The Combined Robotic-assisted Laparoscopic and Thoracic Approach in the Management of Diaphragmatic, Pleural, and Pericardial Endometriosis.

Study Objective: To demonstrate the advantages of a combined robotic-assisted laparoscopic and thoracic approach in the management of extensive diaphragmatic, pleural, and pericardial endometriosis.

Design: A video article demonstrating excision of endometriosis from pericardium, diaphragm, and pleura.

Setting: Thoracic endometriosis is the most common site of extrapelvic endometriosis [1]. Surgical treatment aims to excise all visible disease to relief symptoms and prevent recurrence [2-4].

Interventions: A 41-year-old lady with cyclical shoulder tip and chest pain and known extensive diaphragmatic endometriosis was referred to our center. The procedure was done jointly by a gynecologist and a thoracic surgeon experienced in robotic-assisted endometriosis excision (Supplemental Video 1). Robotic-assisted laparoscopy revealed extensive full-thickness diaphragmatic endometriosis and a full-thickness pericardial nodule. Pericardial endometriosis excision was performed and a 1 cm defect was left open in the pericardium. Multiple diaphragmatic endometriotic nodules were excised and pleural cavity was entered (Image 2). On robotic-assisted thoracic surgery, further deep endometriotic lesions were detected and excised from the posterior aspect of the diaphragm. These lesions were not identified abdominally despite complete division of falciform ligament, full mobilization of the liver, and the use of a 30-degree scope. Superficial endometriotic lesions on parietal pleura were also detected (Image 3) and excised. The defects on the diaphragm were closed (Image 4). Chest and abdominal drains were left in situ. The patient was discharged on day 4.

Conclusion: The combined robotic-assisted laparoscopic and thoracic approach is indicated in selected cases and allows full exploration of the thoracic cavity and both sides of the diaphragm, thus preventing incomplete excision of the disease. Robotic surgery also allows smooth dual-surgeon teamwork.