Coagulation-Induced Diaphragm Fenestrations after Laparoscopic Excision of Diaphragmatic Endometriosis

Abstract

Study objective: To present an unusual consequence of laparoscopic treatment of diaphragmatic endometriosis, to discuss the possible etiologies, and to propose proper management.

Design: A step-by-step explanation of 2 surgeries of the same patient using intraoperative video sequences (Canadian Task Force classification III).

Setting: University hospital.

Patient: A 32-year-old woman.

Interventions: Two Laparoscopic surgeries.

Measurements and main results: Endometriosis is estimated to affect 11% of the population [1,2], with an estimated 12% of these patients having extrapelvic endometriosis [3]. When the diaphragm is involved, the disease potentially causes severe and debilitating symptoms such as catamenial chest or shoulder pain. Serious complications may involve pneumothorax and hemopneumothorax [4-6]. Diaphragmatic endometriosis is more common than realized and has been shown to occur simultaneously in 50% to 80% of cases with pelvic endometriosis [7,8]. A 32-year-old woman was admitted to our hospital with severe disabling dysmenorrhea and right shoulder pain. Despite progestin, nonsteroidal anti-inflammatory drug, and opioid treatment, pain relief remained inadequate. A laparoscopy was performed revealing diaphragmatic endometriosis, which was completely excised. A revision was necessary 14 months later because of pain recurrence in the right hemithorax and suspicion of new or persistent endometriotic lesions. The laparoscopy revealed small diaphragm fenestrations that were closed after exclusion of recurrent diaphragmatic or pleural endometriosis. No chest tube was placed, and the postoperative course was uneventful. Hormonal suppressive treatment was continued. Since the operation the patient has been pain free. Institutional Review Board/Ethics Committee ruled that approval was not required for this study (Req-2017-00415).

Conclusion: The diaphragm fenestrations were possibly the result of tissue necrosis caused by thermocoagulation after excision of deep endometriotic lesions during the first surgery. Using a CO₂ laser for the vaporization of superficial lesions is favorable because of the smaller depth of penetration compared with electrocautery and better access to hard to reach areas [9,10]. Endometriotic lesions involving the entire thickness of the diaphragm should be completely excised and the defect repaired with either sutures or staples [11-13].