Robotic Excision of Morrison's Pouch and Full-Thickness Diaphragmatic Endometriosis

Study Objective

The objective of this video is to display surgical technique for multidisciplinary management of endometriosis of Morrison's pouch and the diaphragm.

Design

N/A.

Setting

Academic medical center.

Patients or Participants

The patient is a 29-year-old G0 who initially presented for lifelong dysmenorrhea, infertility, and new onset debilitating right shoulder pain with menses. She had no previous surgical history and MRI of the abdomen and pelvis was negative for deep infiltrating endometriosis.

Interventions

Patient underwent robotic liver mobilization, peritonectomy of Morrison's pouch, and full thickness diaphragmatic excision followed by thoracoscopy and primary diaphragmatic repair. The case was performed in conjunction with general and cardiothoracic surgery.

Measurements and Main Results

The patient recovered without complication and had complete resolution of her right shoulder pain at her six week follow up.

Conclusion

Multidisciplinary management is essential for treatment of severe diaphragmatic and Morrison's pouch endometriosis. Liver mobilization and retraction allows for complete visualization of Morrison's pouch and resection of disease. Thoracoscopic evaluation ensures no other thoracic disease is present and allows for more straightforward closure of the diaphragm. MRI may not reliably identify diaphragmatic disease, and thorough visual evaluation is essential in the management of patients with symptoms concerning for diaphragmatic endometriosis.