Post-surgical abdominal wall endometriosis: a retrospective cohort study on clinical features, ultrasound accuracy and recurrence

Background Abdominal wall endometriosis (AWE) is a rare but clinically significant condition; yet studies about its preoperative assessment and surgical outcomes remain limited. Our study aimed to characterize its clinical presentation, evaluate the utility of preoperative ultrasound, and investigate postoperative recurrence. Methods We retrospectively analyzed 291 AWE patients who underwent surgical resection. Clinical features, ultrasound-surgical concordance, and factors associated with recurrence were assessed. Lesions were classified into Type I (subcutaneous), Type II (fascial/muscular), and Type III (peritoneal) by infiltration depth, with subgroup comparisons across three types. Results Palpable mass (81.8%) and cyclic pain (46.7%) were the predominant symptoms. 99.7% of patients had prior cesarean section (CS), but no significant differences were found between multiple versus single CS groups in infiltration depth ( P = 0.138), maximum diameter ( P = 0.101), or lesion multiplicity ( P = 0.225). Deeper infiltration was associated with older age at diagnosis ( P = 0.030), longer CS-to-diagnosis interval ( P = 0.023), larger lesions ( P < 0.001), more frequent abdominal wall pain ( P = 0.028), fewer palpable masses ( P = 0.037), and higher rates of postoperative complications ( P = 0.002). Preoperative ultrasound agreed well with intraoperative measurements of maximum lesion diameter (ICC=0.872), but its ability to detect myofascial invasion was limited (positive predictive value 88.8%; negative predictive value 44.7%; false-negative rate 22.9%). The overall postoperative recurrence rate was 1.8%. Exploratory Kaplan–Meier analysis suggested a higher recurrence rate in patients with BMI ≥25 kg/m 2 . However, this result should be interpreted with caution given the limited number of recurrence events. Conclusions AWE occurred mostly in women with a history of CS, yet the number of prior CS did not influence lesion characteristics. Deeper infiltration is associated with greater surgical complexity and higher postoperative complication rates. While preoperative ultrasound reliably measures lesion size, its assessment of myofascial invasion remains limited. The observed recurrence rate was low after surgical excision in our cohort.