title: Endometriosis of the diaphragm: four cases treated with a combination of laparoscopy and thoracoscopy.
abstract: OBJECTIVE
  We aim to describe the clinical characteristics and the principles of combined laparoscopic and thoracoscopic management of women with diaphragmatic endometriosis at our institution.
  
  
  METHODS
  Case series (Canadian Task Force Classification II2).
  
  
  METHODS
  Tertiary care referral center.
  
  
  METHODS
  Four women with diaphragmatic endometriosis.
  
  
  METHODS
  Laparoscopy and thoracoscopy.
  
  
  METHODS
  We retrospectively reviewed the charts of 4 consecutive women with diaphragmatic endometriosis who underwent laparoscopy and thoracoscopy from June 2008 through September 2008.
  
  
  RESULTS
  Four patients underwent a combination of laparoscopy for treatment of abdominopelvic endometriosis and thoracoscopy for treatment of diaphragmatic endometriosis. All patients had a history of chest pain. Three had a history of pelvic pain. Two had a history of catamenial hemothorax or pneumothorax. Two had been previously diagnosed with endometriosis, and three had a history of hormonal pharmacotherapy. All underwent laparoscopy and thoracoscopy without complications. All had uneventful recoveries. At nine-month follow-up, all patients were free of chest pain, and one patient had recurring pelvic pain.
  
  
  CONCLUSIONS
  To the best of our knowledge, this constitutes the only reported series of patients with endometriosis who underwent a procedure systematically combining both laparoscopy and thoracoscopy for treatment of abdominopelvic and thoracic disease. It confirms that combined laparoscopic and thoracoscopic diagnosis and management of diaphragmatic endometriosis is reasonable. The inferior aspect of the diaphragm should be evaluated in all patients undergoing laparoscopy for endometriosis. Concomitant thoracoscopy should be considered for all patients with history of catamenial hemopneumothorax, cyclic chest or shoulder pain, or cyclic dyspnea. The aim of treatment should be to remove endometriotic lesions, to provide symptomatic relief, and to avoid recurrence. The use of these minimally invasive techniques may reduce the need for laparotomy or thoracotomy in affected patients.
authors.affiliation: Center for Special Minimally Invasive Surgery, Stanford University Medical Center, Palo Alto, California 94304, USA. Cnezhat@stanford.edu
authors.forename: Camran
authors.initials: C
authors.lastname: Nezhat
authors.forename: Linda M
authors.initials: LM
authors.lastname: Nicoll
authors.forename: Lisa
authors.initials: L
authors.lastname: Bhagan
authors.forename: Jian Qun
authors.initials: JQ
authors.lastname: Huang
authors.forename: Dorian
authors.initials: D
authors.lastname: Bosev
authors.forename: Babak
authors.initials: B
authors.lastname: Hajhosseini
authors.forename: Ramin E
authors.initials: RE
authors.lastname: Beygui
mesh_terms: D000328:Adult; D002637:Chest Pain / Q000209:etiology; D003964:Diaphragm; D004715:Endometriosis / Q000601:surgery*; D005260:Female; D006491:Hemothorax / Q000209:etiology; D006801:Humans; D010535:Laparoscopy; D053685:Laser Therapy; D009135:Muscular Diseases / Q000601:surgery; D017699:Pelvic Pain / Q000209:etiology; D010388:Pelvis; D012189:Retrospective Studies; D013906:Thoracoscopy