Master Class

Diaphragmatic and thoracic endometriosis


The first case of diaphragmatic endometriosis was reported by Alan Brews in 19541. Unfortunately, no guidelines exist to enhance the recognition and treatment.

Diaphragmatic and thoracic endometriosis often is overlooked by the gynecologist, not only because of lack of appreciation of the symptoms but also because of the failure to properly work-up the patient and evaluate the diaphragm at time of surgery. In a retrospective review of 3,008 patients with pelvic endometriosis published in Surgical Endoscopy in 2013, Marcello Ceccaroni, MD, PhD, and his colleagues found 46 cases (1.53%) with the intraoperative diagnosis of diaphragmatic endometriosis, six with liver involvement. Multiple diaphragmatic endometriosis lesions were seen in 70% of patients and, the vast majority being right-sided lesions (87%), with 11% of cases having bilateral lesions.2 While in the study, superficial lesions were generally vaporized using the argon beam coagulator, deep lesions were removed by sharp dissection, highlighting the need to have adequately trained minimally invasive surgeons treating diaphragmatic lesions via incision. If a pneumothorax occurred, and reabsorbable suture was placed after adequate expansion of the lung via positive pressure ventilation and progressive air suctioning with complete evacuation of the pneumothorax prior to the final closure (i.e., a purse string around the suction device), then the integrity of the closure could be proven using a bubble test with 500cc of saline placed at the diaphragm.

Dr. Charles E. Miller

Dr. Charles E. Miller

In this edition of Master Class in Gynecologic Surgery, I have invited world-renowned minimally invasive and endometriosis expert surgeon, Ceana Nezhat, MD, of Northside Hospital, Atlanta, to discuss his recommendations and techniques of treating diaphragmatic and thoracic endometriosis. Along with his brothers, Camran and Farr, Ceana has published numerous articles and books highlighting operative procedures for the most difficult aspects of endometriosis surgery, including diaphragmatic and thoracic disease.

As the gynecologic surgeon studies Dr. Nezhat’s thorough discourse, it is obvious that, at times, a multidisciplinary team must be involved. Although possible, it would appear that risk of diaphragm paralysis secondary to injury of the phrenic nerve is indeed rare. This likely is because of the greater incidence of right-sided disease, rather than involving the central tendon, and lower likelihood that the lesion penetrates deeply. Nevertheless, a prudent multidisciplinary approach and knowledge of the anatomy will inevitably further reduce this rare complication.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He reported having no financial disclosures related to this column.


1. Proc R Soc Med. 1954 Jun; 47(6):461-8.

2. Surg Endosc. 2013 Feb;27(2):625-32.

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