This video presents a five-step approach to the laparoscopic excision of pericardial and diaphragmatic endometriosis. Clinically, endometriosis affects the thoracic cavity in less than 1% of cases, most commonly involving the diaphragm and treated using a VATS approach.
Pericardial endometriosis is an even rarer entity, with only 4 case reports published to date. We present the case of a 35-year-old in order to illustrate the approach to a laparoscopic excision of diaphragmatic and pericardial endometriosis. In consultation with the
Thoracic team, she is consented for a completion surgery of thoracic endometriosis identified at a prior laparoscopy, symptomatic for right shoulder and mid-chest pain, and unresponsive to medical therapy. The surgical approach consists of 5 reproducible steps:
1. Upper abdominal survey
2. Liver mobilization
3. Excision of diaphragmatic and pericardial lesions
4. Intra-thoracic laparoscopic exploration
5. Closure of the diaphragmatic defect
University of Calgary
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Video Transcript: Laparoscopic Excision of Pericardial and Diaphragmatic Endometriosis
This video presents a five-step approach to the laparoscopic excision of pericardial and diaphragmatic endometriosis. Anatomy, derived from the Greek words dia and phragma, which mean apart and fence, the diaphragm is a musculotendinous dome that separates the thoracic from the abdominal cavity. Seen from its under surface here, the diaphragm is divided into three parts, the central tendon, the coastal part and the crural part. It receives vascular supply mainly from the phrenic arteries, deriving from the aorta, and innervation mainly from the phrenic nerves.
The phrenic nerves originate from C3 to C5, travel alongside the pericardium and insert into the diaphragm centrally on the lateral borders of the pericardium. Injury to the main branch can result in diaphragmatic paralysis. Clinically, endometriosis affects the thoracic cavity in less than 1% of cases. A recent systematic review of extraperitoneal endometriosis by Andres et al., reported 628 cases of thoracic endometriosis, which most commonly affects the diaphragm, followed by the pleura and the lung. The majority of cases are right-sided and treated using a VATS approach.
Pericardial endometriosis is an even rarer entity. To date, only four case reports have been published. Of these, only one had a histopathological confirmation and was treated through a midline laparotomy. The remaining three cases reported pericardial effusions, which resolved following either surgical or medical therapy, but without pericardial excision.
We present the case of a 35-year-old in order to illustrate the approach to a laparoscopic excision of diaphragmatic and pericardial endometriosis. In consultation with a thoracic team, she consented for a completion surgery for thoracic endometriosis, which was identified at a prior laparoscopy and remained unresponsive to medical therapy.
The surgical approach can be summarised in five steps:
- The upper abdominal survey
- Liver mobilization
- Excision of diaphragmatic endometriosis
- Exploration of the thoracic cavity
- Closure of the defect
Performed routinely at the time of laparoscopy, an upper abdominal survey reveals a full-thickness endometriotic lesion on the right hemidiaphragm. Another can be visualized on the left side, abutting the pericardium. To optimize exposure, the liver can be mobilized with a Nathanson Liver Retractor. Lysis of perihepatic adhesions can also aid with visualization, as well as a transection of the round and falciform ligaments or a part of coronary ligaments, as these are the main ligaments that anchor the liver to the diaphragm.
Here the right diaphragmatic lesion is tackled first. The peritoneum is incised using an ultrasonic device. The dissection is carried out until the full-thickness portion of the lesion is encountered, as evidenced here, with the drainage of chocolate cyst fluid. The thoracic cavity is then entered, allowing visualization of the pleural surface. Examination of this surface helps guide and delineate the extent of the resection. The excision is then completed, taking care to incorporate any visible full-thickness lesions.
For the pericardial lesion, the peritoneum is once again incised using an ultrasonic device. Dissection of a plane can help distinguish areas of superficial involvement from those with deeper infiltration. In turn, this helps minimize the size of the pericardial window that will need to be performed. Drainage of pericardial fluid signals the entry into the pericardial cavity. The excision is pursued circumferentially, with the active blade turned to aim away from the heart. The pericardial window is complete when the full-thickness lesion is incorporated into the specimen.
Prior to defect closure, the thoracic cavity should be explored with a laparoscope to rule out any residual involvement of the lung or pleura. Closure of the diaphragmatic defect is performed in two layers using an Endo Stitch suturing device and braided polyester non-absorbable sutures. The first layer consists of mattress sutures to allow maximal security in the approximation of tissues that are constantly under stress. Upon tying the last stitch, suction is used to empty the thoracic cavity during maximal lung expansion.
The second reinforcing layer is then performed in a running fashion, using the same suture material. On the other hand, small pericardial defects are usually left unclosed, similar to when pericardial windows are created for patients with cardiac tamponade. Post-operative care should align with the Enhanced Recover After Surgery Pathways designed for thoracic surgery, which includes early mobilization, dietary advancement at tolerance, multimodal analgesia, as well as urinary catheter removal and chest x-ray on post-op day one. If a chest tube is inserted intra-op or post-op, early removal is recommended as soon as non [unclear] output falls below 300 cc per 24 hours with no air leak.
The long-term outcomes for diaphragmatic excision of endometriosis are limited to retrospective studies, reporting a high rate of pain improvement or resolution. Hormonal suppression has been shown to reduce the risk of recurrence of endometriosis-related pneumothoraxes and should be continued post-op. In this video, we presented a case of pericardial and diaphragmatic endometriosis, successfully treated with a multidisciplinary surgical intervention using a five-step approach.