Endometriosis is estimated to occur in 10-15 % of the female population. Endometriosis involves the diaphragm in 1-1.5% of patients with endometriosis. Diaphragm endometriosis is a rare occurrence. Diaphragm endometriosis can be Asymptomatic and an Incidental finding.
As endometriosis invades deeper into the diaphragm and becomes full thickness, patients can present with right upper abdominal pain, rib cage pain, shoulder pain, scapula pain, pain on inspiration, and sometimes nausea. Similar to endometriosis in other locations, endometriosis will invade progressively deeper, and lesions can bleed into themselves, producing an Endometrioma. We have removed Endometriomas from the ribs.
We have excised endometriosis from both the left and right sides of the diaphragm, but the right side is more common. At laparoscopy, when looking at the liver, the diaphragm visible between the liver edge and the anterior ribs is the anterior aspect of the diaphragm. Symptomatic Endometriosis involves the posterior diaphragm more often. To visualize the posterior aspect of the diaphragm, it is necessary to either push the liver down or elevate the liver to look at the diaphragm underneath/posterior to the liver. Otherwise, diaphragm involvement could go unnoticed. It is important to evaluate the entire abdomen and pelvis. Peritoneal pockets and other subtle lesions on the pelvic sidewalls can radiate pain into the upper abdomen and rib cage. Laparoscopic excision of pelvic sidewall endometriosis can sometimes relieve upper abdominal pain.
Similar to endometriosis in other locations, endometriosis of the diaphragm is excised. Depending on the depth of the endometriosis lesions, some diaphragm excisions will be full thickness with entry into the pleural space. When endometriosis is excised from the diaphragm, I work with a surgeon who specializes in laparoscopic surgery on the diaphragm. Full-thickness excisions of the diaphragm are repaired, usually with permanent sutures. At our center, we have excellent results with laparoscopic excision of endometriosis of the diaphragm, even when full thickness to the pleural space. We are able to do this with 5mm incision sites, no tubes, no drains, straight outpatient. The overall healing course is unchanged when diaphragm work is done using this approach.
The more that I do the better the patient feels after surgery.