Endometriosis is a common condition, affecting approximately 11% of American women of reproductive age, according to the U.S. Department of Health and Human Services’ Office on Women’s Health. Occasionally, endometrial-like glands and stroma can be found outside the uterine cavity in the pleura, lung and diaphragm.

“Diaphragmatic endometriosis is the most common type of extra pelvic endometriosis,” says Miguel Luna, MD, a Cleveland Clinic physician. “However, it is very rare – about 12% of women with pelvic endometriosis may present with concomitant diaphragmatic endometriosis – and not a lot of surgeons have exposure to the condition.”

As an endometriosis specialist, Dr. Luna sees a higher volume of complex cases. He shared insight into surgical management of diaphragmatic endometriosis in a video article in the Journal of Minimally Invasive Gynecology (JMIG), which won the 2021 JMIG Best Video Award.

Symptoms and surgical indications

A large percentage of patients with diaphragmatic endometriosis are asymptomatic. Those who are symptomatic may experience cyclic shoulder pain, right upper quadrant pain, catamenial pneumothorax and hemoptysis or pleural effusion.

“Diaphragmatic endometriosis can be managed medically,” says Dr. Luna. “Surgery is generally reserved for patients who have significant symptoms or for whom medical management has failed.”

Ablation or resection of diaphragmatic endometrial lesions is typically done via laparoscopy. Surgeons performing the procedures must be familiar with diaphragmatic, liver and thoracic anatomy. Before surgery, patients should undergo diagnostic imaging, preferably magnetic resonance imaging, to map suspicious lesions.

“If the lesion is isolated to the diaphragm alone and you are confident the pleura and lung are not affected from the pre-operative workup, then video assisted thoracoscopic surgery (VATS) is not generally indicated,” says Dr. Luna.

VATS is often performed at the same time as pelvic procedures for endometriosis.  

“We usually have a thoracic surgeon on the team working with us,” says Dr. Luna. “Once the abdominal and pelvic portions of the surgery are complete, then the thoracic surgery team takes over. We reposition the patient, and the thoracic team proceeds.” The surgeon then makes a small incision between the rib spaces to insert the video camera and perform the ablation or resection of thoracic lesions, if present.

Surgical recommendations

Dr. Luna offers advice for surgeons who are considering adding surgical management of diaphragmatic endometriosis to their service:

• Gather a skilled team – “The most important thing is to be prepared pre-operatively,” he says. “Once you know you have a case of diaphragmatic endometriosis, it’s critical to involve all the team members who can help you in surgery.” This includes a cardiothoracic surgeon, an anesthesiologist and a radiologist, who may need to perform intraoperative ultrasound if the lesion is difficult to find.
• Establish good triangulation of laparoscopic ports. “If you are doing pelvic excision of endometriosis and then plan to go up under the diaphragm, you may need to replace or shuffle your ports,” says Dr. Luna. “That way, when you perform the laparoscopic diaphragmatic endometriosis excision, you have triangulation that will allow you to suture and obtain adequate exposure behind the liver.”
• Perform a thoracoscopic evaluation when indicated. This includes visual inspection of the parietal and visceral pleura, as well as the thoracic portion of the diaphragm.
• Use bronchoscopy for double-lumen endobronchial tube placement for selective ventilation. “If you create a hole or defect in the diaphragm, the CO2 from the laparoscopy of the abdomen will enter the pleural cavity and collapse the lung,” says Dr. Luna. “If the patient doesn’t have a double-lumen tube, the anesthesiologist will not be able to ventilate the patient properly.”
• Consider marking the margins of the resection with surgical clips. This can be helpful after a difficult resection or re-operation for recurrent pain. “If symptoms were to recur, this area could be easily identified in pre-operative imaging and intraoperatively, if needed,” says Dr. Luna.
• Use an intercostal nerve block for postoperative pain control. Inject one to two cubic centimeters of liposomal bupivacaine in the intercostal spaces where VATS’ incisions have been made. “Intercostal nerve block has been shown to significantly reduce postoperative pain and opiate consumption in patients undergoing video thoracic surgery,” says Dr. Luna.

While surgeons at Cleveland Clinic routinely perform concomitant thoracoscopy when diaphragmatic endometriosis is addressed, Dr. Luna urges surgeons to schedule separate pelvic and diaphragmatic endometriosis excisions if the right team isn’t in place. “Don’t feel compelled to do both at the same time,” he says.

Finally, Dr. Luna encourages gynecologists and gynecological surgeons to listen to their patients.

“We see a lot of patients who present with symptoms of diaphragmatic endometriosis that have been in pain for a very long time,” he says. “Diaphragmatic endometriosis may be uncommon, but it can be debilitating. It’s important to have a high index of suspicion when symptoms are present, conduct a complete medical examination and refer the patient for management when appropriate.”