Department of Obstetrics and Gynaecology, University Hospital of Berne, Berne, Switzerland.
Department of Obstetrics and Gynaecology, University Hospital of Berne, Berne, Switzerland.
J Minim Invasive Gynecol. 2018 Jul-Aug;25(5):771-772. doi: 10.1016/j.jmig.2017.10.028. Epub 2017 Oct 31.
To present an unusual consequence of laparoscopic treatment of diaphragmatic endometriosis, to discuss the possible etiologies, and to propose proper management.
A step-by-step explanation of 2 surgeries of the same patient using intraoperative video sequences (Canadian Task Force classification III).
University hospital.
A 32-year-old woman.
Two Laparoscopic surgeries.
Endometriosis is estimated to affect 11% of the population [1,2], with an estimated 12% of these patients having extrapelvic endometriosis [3]. When the diaphragm is involved, the disease potentially causes severe and debilitating symptoms such as catamenial chest or shoulder pain. Serious complications may involve pneumothorax and hemopneumothorax [4-6]. Diaphragmatic endometriosis is more common than realized and has been shown to occur simultaneously in 50% to 80% of cases with pelvic endometriosis [7,8]. A 32-year-old woman was admitted to our hospital with severe disabling dysmenorrhea and right shoulder pain. Despite progestin, nonsteroidal anti-inflammatory drug, and opioid treatment, pain relief remained inadequate. A laparoscopy was performed revealing diaphragmatic endometriosis, which was completely excised. A revision was necessary 14 months later because of pain recurrence in the right hemithorax and suspicion of new or persistent endometriotic lesions. The laparoscopy revealed small diaphragm fenestrations that were closed after exclusion of recurrent diaphragmatic or pleural endometriosis. No chest tube was placed, and the postoperative course was uneventful. Hormonal suppressive treatment was continued. Since the operation the patient has been pain free. Institutional Review Board/Ethics Committee ruled that approval was not required for this study (Req-2017-00415).
The diaphragm fenestrations were possibly the result of tissue necrosis caused by thermocoagulation after excision of deep endometriotic lesions during the first surgery. Using a CO laser for the vaporization of superficial lesions is favorable because of the smaller depth of penetration compared with electrocautery and better access to hard to reach areas [9,10]. Endometriotic lesions involving the entire thickness of the diaphragm should be completely excised and the defect repaired with either sutures or staples [11-13].
介绍腹腔镜治疗膈膜子宫内膜异位症的一种罕见后果，讨论可能的病因，并提出适当的治疗方法。
使用术中视频序列逐步解释同一患者的 2 次手术（加拿大任务组分类 III）。
大学医院。
一名 32 岁女性。
两次腹腔镜手术。
子宫内膜异位症估计影响 11%的人口[1,2]，其中约 12%的患者有盆腔外子宫内膜异位症[3]。当膈膜受到影响时，疾病可能会导致严重的衰弱症状，如月经性胸痛或肩部疼痛。严重的并发症可能包括气胸和血气胸[4-6]。膈膜子宫内膜异位症比人们意识到的更为常见，并且已经在 50%至 80%的同时患有盆腔子宫内膜异位症的病例中显示出同时存在[7,8]。一名 32 岁女性因严重的致残性痛经和右肩疼痛入院。尽管使用孕激素、非甾体抗炎药和阿片类药物治疗，疼痛缓解仍不理想。腹腔镜检查显示膈膜子宫内膜异位症，完全切除。14 个月后，由于右胸腔疼痛复发并怀疑存在新的或持续的子宫内膜异位病灶，需要进行修订。腹腔镜检查显示膈膜有小的裂孔，在排除膈膜或胸膜子宫内膜异位症复发后进行了封闭。未放置胸腔引流管，术后过程顺利。继续进行激素抑制治疗。自手术以来，患者一直无疼痛。机构审查委员会/伦理委员会裁定该研究无需批准（Req-2017-00415）。
膈膜裂孔可能是第一次手术中切除深部子宫内膜异位病灶时热凝引起的组织坏死所致。与电烙术相比，使用 CO 激光汽化浅层病变更有利，因为其穿透深度较小，并且更容易到达难以到达的区域[9,10]。应完全切除累及整个膈膜厚度的子宫内膜异位病灶，并使用缝线或订书钉修复缺陷[11-13]。
