially.
An onlay portion of the same mesh was used; it was undermined below the superficial rectus sheath, creating a sandwich with these 2 layers of Flex HD. This was sewn in using a combination of interrupted 0 Vicryl suture, and PDO Stratafix 6-0 suture. The wound was irrigated. A Blake fluted 15 drain was brought in on the patients right side and brought out through a stab wound done in the right inguinal region. Skin flaps all looked viable.
There was no evidence of hemorrhage, 0.25 percent Marcaine with epinephrine was infused for postoperative pain control. A photograph had been taken of the tumor as well as the resection bed. The tumor was measured and found to be 8 cm in total length and then the subcutaneous tissues were reapproximated using a combination of 2-0 Vicryl for Scarpas fascia, followed by 3-0 Vicryl deep dermal reapproximation, followed by 4 – 0 Monocryl subcuticular skin closure followed by Dermabond.
The drain was secured using 3-0 nylon suture and placed to bulb suction. The patient tolerated the procedure well and was returned to the recovery area in stable condition with sponge and needle counts correct at the end of the case.
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