Diaphragmatic Endometriosis And The Risk Of A Lung Collapse

Endometriosis is a disease where tissue similar to the lining of the uterus grows outside the uterus, causing severe pain. Statistically speaking, Diaphragmatic Endometriosis is a rare form of Endometriosis. However, because gynecologists not being familiar with these forms of the disease, diaphragmatic endometriosis is often partially treated or not seen during surgery. This could lead to severe consequences, like Pneumothorax. Also known as lung collapse.  

About 25 million women are estimated to be suffering from endometriosis in India Estimates of incidence of endometriosis range up to 10% among the general population, 0.5% to 5% among fertile women, and 25% to 40% in infertile women. The average age at diagnosis of endometriosis is 28 years, with risk increasing beyond 30 years and peaking at early to mid-40 years.

Why is it hard to diagnose Diaphragmatic Endometriosis?

The diaphragm is a thin muscle that separates the chest from the abdomen. This allows a person to breathe. This diaphragm is divided into two parts, right and left. The liver is to the right side. A part of the diaphragm is behind the liver. To see Endometriosis on the diaphragm a surgeon will have to look in the opposite direction to pelvis which most of the gynaecologists dont do routinely. So, abdomino-pelvic examination during robotic or laparoscopic surgery is very important to detcet endo on diaphragm. On the left side is the spleen, which may also require some mobilization for Endometriosis to be seen on the diaphragm. Adding to this, Diaphragm is usually thin in size. This makes it easy for Endometriosis to infiltrate the skeletal muscle.

Endometriosis on the right, behind the liver, is more common than on the left, near the spleen.

What are the symptoms?

Like endometriosis itself, diaphragmatic endometriosis can be asymptomatic and symptomatic. The pain can be intense, getting worse with bouts of cough or when breathing. It is more so during menstruation.

The usual symptoms include

·chest pain,

·shoulder pain,

·pain under the ribs,

·neck pain and

·shortness of breath.

The risk factor

There is a risk that endometriosis can cause holes in the diaphragm, owing to the fact that the diaphragm is thin and is easy to infiltrate. It can cause holes in the diaphragm allowing air and fluid to enter the pleural space causing the lungs to collapse!

If the volume of air trapped in the pleural space is larger or it affects the heart, Endometriosis can be life-threatening even.

Treatments available

One of the operational challenges of treating Diaphragmatic Endometriosis is the visualization of the surface of the diaphragm. Laparoscopy remains the gold standard to treat Endometriosis. Robotic surgery doe have an edge over laparoscopic surgery specially for diaphragmatic endometrioiss because of its location. A scope inserted through the umbilical incision can visualize the anterior and mid-diaphragm and a subcostal laparoscope port incision can visualize the entire diaphragm.

During the surgery, the diaphragm is pulled away from the liver, followed by excision surgery where we remove the endometriosis. Mobilizing the liver will also facilitate easy access to suture the defects caused by Endometriosis. When lesions are large (>5mm), the diaphragm defects should be sutured to prevent the occurrence of diaphragmatic hernias.

As the procedure is done outside the pelvic cavity, the surgery requires a multidisciplinary team of experts to collaborate. Choosing your surgeon is key!

The article is authored by Dr Vimee Bindra – Endometriosis Specialist and Gynecologist