Polypoid Endometriosis Mimicking Peritoneal Carcinomatosis.

Abstract

A 36 year-old female, gravida 0, presented with pelvic pain and bulk symptoms attributed to a fibroid uterus. Her medical history was significant for two prior myomectomies and a laparoscopically-confirmed endometriosis that was aborted due to severe anatomic distortion complicated by bowel adhesions. She had been on GnRH antagonist for 3-years for suspected endometriosis. The patient was consented and a diagnostic laparoscopy, excision of peritoneal lesions, and total laparoscopic hysterectomy with bilateral salpingectomy. Upon laparoscopic entry, diffuse nodules were noted throughout the abdomen, mimicking peritoneal carcinomatosis [Figure 1A]. Gynecologic Oncology was consulted intraoperatively, and a biopsy was taken. Frozen section analysis returned as benign tissue, consistent with endometriosis. The previously diagnosed "dense bowel adhesions" were evaluated at it was noted an approximate 9-cm degenerating FIGO Grade 6 leiomyoma had omental and minimal bowel adhesions. As a patient-centered discussion was held with the patient preoperatively, the decision was made to proceed with hysterectomy. The minimally invasive approach allowed for systematic evaluation of the pelvis. Multiple polypoid lesions were observed studding the peritoneum, pelvic sidewalls, and posterior cul-de-sac [Figure 1B]. Ovaries appeared normal without evidence of endometrioma [Fig. 2]. Visible polypoid endometriotic lesions on non-vital structures were excised using monopolar scissors, employing electrosurgical desiccation to ensure precise removal while minimizing damage to surrounding tissues. [Fig. 3A & 3B]. During the dissection, it became evident that the endometriosis was not superficial, highlighting the importance of excisional techniques for optimal removal. Careful dissection was performed to avoid injury to underlying structures. Postoperatively at her 6-week follow up, the patient reported significant improvement in her pain; GnRH antagonist therapy was discontinued. Final pathology confirmed polypoid endometriosis with no evidence of malignancy. This case highlights the importance of perioperative planning-including advanced imaging, surgeon expertise, biopsy, and multidisciplinary team involvement-when encountering peritoneal lesions mimicking carcinomatosis.