Laparoscopic management of diaphragmatic endometriosis by three different approaches.

OBJECTIVE: To report our three surgical approaches in the management of diaphragmatic endometriosis.

DESIGN: Video article presenting laparoscopic surgical techniques, with and without robotic assistance.

SETTING: University hospital.

PATIENT(S): Nulliparas with deep endometriosis associated with multiple endometriosis lesions of the diaphragm.

INTERVENTION(S): Laparoscopic approach in women who present with small black-pigmented diaphragmatic lesions, with or without infiltration of the diaphragm, which are ablated using plasma energy. Robotic-assisted laparoscopic route in larger deep infiltrating implants, which are resected. To avoid phrenic nerve injury, robotic-assisted thoracoscopy is preferred in large lesions involving the central tendon of the diaphragm.

MAIN OUTCOME MEASURE(S): The steps of each technique are emphasized. Surgical technique reports in anonymous patients are exempted from ethical approval by the Institutional Review Board.

RESULT(S): Seven patients have been managed by these procedures from July 2015 to March 2016. Patients' functional outcomes were uneventful, with no phrenic nerve palsy or residual chest and right shoulder pain.

CONCLUSION(S): By combining resection and ablation techniques, the laparoscopy and thoracoscopy route, conventional and robotic-assisted minimally invasive approach, we offer a surgical strategy that is as conservative as possible, with an aim to limit postoperative adhesions between the liver and the diaphragm, and avoid diaphragmatic paralysis.