Considerations for The Surgical Management of Diaphragmatic Endometriosis.

OBJECTIVES The objective of this video is to review relevant surgical anatomy, resection and ablation methods, and techniques to optimize management of diaphragmatic endometriosis. DESIGN Video footage of surgical anatomy and surgical technique. IRB approval was not required. SETTING Thoracic endometriosis lesions can involve the pleura, lung, and diaphragm. The prevalence of thoracic endometriosis is unknown, but the majority of cases involve the diaphragm. A large percentage of patients are asymptomatic. Those who are symptomatic can present with cyclic shoulder pain, right upper quadrant pain, or catamenial pneumothorax. Symptomatic cases refractory to medical management or recurrence require surgical management 1 , 2 . Safe and efficient management of these cases depends on an experienced multidisciplinary team. In this video, the experiences and management tools used by our team are described. INTERVENTIONS Laparoscopic management of primary and recurrent symptomatic diaphragmatic endometriosis. 1. The surgeon performing these procedures must be familiar with liver, diaphragmatic, and thoracic anatomy. 2. Preoperative MRI should be used to map suspicious lesions. 3. Bronchoscopy should be available for double-lumen endobronchial tube placement for selective ventilation. 4. The operating room should have video assisted thoracoscopy capability, and a thoracic surgeon should be available. Intercostal nerve block with liposomal bupivacaine can be useful for postoperative pain control 3 , 4 . CONCLUSION A multidisciplinary skilled team approach to the surgical management of diaphragmatic endometriosis to optimize outcomes is preferred.