Diaphragmatic Endometriosis Adjacent to Pericardium and Heart, a Mullerian Defect Removed by En Bloc Peritonectomy

Abstract

Study Objective

To present a form of diaphragmatic endometriosis in the central tendon area near to the pericardium and heart removed en bloc by peritonectomy. And to discuss the Mullerian origin of endometriosis based on the sites of involvement.

Design

Edited didactic video showing en bloc peritonectomy applied to the removal of diaphragmatic and pelvic endometriosis.

Setting

Laparoscopic surgery using the latest generation of ultrasonic scissors for dissection and peritonectomy.

Patients or Participants

24 yo patient with intense pelvic, abdome and chest pain, presenting with grade IV AAGL endometriosis and diaphragmatic lesions near to pericardium and heart.

Interventions

Considering the location and distribution of the endometriosis lesions following a pattern called the Mullerian Path track and the layers of connective tissue below the peritoneum, the technique of en bloc removal by extensive peritonectomy was applied to all affected areas in the pelvis (Toldt's fascia, left parametrium, rectum and rectum), right parametrium, right iliac fossa and appendage, above the right kidney and in the diaphragm, including the central tendon area near the pericardium and heart.

Measurements and Main Results

As could be seen in the video, endometriosis follows a distribution path of probable Mullerian embryonic origin that is completely related to the simultaneous construction of the colon in the process of gastrulation. This determines the involvement of the pelvis and the right diaphragm that can reach close to the heart. It is also possible to see the usefulness of en bloc removal with peritonectomy using the ultrasonic device via the laparoscopic route. It can also be seen that endometriosis forms extensive "marble-like" lesions within the connective tissue, as opposed to simply spots on the surface of the peritoneum.

Conclusion

The technique presented seems effective and safe both for diaphragmatic lesions, including those close to the pericardium and heart, and for pelvic endometriosis. The technique may also be reproduced.