Diaphragmatic Endometriosis: A Novel Resection Strategy

INTRODUCTION: While diaphragmatic endometriosis only accounts for around 1% of endometriosis lesions, it is the most common site of extra-pelvic disease. It is often diagnosed incidentally during laparoscopy. Symptoms may include catamenial right upper quadrant pain, chest pain, dyspnea, and shoulder pain, although many women are asymptomatic. MRI as an imaging modality has fairly low sensitivity in detecting diaphragmatic lesions. These lesions are often seen more commonly on the right hemi-diaphragm, which is thought to be due to the clockwise flow of peritoneal fluid within the abdominal cavity. In fact, bilateral lesions are only seen 3% of the time, which is thought to be a result of the natural barrier formed by the falciform ligament There are no standardized guidelines for surgical resection, complicating management of these lesions. Some methods may include ablation or fulguration of these lesions, peritoneal stripping, partial- or full-thickness resection of the diaphragm, video-assisted thoracic surgery, which may also include wedge resection of affected lung tissue. OBJECTIVE: In this video, we review the etiology of diaphragmatic endometriosis, review important aspects of surgical planning, and aim to present a novel technique for the excisional management of diaphragmatic endometriosis lesions. METHODS: We present the case of a 24-year-old nulliparous patient with PCOS, severe dysmenorrhea, dyspareunia, and dyschezia, raising high suspicion for endometriosis. She had been on OCPs for over 10 years with inconsistent relief. She elected to proceed with fertility-sparing surgical management with a desire to become pregnant in the next few years. During her initial surgery, she was found to have stage IV endometriosis, as well as diaphragmatic lesions on both sides of the falciform ligament. Diaphragmatic lesions are associated with advanced pelvic disease over 78% of the time. Following her laparoscopy, she was started on Myfembree, as medical management of diaphragmatic endometriosis is considered first line. However she experienced progressing pleuritic chest pain over the next 9 months, so a second laparoscopy was planned for her remaining pelvic and diaphragmatic disease. Some preoperative surgical considerations include reviewing the possibilities of diaphragmatic injury, VATS, phrenic nerve injury, and iatrogenic pneumothorax. Regarding robotic port placement, our ports were placed in a fashion to allow them to be used for both pelvic and diaphragmatic resection. A footboard was used to transition the patient from lithotomy to reverse Trendelenburg. We illustrate a novel technique when resecting diaphragmatic lesions. The affected peritoneum is grasped and elevated, then incised using traction applied with the bipolar Maryland forceps, while the other instrument provides dynamic countertraction. This allows for fine separation of the peritoneum from underlying muscle and controlled use of bipolar energy to transect the tissue. Compared to a more traditional technique using scissors with monopolar energy, this minimizes the risk of inadvertent thermal injury. Unaffected muscle fibers are carefully dissected away from the overlying peritoneum. RESULTS: Treating diaphragmatic endometriosis is difficult, as there is no one-size-fits-all approach, and it is usually associated with advanced disease. CONCLUSIONS: Some of the challenges associated with diaphragmatic endometriosis resection could be mitigated with our technique.