not-yet-known not-yet-known not-yet-known unknown 1 Discussion: Cutaneous endometriosis is characterized by the presence of endometrial glands and stroma in the skin and can occur as either primary or secondary cutaneous endometriosis. Primary cutaneous endometriosis occurs spontaneously, and its etiology is unclear. Surgical procedures involving the abdomen or pelvis are risk factors for secondary cutaneous endometriosis.(4) In abdominal and pelvic surgery, its incidence is about 0.03-1.08%. It typically occurs after cesarean section, with an incidence of 0.03-0.4%. However, cases have also been reported in association with episiotomy, trocar scars, appendectomy, and hernia repair scars.(6,7) Tamrakar et al. reported a cesarean section rate of 44.22% in a tertiary care center in Nepal, which exceeds the WHO recommended rate of 10-15%. With the increasing trend of cesarean sections, cases of cesarean site scar endometriosis are on the rise.(8) In the context of scar endometriosis, the most accepted hypothesis is the direct implantation of endometrial tissues through iatrogenic processes. Other theories include lymphatic or hematogenous dissemination, metaplastic transformation, and modification of cell immunity.(1,6,9) Pregnancy is a state of altered immune response, and the risk of developing scar endometriosis following a cesarean section would increase. Studies from some research suggest that having two cesarean sections does not increase the risk of being diagnosed with endometriosis compared to having one cesarean section. Additionally, those diagnosed with cesarean scar endometriosis after the first cesarean section are not at increased risk of developing endometriosis subsequently.(7) A systematic review by Meral Rexhepi et al., found that Pfannenstiel incision is the most commonly found incision in cesarean scar endometriosis (CSE), and patients with this type of incision presented a shorter latency period compared to those with a vertical midline incision. Pfannenstiel incisions are more preferred for its cosmetic benefits and lower risk of surgical hernias, despite requiring more extensive dissection, causing more damage to abdominal capillaries and leading to greater blood loss which facilitates the implantation of endometrial cells at incision site, making them difficult to remove during the CS procedure. However, they involve greater dissection of planes, more damage to longitudinal abdominal capillaries, and consequently, more blood loss, which can promote the implantation of endometrial cells at the edge of the surgical incision, making them difficult to remove during the cesarean procedure.(9,10) The presentation of scar endometriosis is quite nonspecific, including cyclic abdominal pain, swelling, or bruising of the scar. Our case was presented with cyclic abdominal pain with pin point bleeding from the scar site. It is a challenging diagnosis to establish because it is typically reached by exclusion rather than through a straightforward positive diagnostic process.(11) Conditions such as abscess, suture granuloma, hematoma, desmoid tumor, sarcoma, and metastatic malignancy should be considered in the differential diagnosis of abdominal wall endometriosis.(2) Comprehensive evaluation, including detailed medical history and physical examination, is essential and Surgeons should consistently consider scar endometriosis in their differential diagnosis to ensure timely and appropriate management. It is very difficult to predict the time between the surgery and the onset of the disease The average age of patients with cesarean scar endometriosis is 35 years with latency period of 3 month to 20 years.(9) In our case, she was 27 years old with presentation of symptoms 3 months after caesarean section. In addition to history and clinical examination, imaging modalities that aid in the diagnosis of scar endometriosis include magnetic resonance imaging (MRI), ultrasonography (US), and computed tomography (CT), with US generally being the initial imaging modality of choice due to its cost and availability.(2) The sensitivity of USG (65%) in diagnosing endometriosis is lower than that of MRI (90-92%), but both have quite similar specificity (around 95%).(12) In ultrasound, hypoechoic area surrounded by a hyperechoic ring, with low or even absent blood flow when viewed in Doppler mode is suggestive of endometriosis.(13) In our case, only USG added to the clinical diagnosis of the disease. The findings showed an irregular heterogeneous lesion measuring approximately 0.8 cm × 0.71 cm. It had a predominantly hypoechoic echotexture with scattered hyperechoic echoes internally, located within the previous LSCS scar, suggestive of scar endometriosis. Now, MRI has started to surpasses ultrasound in identifying a wider range of areas affected by endometriosis development.(14) The diagnosis of scar endometriosis is confirmed by histopathological examination, which requires the presence of at least two out of the following three features: 1) endometrial-type glands, 2) endometrial stroma (often containing a fine capillary network; long-standing cases may show fibrosis, decidual change, or myxoid change), and 3) evidence of chronic hemorrhage (hemosiderin-laden or foamy macrophages).(12,15) For the confirmation of diagnosis histopathological examination was done which showed the presence of endometrial glands lined by columnar cells within the dermis, surrounded by stroma. The adjacent area showed variable-sized blood vessels with hemorrhages and mixed inflammatory cells. No cellular atypia or granulomas were observed. 3 out of 3 features were present in our case which confirmed the diagnosis of scar endometriosis. The presence of endometrial tissue can also be confirmed with immunohistochemistry staining for ER (estrogen receptor) and PR (progesterone receptor).(16) But this test was not done in our case due to unavailability of the test. The first-line management of scar endometriosis is wide lesion excision with a minimum 1 cm safe margin in order to avoid recurrence.(17,18) The risk of recurrence in case of incomplete excision is around 12.5-28.6%.(13) Medical treatment is reserved for patient who are not fit for surgery. However, it only improves the symptoms of patients with no improvement in lesions of scar endometriosis and condition recur after the stoppage of treatment. Treatments include oral contraceptive pills, progestins, dienogest, or gonadotropin-releasing hormone agonists.(12,17,19) The scar endometriosis may undergo Malignant transformation which is very rare (0.3–1%).(1,6) In our case, the patient initially chose medical management. She was prescribed Tab. Paracetamol 500mg TDS (thrice daily) and SOS (as needed), and Tab. Norethisterone 5mg BD (twice daily) for 2.5 months. However, the symptoms persisted despite the medical treatment. Later, she was managed with planned surgical excision. The patient underwent surgical excision of scar endometriosis under spinal anesthesia. During the procedure, an elliptical incision was made around the scar tissue, and the endometrial tissue was excised with clear margins. A specimen of subcutaneous tissue was sent for histopathological examination. Hence, ultrasonography (USG) and magnetic resonance imaging (MRI) are valuable diagnostic tools, and wide excision is the preferred treatment as pharmaceutical interventions may not provide sustained relief. 1 Discussion: