Video Transcript: Surgical Management of Diaphragmatic Endometriosis
Surgical management of diaphragmatic endometriosis by the minimally invasive group at The Ottawa Hospital. This video will define diaphragmatic endometriosis, highlight multidisciplinary peri-operative management, and illustrate a step-wise surgical approach to excision.
Endometriosis located on the surface or muscle of the diaphragm is a rare entity with an unknown prevalence that most commonly presents as catamenial pneumothorax followed by hemothorax then shoulder tip pain. Two surgical options exist for resection. The thoracic approach and the laparoscopic approach.
The former is done via video-assisted thorascopic surgery, or VATS. VATS is performed by thoracic or general surgeons. It allows for exploration of the entire thorax, exposure of possible endometriosis, and tissue resection for histological confirmation.
The laparoscopic approach requires a multidisciplinary team that includes minimally invasive gynecological surgeons, thoracic surgeons, radiologists, and anesthesiologists. The following case highlights this management. A 34-year-old G0 reported 12 years of debilitating catamenial right shoulder pain as well as dysmenorrhea.
Previous laparoscopic ablation of diaphragmatic lesions did not relieve her symptoms. Medical options were not tolerated due to mood-related side effects, and she has consented for surgical excision. Excellence in endometriosis imaging is essential for diagnosis and surgical planning. Abdominal MRI shows a 3.6 by 1.3 centimeter sub-diaphragmatic deposit. CT chest was clear.
Thoracic consultation clarified specific risks relating to the thorax, including bleeding, infection, phrenic nerve injury, pneumothorax requiring chest tube, and risk of diaphragmatic hernia. Communication with anesthesia is crucial as double lumen endotracheal tubes are often required for one lung ventilation and increased surgical exposure. As well, acute events may be anticipated and controlled.
Finally, optimize the operative setup by placing the patient in reverse Trendelenburg using an angled scope and placing super umbilical ports to access the upper abdomen. Here is our surgical approach and case. Visualization of the diaphragm is first achieved by careful resection of the falciform ligament.
Then, after readily accessible lesions are resected, a liver retractor is placed and the right dome of the diaphragm is exposed and carefully examined. Here, more deposits of endometriosis are revealed. Resection of small lesions did not require full thickness resection. Just excision of peritoneum revealing striated muscle underneath. A chocolate cyst is seen being resected here.
After mobilization of the liver with the division of adhesions between the right hepatic lobe and right hemidiaphragm, there was a large endometriotic lesion clearly visible involving the peripheral, lateral, and posterior portion of the central tendon of the diaphragm and adjacent diaphragmatic muscle.
This largest endometriosis lesion was completely resected along with the portion of the diaphragm that was involved. The dissection is so complete that the plural cavity is entered and the lung is revealed. During the resection of the diaphragm, the laparoscope was inserted through the diaphragm into the patient’s right hemithorax to identify presence of any additional deposits of endometriosis within the right pleural cavity.
There was no evidence of endometriosis spread into the right pleural cavity or lung. The resection then continued until the entire lesion was delineated in order to reach healthy tissue. Once the resection is complete, the resulting diaphragmatic defect can be seen in full.
A 14-Fench test tube was then inserted under clear visualization with the laparoscope. It was discontinued on post-operative day one with no respiratory sequelae. The diaphragmatic defect was then closed with multiple interrupted horizontal mattress non-absorbable sutures.
For additional reapproximation, this was then followed by another layer of a running barbed suture. When the closure was complete, there was no significant tension at the level of the muscle. The patient was subsequentially seen at a routine six-week post-operative follow up. She reported regular menses and a complete resolution of the shoulder pain that she had had for the last 12 years of her life.
In summary, diaphragmatic endometriosis is a rare entity with varying clinical presentations. Surgical excision via laparoscopy requires a multidisciplinary team working together for peri-operative management optimization. To conclude, I’d like to thank the great team of collaborators working at The Ottawa Hospital as well as our patients who continue to allow us to share their stories.