Often the lesions of diaphragmatic endometriosis are completely asymptomatic. Although cases of diaphragmatic endometriosis occur less frequently, this complicated form of endometriosis can cause painful symptoms, up to the point of disabling the patient.

It is difficult to diagnose, because many patients have pain in the right shoulder, shoulder blade or right hemithorax, which initially would not show an explicit connection. Other patients think they have diaphragmatic endometriosis, but when a laparoscopic exploratory operation is done, it is found that they do not have lesions of diaphragmatic endometriosis and that the pain is due to irritation induced by menstrual reflux, because always the peritoneal current is from the right to the left and then the menstrual blood produces peritoneal irritation, accompanied by a pain in the shoulder. But there are also those rarer cases where we do indeed encounter shoulder pain produced by diaphragmatic lesions.

Although it is diagnosed less frequently, after several check-ups in different specialties, patients reach the gynecologist specialized in endometriosis, who makes the differential diagnosis.

Prof. Dr. Elvira Bratila, Endomedicare Academy, a surgeon specializing in endometriosis with extensive experience in surgery for complex cases of deep endometriosis, explains: “There is no diaphragmatic endometriosis without pelvic endometriosis. Depending on the diagnosis made by vaginal ultrasound and the correlation between the clinical imaging examination and symptomatology complained of, it is natural to suspect this form and indicate the investigation by MRI, which will confirm the presence and extension of diaphragmatic lesions.”

Once this diagnosis is established, the patient is referred for surgery, which can be performed via abdominal or thoracic approach, depending on the extent of the lesions. Most cases can be performed transabdominally, but when it involves a large area of the diaphragm or extends to the level where the phrenic nerve approaches the diaphragmatic muscle, the thoracic approach is most indicated.

Prof. Dr. Elvira Bratila: “At Endomedicare Academy, we can approach complex cases of diaphragmatic endometriosis in a multidisciplinary team, including the thoracic surgeon. Depending on the extent of the endometriotic lesions, we decide whether we can approach the case transabdominally or if the case requires the specific expertise and technique of thoracic surgery.”

With over 6 years of experience in robotic surgery, the Endomedicare Academy team, coordinated by the first surgeon to perform robotic surgery in gynecology in Romania, Prof. Dr. Elvira Bratila, performs diaphragmatic endometriosis surgery through robotic surgery, using the most advanced robotic platform – the daVinciXi robot, there being few centers in Europe with this expertise in new technology and with an extensive experience in the surgical treatment of deep endometriosis, with over 1000 surgical cases successfully operated in the center in Bucharest, Romania.

Diaphragmatic endometriosis surgery is primarily indicated for robotic surgery, as it is minimally invasive for the patient and extremely easy for the surgeon to approach, compared to laparoscopy, as the robot allows much easier access to the diaphragm. Thus, the medical process brings all the advantages of precision and minimally invasive robotic surgery. The procedure is performed with minimal risk to the patient in terms of post-surgical complications.

In our recent experience, our team successfully performed a complex intervention on a young woman who travelled from the UK to Romania to benefit from the expertise of the team coordinated by Prof. Dr. Elvira Bratila.

“The complexity of the case came from the fact that the patient had extensive diaphragmatic endometriosis, which included a very large part of her right diaphragm. We questioned whether the diaphragm could be closed with the remaining tissue, with separate wires, or whether a prosthetic mesh placement was needed. We performed excision of endometriosis lesions, lesions affecting 75% of the right diaphragmatic muscle. Reconstruction of the muscle was achieved by suturing with separate stitches without the need for prosthetic mesh placement.” – Prof. Dr. Elvira Bratila

The patient recovered quickly and resumed her routine after 3-4 days, which gave us great satisfaction, because she was a very symptomatic patient, with a much deteriorated quality of life due to this rare form of endometriosis, usually asymptomatic. The likelihood of recurrence in this type is quite low, both at pelvic and diaphragmatic levels.