Diaphragmatic lesions are not always symptomatic
but during menstruation they may cause pain in the right shoulder, right scapula, or at the base of the right hemithorax. In some cases, diaphragmatic lesions cause recurrent episodes of pneumothorax during menstruation.
Diaphragmatic endometriosis lesions are regularly identified during laparoscopy, as black microcysts, area of fibrous tissue or holes in the diaphragm.
In a series of 1560 patients undergoing surgery 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 found in the right hemicupola of the diaphragm. This suggests that their appearance is linked to the reflux theory, as well as to the way peritoneal fluid circulates.
Diaphragm surgery is performed on women who present with the painful symptoms mentioned above and concerns 20-25% of women found to have lesions.
In our clinical practice, surgery for diaphragm lesions is preceded by an MRI scan of the diaphragm, the aim of which is to explore the posterior part of the diaphragm, which is hidden by the liver and cannot be seen during laparoscopy of the pelvis.
The 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 along with fragments of the diaphragmatic muscle, which we then repair with a suture, with or without a prosthetic mesh. An exploration of the thoracic cavity, the parietal pleura and the lung is carried out if the diaphragm is opened.
The operation time ranges from 1 to 2 hours. Complications are very rare.
The hospital stay is short, and the patient is usually discharged the next day. Sick leave requires 3 to 4 weeks, depending on a patient’s professional activity.
20 to 25 patients with diaphragmatic endometriosis receive surgery each year at our clinic.
20-25
patients treated each year in our clinic
86%
of patients have lesions only on the right hemicupola of the diaphragm
90%
of patients are free of pain in the right shoulder 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 strong track record in diaphragmatic endometriosis surgery.
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