Diaphragmatic Endometriosis Research Articles

Catamenial Pneumothorax with Diaphragmatic Endometriosis: View from the Thoracoscope

Catamenial Pneumothorax with Diaphragmatic Endometriosis: View from the Thoracoscope

Robotic-Assisted Laparoscopy Excision of a Severe Form of Diaphragmatic Endometriosis: A Retrospective Study of 60 Patients

To assess the feasibility, effectiveness, and safety of the robotic surgical approach in the treatment of severe diaphragmatic endometriosis (DE). Retrospective single-center study using data prospectively recorded in the Franco-European Multidisciplinary Institute of Endometriosis database and the National Observatory for Endometriosis database. Tertiary referral center. Endometriosis care center. Sixty consecutive patients undergoing robotic excision of severe DE from January 2020 to July 2023. Robotic excision of severe DE. Categorical and continuous variables were evaluated and compared using descriptive statistics. A p value of <.05 was considered statistically significant. Full-thickness diaphragmatic resection was performed in 76.7% of patients (46 of 60) and partial diaphragmatic muscle resection in 10% of cases (6 of 60). Peritoneal stripping technique was performed in 60% of patients (36 of 60), divided as follows: as the only technique in the case of extensive superficial diaphragmatic involvement in 13.3% of cases (8 of 60), in addition to full-thickness or partial diaphragmatic resection in the case of concomitant multiple foci in 46.7% of patients (28 of 60). Median operative time was 79.6 minutes with no statistically significative difference related to the surgeon performing surgery (p >.05). Intraoperative and postoperative complications occurred in 1.7% (1 of 60) and 6.6% of cases (4 of 60), respectively. Diaphragmatic hernia (Clavien-Dindo 3b) was the most common postoperative complication and required surgical repair in all cases. Median hospital stay was 24 hours. The rate of patients with complete recovery from DE symptoms has gradually increased during follow-up, reaching 89% after 12 months from surgery. In this case series, robotic treatment of severe DE in expert hands was feasible, effective, and safe.

Diaphragmatic endometriosis excisions and associated pathology in VATS procedures

Diaphragmatic endometriosis excisions and associated pathology in VATS procedures

Diaphragm endometriosis: Random localization or extended form of pelvis endometriosis. A large comparative analysis of 202 cases

ObjectiveThe aim of this study was to investigate and present the clinical characteristics of diaphragm endometriosis, to approach the pathogenetic mechanisms, and to answer the question of whether this disease can be considered an extended form of pelvic endometriosis. Study designIt was a retrospective comparative one-to-one analysis of 202 cases. Two groups of patients were compared: Group 1 patients with diaphragm endometriosis vs Group 2 (control group) with pelvis endometriosis, each with 101 patients. ResultsPatients with diaphragm endometriosis had extreme significantly higher prevalence of severe pelvis endometriosis included deep infiltrated endometriosis and severe adhesions in term of complete Douglas obliteration (p value = 0.0001). There was neither age nor BMI difference in two groups. Besides of cyclic shoulder or upper abdomen pain there was no difference of symptoms. ConclusionDiaphragm endometriosis is a rare condition with an approximate prevalence of 1.1% of all endometriosis cases. Since the symptoms are very specific and patients do not associate the pain with diaphragmatic endometriosis, the symptoms should be asked about explicitly. If patients with diaphragmatic endometriosis have no symptoms, the lesions do not necessarily need to be removed. The pathogenesis is still unclear. The authors of this study consider this disease to be an extended form of severe pelvic and deep infiltrated endometriosis. However, the right-side dominance still cannot be explained. Further research is needed to fully understand the origin of diaphragmatic endometriosis.

Intraoperative Management of Right Diaphragmatic Endometriosis during Laparoscopic Partial Resection of Liver Segment 8

Intraoperative Management of Right Diaphragmatic Endometriosis during Laparoscopic Partial Resection of Liver Segment 8

Perioperative Considerations for the Management of Diaphragmatic Endometriosis with Possible Thoracic Involvement

Perioperative Considerations for the Management of Diaphragmatic Endometriosis with Possible Thoracic Involvement

Diaphragmatic Hernia With Liver Protrusion Following Resection of Diaphragmatic Endometriosis

Diaphragmatic Hernia With Liver Protrusion Following Resection of Diaphragmatic Endometriosis

Diaphragmatic Endometriosis-A Single-Center Retrospective Analysis of the Patients' Demographics, Symptomatology, and Long-Term Treatment Outcomes.

Diaphragmatic endometriosis is rare and forms 0.67-4.7% of all endometriosis cases. Evidence regarding its optimal management is lacking. In this study, we retrospectively analyzed the patient characteristics and long-term treatment outcomes of diaphragmatic endometriosis patients. Over a 4-year period, 23 patients were diagnosed with diaphragmatic endometriosis. The majority of patients had coexisting deep pelvic endometriosis. Cyclic upper abdominal pain was reported by 60.9% of patients, while cyclic chest and shoulder pain were reported by 43.5% and 34.8% of patients, respectively. Most patients were treated with laparoscopic lesion ablation, while 21.1% were treated with minimally invasive excision. The mean follow-up time was 23.7 months. Long-lasting resolution of the chest, abdominal, and shoulder pain occurred in 50%, 35.7%, and 25% of patients, respectively. Nonetheless, 78.9% of patients reported major improvement in their symptoms postoperatively. Significantly higher rates of postoperative shoulder, abdominal, and chest pain were observed in patients who received postoperative hormonal therapy compared with those who did not. All patients treated expectantly remained stable. Therefore, we recommend treating diaphragmatic endometriosis only in symptomatic patients. The risk of incomplete surgery should be minimized by a multidisciplinary diagnostic and therapeutic approach with a careful assessment of the diaphragm and the thoracic cavity.

The Importance of Early Diagnosis and Treatment of Incidental Tension Pneumothorax During Robotic Assisted Video laparoscopy for Treatment of Diaphragmatic Endometriosis: Report of Two Cases

We describe two cases of robotic assisted video laparoscopy for the treatment of diaphragmatic endometriosis, in which incidental Tension pneumothorax occurred during the initial Inspection and inventory of diaphragmatic lesions. We Demonstrate the importance of early diagnosis of this complication and report successful resolution using the thoracic drainage technique.

The Combined Robotic-assisted Laparoscopic and Thoracic Approach in the Management of Diaphragmatic, Pleural, and Pericardial Endometriosis

To demonstrate the advantages of a combined robotic-assisted laparoscopic and thoracic approach in the management of extensive diaphragmatic, pleural, and pericardial endometriosis. A video article demonstrating excision of endometriosis from pericardium, diaphragm, and pleura. Thoracic endometriosis is the most common site of extrapelvic endometriosis [1]. Surgical treatment aims to excise all visible disease to relief symptoms and prevent recurrence [2-4]. A 41-year-old lady with cyclical shoulder tip and chest pain and known extensive diaphragmatic endometriosis was referred to our center. The procedure was done jointly by a gynecologist and a thoracic surgeon experienced in robotic-assisted endometriosis excision (Supplemental Video 1). Robotic-assisted laparoscopy revealed extensive full-thickness diaphragmatic endometriosis and a full-thickness pericardial nodule. Pericardial endometriosis excision was performed and a 1 cm defect was left open in the pericardium. Multiple diaphragmatic endometriotic nodules were excised and pleural cavity was entered (Image 2). On robotic-assisted thoracic surgery, further deep endometriotic lesions were detected and excised from the posterior aspect of the diaphragm. These lesions were not identified abdominally despite complete division of falciform ligament, full mobilization of the liver, and the use of a 30-degree scope. Superficial endometriotic lesions on parietal pleura were also detected (Image 3) and excised. The defects on the diaphragm were closed (Image 4). Chest and abdominal drains were left in situ. The patient was discharged on day 4. The combined robotic-assisted laparoscopic and thoracic approach is indicated in selected cases and allows full exploration of the thoracic cavity and both sides of the diaphragm, thus preventing incomplete excision of the disease. Robotic surgery also allows smooth dual-surgeon teamwork.

True Prevalence of Diaphragmatic Endometriosis and Its Association with Severe Endometriosis: A Call for Awareness and Investigation

To identify characteristics indicating preoperatively the presence of diaphragmatic endometriosis (DE). Comparison of characteristics of patients with DE with characteristics of patients with abdominal endometriosis without diaphragmatic involvement, in a prospective cohort study. Tertiary referral center; endometriosis center. 1372 patients with histologically proven endometriosis. Surgery performed laparoscopically under general anesthesia. All patients with suspected endometriosis underwent a complete bilateral inspection of the diaphragm. Demographic and clinical pathologic characteristics were evaluated using basic descriptive statistics (comparison of the groups using the chi-square test and the Mann-Whitney t-test). A logistic regression analysis was performed to evaluate the relationship (hazard ratio) between symptoms and the presence of DE. DE was diagnosed in 4.7% of the patients (65/1372). There was no significant difference between the two groups (patients with abdominal endometriosis with or without DE) with regard to typical endometriosis pain (dysmenorrhea, dyschezia, dysuria, and/or dyspareunia). However, in the DE group, diaphragmatic pain was present significantly more often pre-operatively (27.7% vs 1.8% p<.001). Four DE patients (6.1 %) were asymptomatic (with infertility the indication for surgery). In the DE group, 78.4 % had advanced stages of endometriosis (rAFS III° or IV°); the left lower pelvis was affected in more patients (73.8%). In cases of ovarian endometriosis, patients with DE showed a significantly higher prevalence of left ovaries involvement (left 63% vs right 35.7%, p<.001). Patients with DE had a significantly higher rate of infertility (49.2% vs 28.7%, p<.05). Patients with shoulder pain, infertility, and/or endometriosis in the left pelvis have a significant higher risk of DE and therefore need specific preoperative counseling and if indicated surgical treatment.

Treatment of Iatrogenic Pneumothorax during Resection of Diaphragmatic Endometriosis using a Laparoscopic Suction Irrigator: A Simple Approach.

Treatment of Iatrogenic Pneumothorax during Resection of Diaphragmatic Endometriosis using a Laparoscopic Suction Irrigator: A Simple Approach.

Surgical Treatment of Catamenial Chest Pain: Excision of diaphragmatic endometriosis during robot-assisted laparoscopic surgery.

10% of women of reproductive age are affected by endometriosis, and diaphragmatic endometriosis represents 1-1.5% of these cases. Diaphragmatic endometriotic lesions often require surgical treatment. This video aims to demonstrate the appearance of diaphragmatic endometriosis and describe our experience with robot-assisted laparoscopic excision of full thickness diaphragmatic endometriosis. The patient was a 37-year-old female with the complaint of cyclical right shoulder pain (for 1 year). She previously had caesarean section scar and umbilical endometriosis excision procedures. The magnetic resonance imaging (MRI) of the abdomen highlighted three endometriotic nodules, one of which was described as full thickness on the right hemi-diaphragm. The patient underwent a robot-assisted laparoscopic endometriosis surgery as a joint procedure between the gynaecology and general surgery teams. The falciform ligament was completely divided to obtain full views of the endometriotic lesions on the diaphragm. Superficial diaphragmatic lesions were first excised. The larger deep nodule, which was described on the MRI, was then excised with the full thickness of diaphragm. Pleural cavity was entered intentionally to achieve complete excision of the nodule. Laparoscopic assessment of the right lower pleural cavity through this opening did not show any endometriotic lesions. After the excision, the diaphragm was repaired with a barbed suture. Negative pressure suction of the pleural cavity was performed at the end of this repair instead of using a chest tube. The patient was discharged on the 3rd day with no complications encountered. Histopathological examination confirmed endometriosis. The patient was asymptomatic three months after surgery. Robotic-assisted surgery is an easy and safe choice especially in such challenging dual compartment surgeries by providing a 3D view that abolishes sensory loss and increases depth perception, providing better manoeuvrability with tremor absence.

Diaphragmatic endometriosis: robotic approaches and techniques

To present different approaches used in the surgical management of diaphragmatic endometriosis using the Davinci Robotic system. A video article presenting patient positioning, port placement, and surgical techniques used in robotic excision of diaphragmatic endometriosis with concomitant pelvic disease. Endometriosis center. Patients undergoing excision of diaphragmatic endometriosis. Systematic robotic approach to excise diaphragmatic lesions depending on the depth of invasion. The advantages and disadvantages of the lithotomy and the lateral decubitus approach were reviewed. Ports placements are illustrated according to the chosen approach. Diaphragmatic peritoneal stripping, diaphragmatic shaving, and diaphragmatic excision are different techniques used according to the depth of invasion. N/A. The choice of approach between the lithotomy position and the left lateral decubitus position depend on the extent of the diaphragmatic disease and the presence of concomitant pelvic lesions. Despite the lack of high-quality evidence, the advantages of the robotic system may improve the outcomes in such difficult cases in comparison with conventional laparoscopy.

8811 Diaphragmatic Endometriosis: Anatomopathology and Correlation with Surgical Technique in 230 Patients Treated in a Referral Center

<h3>Study Objective</h3> To define a decision-making algorithm for Diaphragmatic Endometriosis (DE) surgical treatment correlating laparoscopic appearance of endometriotic implants with their histopatological counterpart. <h3>Design</h3> All the cases of DE surgically treated in Our Department, from January 2004 to January 2021, were analyzed in a retrospective chart review. <h3>Setting</h3> DE lesions were correlated to intraoperative findings (morphology, localization, side of the diaphragm, diameter, depth of infiltration and number) and classified according to their histopathological features as: •"Foci": bidimensional superficial peritoneal lesions, generally ≤ 1 cm diameter. •"Plaques": thin fibrotic lesions, thickening the diaphragmatic peritoneum with no muscular infiltration, > 1cm diameter. •"Nodules": solid, tridimensional implants, associated with partial or full-thickness infiltration of underneath muscle layers and generally > 1cm diameter. <h3>Patients or Participants</h3> Two hundred -thirty patients were collected. <h3>Interventions</h3> The histopathologic revision of all the specimens enabled us to select a different laparoscopic surgical approach, for each lesion, as the following: <h3>Measurements and Main Results</h3> •Argon Beam Coagulator (ABC) and/or Diathermocoagulation (DTC) for diaphragmatic foci; •Diaphragmatic stripping is indicated for endometriotic plaques •Nodulectomy is the right choice for endometriotic nodules, with the need of partial or full-thickness diaphragmatic resection according to the entity of muscular involvement. <h3>Conclusion</h3> A safe eradication of the implants requires a standardization of the surgical technique based on the knowledge of laparoscopic and histopathologic characteristics of lesions, thus avoiding intra- and post-operative morbidities.

Thoracic and diaphragmatic endometriosis: an overview of diagnosis and surgical treatment.

Thoracic endometriosis is a rare disease that can lead to a variety of clinical manifestations. There are currently no guidelines for optimal diagnosis and management of the disease. The purpose of this review is to provide an overview of the diagnosis and surgical treatment of thoracic endometriosis. Various imaging modalities, including computed tomography (CT), MRI and ultrasound, have been reported in the detection of thoracic endometriosis. MRI is the most sensitive imaging study and may aid in preoperative planning. Histopathology of a biopsied lesion remains the gold standard for diagnosis. Surgical management of thoracic endometriosis may involve laparoscopy and/or thoracoscopy, and surgical planning should include preparation for single ventilation capability. A multidisciplinary approach involving a gynaecologic surgeon and thoracic surgeon may be considered. Repairing diaphragm defects and pleurodesis are shown to decrease recurrent symptoms. Although optimal diagnostic testing remains uncertain, a high clinical suspicion for thoracic endometriosis is critical to ensure prompt diagnosis and treatment in order to prevent recurrent symptoms and progression to more serious sequalae. Minimally invasive surgical techniques are becoming increasingly utilized and allow for thorough evaluation and treatment of thoracic endometriosis.

Laparoscopic Management of Innumerable Diaphragmatic Fenestrations

A 50-year-old woman known to have severe endometriosis was referred with cyclic pelvic pain, right shoulder pain, and recurring bilateral pleural effusions necessitating near-monthly thoracentesis of up to one liter of fluid. Gonadotrophin-releasing hormone agonism produced incomplete success. Diaphragmatic endometriosis is a condition affecting 1.5% of patients with endometriosis [1]. The mechanism postulated combines Sampson's theory of retrograde menstruation with clockwise transport of endometrial cells into the right subdiaphragmatic space via peritoneal fluid [1].

Dynamics of thoracic endometriosis in the pleural cavity.

BackgroundThoracic endometriosis-related pneumothorax is a secondary spontaneous pneumothorax caused by thoracic endometriosis. Diaphragmatic endometriosis is well-studied, but visceral and/or parietal pleural lesions are not. Although surgery is an effective treatment, postoperative recurrence rates are unsatisfactory probably due to inadequate understanding of underlying pathophysiology. We aimed to clarify the clinicopathological features of thoracic endometriosis.MethodsIn total, 160 patients who underwent thoracoscopic surgery from a single institution with histopathologically proven thoracic endometriosis from January 2015 to December 2019 were included. Clinicopathological characteristics and surgical outcomes were assessed retrospectively.ResultsThe cohort median age was 41 (range 22–53) years. Pneumothorax was right-sided in 159 (99.4%) and left-sided in only 1 (0.6%) case. Visceral and parietal pleural lesions were diagnosed in 79 (49.4%) and 71 (44.4%) patients, respectively. In total, 104 visceral pleural lesions and 101 parietal pleural lesions were detected. The S4 region and the dorsal 6th intercostal space contained the largest number of visceral pleural (66 lesions) and parietal pleural lesions (25 lesions), respectively. Histopathological evaluation revealed endometriotic tissues, existing in the outer external elastic layer in all lesions, were localized or invaded deeply. The median follow-up period was 370 (range, 6–1824) days. The Kaplan-Meier method revealed that the 1- and 2-year postoperative recurrence rates were 13.8% and 19.3%, respectively.ConclusionsVisceral pleural endometriotic lesions may be disseminated from the visceral pleural surface and infiltrate into the pleura. Intraoperatively, careful observation of the specific sites, such as the visceral pleura of S4 and the parietal pleura of 6th intercostal space, is important to reduce postoperative recurrence.

Robotic Management of Diaphragmatic Endometriosis in 10 Steps

To present 10 standardized steps of the surgical management of diaphragmatic endometriosis using Da Vinci robotic assistance. Surgical education video. The local institutional review board confirmed that the video met ethical criteria required for publication. Patient consent was obtained. Tertiary referral center. The film presents a standardized way of performing excision of diaphragmatic endometriosis using the following 10 steps: (1) The patient is placed in left lateral decubitus and 10° proclivity [1,2]. (2). Three 8-mm wide incisions are made, including on the right medio-clavicular line for the endoscope, on the medio-axillar line for the bipolar forceps, and 2 cm below the xiphoid appendix for the scissors. A 10-mm incision is made 3 cm above the umbilicus for the assistant trocar. (3) The procedure starts by an inspection of the right diaphragmatic surface; the falciform ligament is sectioned to allow exploration of the left diaphragm and supplementary mobilization of the liver. (4) Adhesions are completely sectioned, down to the hepato-phrenic cul de sac, tangentially to the liver surface. (5) Small lesions, which do not require full thickness excision, are first removed, before creating a pneumothorax, using a low monopolar setting at 20 watts [3]. (6) Full thickness excision of transfixing lesions or holes is carried out using monopolar scissors and results in an immediate complete right pneumothorax [2,4]. (7) The pleural cavity is inspected to identify disseminated lesions in the chest, located far from the diaphragm. (8) Repairing of the diaphragm is carried out by performing a unidirectional barbed suture. (9) Before performing the final knot, the laparoscopic suction irrigation canula is introduced into the chest cavity, and the CO2 used for inflation is fully aspirated, leading to the creation of the diaphragm concavity; the use of a chest drain is therefore not necessary. (10) Despite the lack of high-level of evidence data, we routinely use an antiadhesion agent, with an aim to reduce postoperative adhesions. Operative time varies from 30 min to 1 hour. Chest X-ray is routinely performed at postoperative day 1. To date, in 76 patients, X-ray did not reveal postoperative relevant pleurisy requiring chest drainage. The robotic-assisted laparoscopic excision of deep endometriosis involving the diaphragm is a standardized 10-step procedure that allows a complete removal of diaphragmatic lesions with good clinical outcomes.

The importance of diaphragmatic surgery, chemical pleurodesis and postoperative hormonal therapy in preventing recurrence in catamenial pneumothorax: a retrospective cohort study.

Catamenial pneumothorax (CP) is defined as a recurrent, spontaneous pneumothorax occurring within a day before or 72h after the onset of menstruation. Most first episodes go undiagnosed and treated as primary spontaneous pneumothorax, and only after recurrence is the clinical suspicion of CP raised. No gold-standard management approach exists, especially in terms of managing diaphragmatic involvement. This study is a single-centre cohort retrospective study of 24 female patients who underwent surgery for pneumothorax due to diaphragmatic endometriosis between January 2008 and December 2016. Two groups were compared: a group that underwent pleurodesis alone (8 patients) and a group that underwent diaphragmatic surgery and pleurodesis (16 patients). There were differences in BMI and smoking habits between the two groups. The right diaphragm was involved more often (6vs15, p = 0.190). VATS was the preferred surgical approach and only one conversion occurred in the diaphragmatic surgery group (p = 0.470). Diaphragmatic abnormalities were present in all the patients, brown/violet spots (100%) in the pleurodesis group and perforations (100%) in the diaphragmatic surgery group (p < 0.001). There were no differences in days of chest tube removal and length of stay. The recurrence rate was 100% in the pleurodesis alone group while it was only 12.5% in the diaphragmatic surgery group (< 0.001). In our experience, diaphragmatic surgery and pleurodesis followed by hormonal therapy was an effective approach in preventing recurrence in patients with catamenial pneumothorax and diaphragmatic involvement.