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Cited by 11Endometriosis Research and TreatmentGynecological conditions and treatmentsIntestinal and Peritoneal Adhesions

Clinical and surgical characteristics of abdominal wall endometriosis: a multicenter case series of 80 women

Open access
PIRIYEV, ELVIN, NAMAZOV, AHMET, MAHALOV, ISLAM, MAMEDOVA, AYGUL, GEMER, OFER, SCHIERMEIER, SVEN, RÖMER, THOMAS·2023·In Vivo
DOI 10.21873/invivo.13138PMC PMC10026630
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Abstract

BACKGROUND/AIM: Endometriosis of the abdominal wall (AWE) is poorly understood because of its rarity and heterogeneous nature. The aim of this study was to investigate and present the clinical and surgical characteristics of AWE and to propose its classification. PATIENTS AND METHODS: This was a multicentric retrospective study. For this analysis, the data from three endometriosis centers were collected. In total 80 patients were included in this study. The Academic Hospital Cologne Weyertal is a certified, level III endometriosis center in Germany with 750-1,000 endometriosis surgeries being performed annually; Barzilai University Medical Center is a certified endometriosis center in Ashkelon, Israel; and Baku Health Center is an endometriosis Center in Baku, Azerbaijan. RESULTS: The size of nodule (histological specimen) was significant larger in women with than those without adenomyosis (3.34±1.4 vs. 2.55±1.33 cm, p=0.016). The incidence of subfascial involvement was also found to be significantly higher in these women (42% vs. 19%, p=0.03). No significant difference was found in patients with and without obesity. In 78% of cases, the proliferation level (Ki67 marker) was less than 30%. CONCLUSION: AWE has a high prevalence of symptoms such as abdominal wall pain and swelling, as well as bleeding. The strengths of the current study are the investigation of the proliferation marker Ki67 in AWE, the impact of adenomyosis, as well as the suggested classification.

AI snapshot

Written from the paper’s full text.

TL;DR

This multicenter retrospective case series describes clinical and surgical characteristics of abdominal wall endometriosis (AWE) in 80 women and proposes a classification based on localization, depth relative to fascia, and nodule size. It reports that adenomyosis is associated with larger AWE nodules and more subfascial involvement, and that most AWE lesions show low-to-intermediate Ki67 proliferation.

Key findings

  • Among 80 women (mean age 36±5.4 years; mean BMI 26.19±5.23 kg/m²), AWE was most commonly located in a cesarean scar (52/80, 65%), followed by umbilical (22/80, 27.5%), trocar site (4/80, 5%), and other localization (2/80, 2.5%).
  • Adenomyosis was present in 26/80 women (32.5%); those with adenomyosis had significantly larger histological nodules (3.34±1.4 vs. 2.55±1.33 cm, p=0.016) and more subfascial involvement (42% vs. 19%, p=0.03).
  • Ki67 was assessed in 33 patients: <10% in 19 (57%), 10–30% in 7 (21%), and >30% in 7 (21%); overall, 78% had proliferation below 30%.
  • The authors propose classifying AWE by localization (CS, T, U1, U2, O), depth (epifascial, subfascial, total), and histological size (<3 cm vs. ≥3 cm).

Methods

  • Multicentric retrospective study of 80 patients with histologically confirmed AWE who had symptoms and underwent surgery; cases came from three endometriosis centers in Germany (51), Israel (16), and Azerbaijan (13).
  • Preoperative assessment used abdominal ultrasound and MRI; laparoscopy was added when pelvic endometriosis symptoms were present. Endometriosis was classified by #ENZIAN, and Ki67 was examined in the majority of cases at one center.
  • Analyses used Fisher’s exact test, descriptive statistics with confidence intervals, and t-tests for comparing means; data are reported as mean and standard deviation.

Limitations

  • The paper does not include a formal limitations section. It notes the retrospective design, the rarity and heterogeneous nature of AWE, and the prior lack of an acceptable AWE classification.
  • The text states there was a lack of data about the presence of umbilical endometriosis before surgery in nine women with prior abdominal surgery.
  • Evident from the text: Ki67 was available for only 33 of 80 patients, and symptom frequencies are inconsistently reported (e.g., abdominal wall pain as 69 women/86.25% in the abstract vs. 70/87.5% in Table II).

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.21873/invivo.13138

Cites

25 of 25 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 19 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Left side dominancy was observed for nodule location relative to the abdominal midline.

    “Left side dominancy was observed (Table II).”
    Quote in the paperNot a substantial claim
  • Findingown data

    No significant relationship was observed between umbilical endometriosis and a history of cesarean deliveries.

    “No significant relationship was observed between umbilical in vivo 37: 756-762 (2023) endometriosis and a history of cesarean deliveries.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Of the 22 women with umbilical endometriosis, only two (9%) had had a previous cesarean section.

    “Of the 22 women with umbilical endometriosis, only two (9%) had had a previous cesarean section; 15 women (68%) were nulliparous.”
    Quote in the paperNot a substantial claim
  • Findingown data

    In all cases with umbilical endometriosis, the nodule was epifascial.

    “In all cases with umbilical endometriosis, the nodule was epifascial”
    Quote in the paperNot a substantial claim
  • Findingown data

    In 13 cases with cyclic bleeding, the localization of the nodule was in the umbilicus.

    “In 13 cases with cyclic bleeding, the localization of the nodule was in the umbilicus.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 18
  • Classified as probably not a substantial claim. 18
  • The quote only partly states this claim. 3

  • May combine two claims.

    Findingown data

    The incidence of cyclical bleeding from umbilical nodules was 60% (n=13) and was observed more commonly than cyclical bleeding from nodules in other locations (17.5%).

    “The incidence of cyclical bleeding from the nodule was 60% (n=13) and was observed more commonly than cyclical bleeding from nodules in other locations (17.5%;Table II).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    All four women with trocar site endometriosis had undergone previous laparoscopic surgery due to endometriosis and all nodules were on the left accessory trocar tract.

    “All of them had undergone previous laparoscopic surgery due to endometriosis and all endometriotic nodules were observed on the left accessory trocar tract.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    In 22 cases, the nodule was in the umbilicus, so side differentiation was not possible.

    “In 22 cases, the nodule was in the umbilicus, so side differentiation was not possible.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Nulliparity was observed in 25% of the women.

    “Nulliparity was observed in 25% of the women”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Obesity (BMI ≥30) was observed in 17 (21.25%) women.

    “Obesity (BMI ≥30) was observed in 17 (21.25%)women.”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    The size of the nodule (histological specimen) was larger in women with adenomyosis than in those without, with a statistically significant difference (3.34±1.4 vs 2.55±1.33 cm, p=0.016).

    “In those women, the size of AWE was found to be larger than in the women without adenomyosis.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The mean age of the patients was 36±5.4 years.

    “The mean age of the patients was 36±5.4 years.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Coexistence of pelvic endometriosis was observed in up to 40% of the series, which is higher than previously reported 6-13%.

    “This may be attributed to coexistence of pelvic endometriosis observed in up to 40% of our series, which is higher than previously reported of 6-13% (4, 15).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [4]

      Not checked in the free run.

    • cites [15]

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Abdominal wall pain was the leading symptom related to endometriotic nodules and was observed in 69 women (86.25%).

    “Abdominal wall pain was the leading symptom related to endometriotic nodules and was observed in 69 women (86.25%).”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    The mean nodule size measured histologically was larger than the preoperative size measured by both MRI and ultrasonography (2.79±1.37 vs 2.22±1.21 cm).

    “Size of nodule, mean±SD, cm Imaging 2.22±1.21Histological 2.79±1.37”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Ultrasonography was the common diagnostic imaging modality and was performed in 87.5% of cases.

    “Ultrasonography was the common diagnostic imaging modality and performed in 87.5% of cases.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The mean BMI was 26.19±5.23 kg/m2.

    “The mean BMI was 26.19±5.23 kg/m 2 .”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingreasoning

    Dysmenorrhea as a presenting symptom of pelvic endometriosis was revealed in 60% of patients.

    “Another important finding concerns dysmenorrhea as a presenting symptom of pelvic endometriosis, which was revealed in 60% of our patients.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    In the present study, both ultrasound and MRI gave accurate results.

    “In the present study, both these methods gave accurate results, however, ultrasound is a cost-effective method.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Histological confirmation of the resected endometriosis nodules was mandatory for inclusion.

    “Histological confirmation of the resected endometriosis nodules was mandatory.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    In 13 women (59%) with umbilical endometriosis, there was no history of abdominal surgery, making these cases of primary umbilical endometriosis.

    “However, in 13 women (59%), there was no history of abdominal surgery, making these cases of primary umbilical endometriosis.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: No history of abdominal surgery defines primary umbilical endometriosis.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationcitation

    Inguinal endometriosis can be considered an extension of pelvic endometriosis into the inguinal canal and should not be included as a type of AWE.

    “Due to the possible etiology of peritoneal fluid spread via the round ligaments and the assumable direct relationship with pelvic endometriosis (13,14), inguinal endometriosis can be considered an extension of pelvic endometriosis into the inguinal canal and should not be included as a type of AWE.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [13]

      Not checked in the free run.

    • cites [14]

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Adenomyosis was diagnosed using transvaginal ultrasound or during laparoscopy.

    “Adenomyosis was diagnosed using transvaginal ultrasound or during laparoscopy.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The most common localization of AWE is a cesarean scar.

    “The most common localization of AWE is a cesarean scar (2).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [2]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    No existing classification systems mention AWE alongside other forms of endometrioid disease, except for the #ENZIAN, which simply classifies it as F (localization).

    “No existing classification systems mention AWE alongside other forms of endometrioid disease, except for the #ENZIAN, which simply classifies it as”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation

    AWE is most likely an aggregation of etiopathogenically different conditions unified by the implantation and embedding of ectopic endometrial tissue within the same anatomical area.

    “AWE is most likely an aggregation of etiopathogenically different conditions unified by one common feature -the implantation and embedding of ectopic endometrial tissue within the same anatomical area (1).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Rising occurrence of AWE in recent times has been linked to increased surgical activity in obstetrics and gynecology, mainly abdominal delivery, strengthening the mechanical origin of AWE.

    “Moreover, rising occurrence in recent times his been linked to increased surgical activity in obstetrics and gynecology, and mainly to abdominal delivery, thereby strengthening the general opinion on the mechanical origin of AWE (1).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    MRI can evaluate the relationship between nodules and adjacent structures, which could be helpful for appropriate presurgical planning in cases with possible abdominal wall reconstruction.

    “Moreover, MRI can evaluate the relationship between nodules and adjacent structures, which could be helpful for appropriate presurgical planning in cases with possible abdominal wall reconstruction (23,24).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [23]

      Not checked in the free run.

    • cites [24]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Endometriosis was classified according to the #ENZIAN classification.

    “Endometriosis was classified according to the #ENZIAN classification (9).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9]

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Some authors reported the use of oral progesterone or gonadotropin-releasing hormone analogs, with a low rate of success, and high recurrence of symptoms after cessation of treatment.

    “Some authors reported the use of oral progesterone or gonadotropinreleasing hormone analogs, with a low rate of success, and high recurrence of symptoms after cessation of treatment (6).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6]

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    AWE is a rare condition with a high prevalence of symptoms such as abdominal wall pain and swelling, as well as bleeding.

    “AWE is a rare condition with a high prevalence of symptoms such as abdominal wall pain and swelling, as well as bleeding.”
    • Also stated in: § Abstract · plain
      “AWE has a high prevalence of symptoms such as abdominal wall pain and swelling, as well as bleeding.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    For curative treatment, complete local surgical excision is required.

    “For curative treatment, complete local surgical excision is required (3).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [3]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The primary form of umbilical endometriosis is the most common, comprising 69% of umbilical endometriosis.

    “The primary form of umbilical endometriosis is the most common, comprising 69% of umbilical endometriosis (18).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [18]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The study was multicentric and retrospective.

    “This was a multicentric retrospective study”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Both ultrasound and MRI are appropriate methods for the assessment of AWE.

    “Both ultrasound and MRI are appropriate methods for the assessment of AWE (4).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [4]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The proliferation marker Ki67 represents an important predictive marker for the success of hormone therapy and helps in the optimization of endometriosis therapy.

    “Thus, the proliferation marker Ki67 represents an important predictive marker for the success of hormone therapy and helps in the optimization of endometriosis therapy (21).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [21]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    For ultrasound assessment, the Morphological Uterus Sonographic Assessment criteria were taken into account.

    “For the ultrasound assessment, the Morphological Uterus Sonographic Assessment criteria were taken into account (10).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10]

      Not checked in the free run.

32 of 32

  • The paper relies on this without support.

    The depth of AWE can be used to distinguish the severity of the disease, which is important for proper management and better outcomes.

    “As in case of intrapelvic or intrabdominal implantation, the depth of AWE might be used to distinguish the severity of the disease, which is of particular importance for proper management and better outcomes.”

  • The paper relies on this without support.

    No history of abdominal surgery defines primary umbilical endometriosis.

    “However, in 13 women (59%), there was no history of abdominal surgery, making these cases of primary umbilical endometriosis.”
2 of 2

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Medical therapy, including NSAIDs, oral contraceptives, gonadotropin-releasing hormone analogues, and aromatase inhibitors, has been shown to alleviate symptoms without necessarily affecting the size of the lesions.

    “Medical therapy, including NSAIDs, oral contraceptives, gonadotropin-releasing hormone analogues, and aromatase inhibitors, has been shown to alleviate symptoms without necessarily affecting the size of the lesions14.”

    From Postcesarean section abdominal wall endometriosis: a rare case report (2024) · cites this paper as [14]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Fascial-involvement counts disagree between Tables II and III

    Minor

    Table III's two adenomyosis groups report 13 and 27 cases of fascial involvement, totaling 40; Table II reports 42.

  • Abdominal wall pain count differs from Table II

    Minor

    The results report abdominal wall pain in 69 women, while Table II reports 70.

  • Infiltration-category totals disagree between Tables II and III

    Minor

    Table III totals 59 epifascial and 21 subfascial/total cases across the adenomyosis groups. Table II instead reports 58 and 22, respectively.

  • Nulliparity prevalence differs from Table I

    Minor

    The results state that 25% of women were nulliparous, but Table I reports 16 of 80 women, or 20%.

  • Table IV gives the wrong percentage for other localizations

    Minor

    In the BMI <30 group of 59 women, five other localizations represent about 8.47%, not 22.7%.

    Reported 22.7 · recomputed 8.474576

  • Overall bleeding rate is presented as the rate at other locations

    Minor

    Table II's 17.5% is the overall rate: 14 of 80 women had cyclic bleeding. With 13 bleeding nodules at the umbilicus, only one of the 58 nodules at other locations bled, a rate of about 1.7%, not 17.5%.

  • Cesarean-scar counts disagree between Tables II and III

    Minor

    Table III lists 21 women with adenomyosis and 32 without adenomyosis as having a cesarean-scar nodule, totaling 53. Table II reports 52.

7 of 7

Cites

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Related

Authors
PIRIYEV, E., NAMAZOV, A., MAHALOV, I., MAMEDOVA, A., GEMER, O., SCHIERMEIER, S., & RÖMER, T.
Affiliations
  • Witten/Herdecke University (DE)
  • Ben-Gurion University of the Negev (IL)
  • İ.M. Seçenov adına Birinci Moskva Dövlət Tibb Universitetinin Bakı filialı (AZ)
  • University of Cologne (DE)
ORCID
Venue
In Vivo
Publisher
International Institute of Anticancer Research
Published
2023
Volume
37
Issue
2
Pages
756-762
ISSN
  • 0258-851X (ISSN-L)
  • 1791-7549
DOI
10.21873/invivo.13138
PMC
PMC10026630
OpenAlex
W4323348102
Semantic Scholar
9430636d6b7f410f1f81c7ee5c9b9ed7947f0afb
Cited by
11
References
26
Citations by year
2026: 3 · 2025: 1 · 2024: 7
FWCI
2.64
Type
journal article
Language
en
Open access
Licence
cc-by-nc-nd
Locations
  • In Vivo (publishedVersion, cc-by-nc-nd)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
  • Health Sciences › Medicine › Obstetrics and Gynecology › Gynecological conditions and treatments
  • Health Sciences › Medicine › Surgery › Intestinal and Peritoneal Adhesions
Keywords
abdominal wall endometriosis, endometriosis classification, adenomyosis, Ki-67 proliferation marker, nodule size, obesity, abdominal wall pain, surgical characteristics
MeSH terms
Endometriosis, Female, Humans, Retrospective Studies, Ki-67 Antigen, Abdominal Wall, Adenomyosis

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