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Minimally invasive treatment of diaphragmatic endometriosis: a 15-year single referral center’s experience on 215 patients

A Correction to this article was published on 13 January 2021

This article has been updated



Diaphragmatic endometriosis (DE) is a rare and often misdiagnosed condition. Most of the times it is asymptomatic and due to the low accuracy of diagnostic tests, it is almost always detected during surgery for pelvic endometriosis. Its management is challenging and, until now, there are not guidelines about its treatment.


We describe a consecutive series of patients with DE managed by laparoscopy and videothoracoscopy (VATS) in our referral center in a period of 15 years. We developed a flow-chart classifying DE implants in foci, plaques and nodules and proposing an algorithm with the aim of standardizing the surgical approach.


215 patients were treated for DE. Lesions were almost always localized on the right hemidiaphragm (91%), and the endometriotic implants were distributed as: foci in 133 (62%), plaques in 24 (11%) and nodules in 58 patients (27%), respectively. In all cases of isolated pleural involvement, concomitant diaphragmatic hernia or lesions of the thoracic side of the diaphragm VATS was performed, alone or combined with laparoscopy, resulting in a total of 26 procedures. Following the proposed algorithm, specific surgical techniques were identified as the better approaches for the different types of the lesion, such as Argon Beam Coagulation and diathermocoagulation for diaphragmatic foci, peritoneal stripping for plaques, and nodulectomy or full-thickness resection of diaphragm for nodules.


It is crucial to standardize the surgical approach of DE, according to the type of lesion, thus reducing the rate of under- or over-treatments and intra or postoperative complications. This kind of surgery should be performed in a Referral Center by a gynecologic surgeon with oncogynecologic expertise and skills, with the eventual support of a laparoscopic general surgeon, a specialized thoracic surgeon and a trained anesthesiologist.

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Correspondence to Giovanni Roviglione.

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Marcello Ceccaroni, Giovanni Roviglione, Antonino Farulla, Pietro Bertoglio, Roberto Clarizia, Andrea Viti, Daniele Mautone, Matteo Ceccarello, Anna Stepniewska, and Alberto Claudio Terzi declare that they have no conflict of interest.

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Ceccaroni, M., Roviglione, G., Farulla, A. et al. Minimally invasive treatment of diaphragmatic endometriosis: a 15-year single referral center’s experience on 215 patients. Surg Endosc 35, 6807–6817 (2021).

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  • Endometriosis
  • Laparoscopy
  • Diaphragm
  • Minimally invasive surgery
  • Thoracoscopy