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Diaphragm Endometriosis Discussion
"My wife has been operated for the first time for endometriosis, and although identified to spread to the diaphragm, it was obviously ignored. Sleepless nights due to pain."
We have excellent results with endometriosis of the diaphragm, even when it is full-thickness to the pleural space; laparoscopic, outpatient, no drains, no chest tubes. Diaphragm disease is excised working with a surgeon who specializes in laparoscopic surgery on the diaphragm. Even though some centers perform VATS (video-assisted thorascopic surgery), we have not needed to do this. Endometriosis on the diaphragm originates on the peritoneal (intra-abdominal) side, so if endometriosis is present on the diaphragm, we should be able to visualize it at laparoscopy ("lapar" means abdomen, "scopy" refers to tube with a light). Sometimes mesh is used to close defects of the diaphragm, but we have not needed to do that. Full thickness excision sites of the diaphragm are repaired with permanent 2-0 Ethibond sutures.
"Can you have diaphragmatic endometriosis without having any other form of endometriosis?"
Endometriosis of the diaphragm can produce pain to right rib cage, right upper back, shoulder, and scapula. Diaphragm endometriosis can sometimes present as nausea, possibly due to irritation of the Vagus nerve. When you look into the upper abdomen at the liver and diaphragm, you are looking at the anterior aspect of the diaphragm. Symptomatic endometriosis tends to involve the posterior aspect of the diaphragm, the portion that is underneath the liver. To get to the posterior aspect of the right diaphragm, it is necessary to push the right lobe of the liver down or, more commonly, to go underneath the right lobe of the liver and lift the liver up so we can work underneath the right lobe of the liver. There is a surgeon that I work with who specializes in laparoscopic surgery on the diaphragm, and we do these cases through 5mm sites with no tubes, no drains, generally outpatient. I would coordinate with this general surgeon so we could thoroughly check the diaphragm at surgery. Thoracic surgery is usually not necessary. Endometriosis starts on the abdominal side of the diaphragm, so if endometriosis is there, then we should see it and remove it. If a person has menstrual related pneumothorax, we also have a Thoracic surgeon who can perform VATS. Partial thickness excisions of the diaphragm heal well and do not need repair. Full thickness excisions of the diaphragm with entry into the pleural space are closed with permanent sutures. Endometriosis lesions can be small or diffuse, superficial or deep, can bleed to form endometriomas or areas of firm nodularity. We have removed endometriomas from the ribs. Endometriosis can involve the left diaphragm, but this is less common Endometriosis is most commonly a multi-focal condition. It usually has multiple sites of involvement. It is possible for endometriosis to be found in only one site, but this is much less common. For example, ovarian endometrioma is almost always stuck to pelvic sidewall, uterosacral ligament, and/or uterus. If having a laparoscopy for diaphragm endometriosis, it is important to also evaluate and excise any endometriosis from the pelvis.
"...diagnosed with diaphragm endometriosis after more than one year of right upper abdominal pain. Diaphragm endometriosis not treated because surgeon was concerned about risk of pneumothorax. What is the risk of experiencing catamenial pneumothorax from the endometriosis itself?"
Excision of the diaphragm can be partial thickness or full thickness, with entry into the pleural space. Entry to the pleural space allows the Carbon dioxide gas, used to distend the abdomen during laparoscopy, to go into the chest cavity (pleural space). Pleural space is the space between the lung and the lining of the chest wall, the Pleura. The lung is intact and collapses due to the pressure of the gas. If the surgeon just closes the hole in the diaphragm and left the CO2 gas in the chest cavity, then that would be a Pneumothorax that would require a chest tube, but this is Not what we do. Depending on the extent of the diaphragm involvement, we may have zero, one, or several openings into the pleural space. Sometimes we close the openings as we progress through the surgical procedure, and sometimes we close all the openings in the diaphragm at the end of the dissection. Regardless, when it comes to closure of the last opening of the diaphragm into the pleural space, we get most of the gas out of the pleural space before we tighten the last suture that closes/repairs the last opening in the diaphragm. The residual gas in the chest cavity is minimal, not clinically significant, and easily absorbed into the patient's system. All endometriosis and associated fibrosis must be excised from the pelvis. If there is a lot of right upper abdominal/chest/shoulder pain, then the diaphragm endometriosis needs to be excised. If the diaphragm endometriosis is asymptomatic, observation is appropriate. Penumothorax with menstrual cycles is possible, but uncommon. Exact incidence is uncertain.