srjmcrSRJMCRSRJMCR2788-954810.47310/srjmcr.2025.v05i01.003Cesarean Scar Endometriosis: A Rare yet Misleading Postoperative Complication – A Case Report and Surgical PerspectiveScar endometriosis is a rare but significant complication of cesarean section, resulting from the iatrogenic implantation of endometrial cells into the surgical wound. It often presents as a painful, progressively enlarging mass at the incision site, leading to frequent misdiagnosis as a hernia, neuroma, or ovarian pathology. We report a case of a 29-year-old woman with a history of cesarean section (4 years prior) who presented with persistent lower abdominal pain and a firm, tender suprapubic mass (6×6 cm). Initially misdiagnosed as a twisted ovarian cyst, ultrasonography revealed a heterogeneous, hypoechoic mass (5×3×4 cm) within the rectus abdominis muscle, raising suspicion for scar endometriosis. Due to uncertain diagnosis and worsening pain, an exploratory laparotomy was performed, revealing a 6×4 cm jumbled-up mass comprising the rectus sheath, rectus muscle, and parietal peritoneum, containing chocolate-colored fluid, characteristic of endometriotic cysts. Complete surgical excision was performed, and histopathology confirmed endometriotic glands and stroma with hemosiderin-laden macrophages, establishing the diagnosis. Postoperatively, the patient received Medroxyprogesterone acetate (500 mg monthly for 3 months) to reduce recurrence risk and remained asymptomatic at 6-month follow-up. This case highlights the importance of considering scar endometriosis in women presenting with localized pain over prior surgical scars. Given its potential for misdiagnosis, early clinical suspicion, imaging, and histopathological confirmation are essential. Complete surgical excision remains the gold standard treatment, ensuring long-term relief and preventing recurrence.