Surgical management of extensive diaphragmatic and pleural thoracic endometriosis: a case report

Background: Thoracic endometriosis is a rare disorder caused by endometriotic tissue infiltration of the diaphragm, pleura, lung parenchyma, and airways, causing significant symptoms and clinical challenges. Diagnosis can be determined, after ruling out other pulmonary diseases, due to the cyclic nature of symptoms that often coincide with the patient's menstrual cycle. Treatment strategies include hormonal and surgical management, but this can be challenging as it can involve the diaphragm, lung, and chest wall. This case sheds light on the many aspects required for treatment and surgical management. The rare and complex nature of thoracic endometriosis allows this case report to contribute to the limited clinical knowledge of what is currently known. As well as the decision-making process between primary diaphragm repair versus the use of mesh for repair. We present a case that reviews important surgical principles in managing and treating thoracic endometriosis. Case Description: A 32-year-old female with a history of endometriosis presented to the clinic with catamenial chest and right shoulder pain. Magnetic resonance imaging (MRI) was obtained, confirming the presence of endometriotic lesions in the right posterior diaphragm. The patient's history included previous laparoscopic pelvic endometriosis surgeries but many of her symptoms persisted. She expressed a desire for pregnancy and opted for surgical excision of the endometriotic lesions. A collaborative surgical effort between obstetrics and gynecology (OBGYN) and thoracic surgery was performed. Right video-assisted thoracoscopic surgery (VATS) diaphragm excision, lung wedge resection, and endometriotic ablation were performed by the thoracic surgery team, followed by laparoscopic ovarian cystectomy and endometrioma resection performed by the OBGYN surgeons. The patient recovered and had vastly improved chest and shoulder pain at her 2 and 12 months follow-up visits. Conclusions: Surgical management of thoracic endometriosis can be challenging but effective in helping patients with continuous symptoms. This case underscores the importance of multidisciplinary healthcare, patient-centered approaches, and explores the principles of diaphragm repair.