Tips and Tricks for Diaphragmatic Endometriosis Resection and Management of Iatrogenic Pneumothorax

Abstract

<h3>Study Objective</h3> To highlight the relevant surgical anatomy and techniques for safe and efficient laparoscopic resection of diaphragmatic endometriosis as well as strategies for management of iatrogenic pneumothorax. <h3>Design</h3> Stepwise demonstration of techniques with narrated video footage. <h3>Setting</h3> Diaphragmatic endometriosis has a reported incidence of 0.1-1.5%. Patients may be asymptomatic or present with right upper quadrant abdominal pain, shoulder pain, or chest pain. Treatment may include laparoscopy alone or a combination of laparoscopy and thoracoscopy. <h3>Patients or Participants</h3> A 32-year-old female presents with symptomatic diaphragmatic endometriosis. <h3>Interventions</h3> The patient elected to undergo laparoscopic resection of diaphragmatic endometriosis. The key principles for safe and effective laparoscopic resection of diaphragmatic endometriosis include: • Grasping and tenting the endometriotic lesion away from the diaphragm • Gentle deflection of the liver to improve visualization during the procedure • Use of the open and spread technique to serially thin and separate the endometriotic lesions from the underlying diaphragm, when possible The key principles for management of iatrogenic pneumothorax, which may occur with even the most meticulous surgical technique, include: • Recognition of diaphragmatic injury by visualizing the loss of diaphragmatic tenting • Communication with the anesthesia team • Use of the laparoscopic suction irrigator to re-establish the negative pressure within the pleural cavity • Prompt chest x-ray in the PACU and, in the asymptomatic patient, administration of supplemental oxygen to improve the resolution rate of the pneumothorax • Consideration of needle aspiration or chest tube placement if the patient is symptomatic. <h3>Measurements and Main Results</h3> The patient recovered well without any postoperative complications. <h3>Conclusion</h3> In conclusion, laparoscopic resection of diaphragmatic endometriosis is reasonable in the appropriately selected patient. Surgical techniques used should ensure complete resection of endometriotic lesions while minimizing the risk of diaphragm injury. Prompt recognition and management of iatrogenic pneumothorax is crucial, and a surgeon should use these key principles when managing this complication.