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Diaphragmatic Endometriosis

This video presents two cases of diaphragmatic endometriosis, emphasizing diagnostic challenges, multidisciplinary management, and laparoscopic techniques for safe resection of thoracic endometriosis lesions. Presented By Dr. Mohamed Bedaiwy Dr. Anna McGuire Bahi Elbasueny Dr. Gabriel Chan This case series illustrates the diagnostic and surgical management of diaphragmatic endometriosis, a rare manifestation of thoracic endometriosis syndrome involving endometrial implants on the diaphragm, pleura, or lung. Symptoms can range from catamenial right upper-quadrant pain to pneumothorax or hemothorax, typically appearing later than pelvic endometriosis. Because imaging is often negative and lesions may be concealed beneath the liver, diagnosis frequently depends on thorough laparoscopic exploration. Most patients also present with concurrent pelvic disease, and a detailed menstrual and pain history remains critical for recognition. The first patient, a 35-year-old woman with catamenial upper-quadrant pain and prior pelvic endometriosis, underwent total laparoscopic hysterectomy, excision of pelvic lesions, and diaphragmatic exploration. Retraction of the liver revealed dense adhesions between the diaphragm and hepatic surface. Careful monopolar dissection exposed a deeply infiltrating lesion requiring full-thickness resection, which briefly entered the pleural cavity. The diaphragm was repaired with interrupted sutures, and postoperative recovery was uncomplicated except for a small pneumothorax managed conservatively. Although histology was negative for endometriosis, current ESHRE guidelines emphasize that receptor-based immunohistochemistry may be required for definitive diagnosis, as routine histology often yields false negatives. The second case involved a 44-year-old woman with chronic pelvic endometriosis and persistent right upper-quadrant pain despite hormonal therapy. Laparoscopy revealed a diaphragmatic nodule, which was excised with monopolar and blunt dissection without entering the pleura. The lesion was confirmed histologically as endometriosis, and the patient experienced complete symptom resolution by six weeks postoperatively. Together, these cases underscore the importance of maintaining a high index of suspicion for diaphragmatic endometriosis in patients with cyclical upper-abdominal pain, especially those with known pelvic disease. Optimal management combines preoperative planning, multidisciplinary collaboration with thoracic surgery, and meticulous laparoscopic technique using liver retraction and reverse Trendelenburg positioning for enhanced visualization. Even when histology is negative, intraoperative findings supported by receptor staining can confirm the diagnosis. Early recognition and comprehensive surgical management are key to improving outcomes and preventing recurrence in this complex condition.