June 2021: First patients treated at IFEM Endo with HIFU for rectal endometriosis
Lesions of the diaphragm are not always symptomatic.
They may, however, be responsible for pain during menstruation in the right shoulder, the right scapula, or at the base of the right hemithorax. In some cases, diaphragm lesions are the cause of recurrent pneumothorax episodes during menstruation.
Lesions of endometriosis of the diaphragm are regularly identified during laparoscopy, in the form of black microcysts, fibrous placards or orifices through the diaphragm.
In a series of 1,560 patients operated on at Rouen University Hospital, we found diaphragm lesions in 10.8% of cases (Stochino-Loi, Roman et al, JMIG 2020). In 90% of cases, they were located in the right hemicupola of the diaphragm, suggesting that their appearance is linked to the reflux theory, combined with the direction of circulation of the peritoneal fluid.
Diaphragm surgery is performed on women with the above-mentioned painful symptoms, i.e. 20-25% of women with lesions.
In our practice, surgery for diaphragm lesions is preceded by a diaphragm MRI imaging workup, the aim of which is to explore the posterior part of the diaphragm, masked by the liver and not visible in pelvic laparoscopy.
Surgery is performed in a second phase, after pelvic surgery, as it requires a different technique and set-up.
Diaphragm surgery can be performed laparoscopically, with or without robotic assistance.
At IFEM Endo, we currently perform this surgery by laparoscopy with robotic assistance.
We meticulously remove the lesions, sometimes including fragments of the diaphragmatic muscle, which we then repair with sutures, with or without prosthetic plates. If the diaphragm is opened, the thoracic cavity, parietal pleura and lung are explored.
The operation lasts from 1 to 2 hours. Complications are very rare.
Hospitalization is short, and the patient is usually discharged the following day. Time off work lasts 3 to 4 weeks, depending on the patient's professional activity.
20 to 25 patients with diaphragmatic endometriosis undergo surgery at our facility every year.
20-25
patients operated on each year at our facility
86%
of patients have lesions only on the right hemicupola of the diaphragm
90%
of patients are free of right shoulder pain after surgery
Bibliography
Roman H, Darwish B, Provost D, Baste JM. Laparoscopic management of diaphragmatic endometriosis by three different approaches. Fertil Steril. 2016 Aug;106(2):e1. doi: 10.1016/j.fertnstert.2016.03.051. Epub 2016 Apr 18. PMID: 27103401.
Ceccaroni M, Roviglione G, Giampaolino P, Clarizia R, Bruni F, Ruffo G, Patrelli TS, De Placido G, Minelli L. Laparoscopic surgical treatment of diaphragmatic endometriosis: a 7-year single-institution retrospective review. Surg Endosc. 2013 Feb;27(2):625-32. doi: 10.1007/s00464-012-2505-z. Epub 2012 Sep 6. PMID: 22955897.
Nirgianakis K, Lanz S, Imboden S, Worni M, Mueller MD. Coagulation-Induced Diaphragm Fenestrations after Laparoscopic Excision of Diaphragmatic Endometriosis. J Minim Invasive Gynecol. 2018 Jul-Aug;25(5):771-772.
Bourdel N, Fava V, Budianu MA, Chauvet P, Canis M, Chadeyras JB.Laparoscopic Resection of Diaphragmatic Endometriosis in 10 Steps. J Minim Invasive Gynecol. 2019 Nov-Dec;26(7):1224-1225.
Nezhat C, Nicoll LM, Bhagan L, Huang JQ, Bosev D, Hajhosseini B, Beygui RE. Endometriosis of the diaphragm: four cases treated with a combination of laparoscopy and thoracoscopy. J Minim Invasive Gynecol. 2009 Sep-Oct;16(5):573-80.
Redwine DB.Diaphragmatic endometriosis: diagnosis, surgical management, and long-term results of treatment. Fertil Steril. 2002 Feb;77(2):288-96.
Zanotti KM, Abdelbadee AY. Robotic management of endometriosis: where do we stand? Minerva Ginecol. 2015 Jun;67(3):257-72.
Our team has a wealth of experience in diaphragmatic endometriosis surgery.
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