Diaphragmatic endometriosis: diagnosis, surgical management, and long-term results of treatment  David B Redwine, M.D.  Fertility and Sterility  Volume 77, Issue 2, Pages 288-296 (February 2002) DOI: 10.1016/S0015-0282(01)02998-3

FIGURE 1 (A), Case 1: A sentinel lesion (arrow) is noted on the right anterolateral aspect of the right hemidiaphragm. A typical vascular bundle is seen traversing the diaphragm (arrowhead). (B), Case 1: Laparoscopy from an umbilical port. With the liver under strong retraction by a blunt probe, the symptomatic lesion of the posterior diaphragm is seen within the arrowheads. The arrow denotes the sentinel lesion shown in Frame A. (C), Case 1: The liver capsule (arrowhead) has been torn and lies draped like a curtain to the side of the liver. The asterisk denotes the surface of the liver parenchyma. (D), Case 2: A right upper quadrant laparotomy incision has been made, allowing the surgeon’s hand (asterisk denotes a finger) to retract the liver inferiorly, exposing the posterior diaphragm with the symptomatic lesions seen in the left lower quadrant of the frame. The vena cava lies between the arrowheads. (E), Case 2: With the liver retracted manually inferiorly, the affected portion of the diaphragm is grasped with a long Allis clamp and tented up toward the abdominal incision. (F), Case 2: A long scissors (s) or electrosurgery is used to perform a full-thickness resection of the diaphragm, exposing the lung. A large curved retractor (r) is being used to retract the liver inferiorly in this case. Normal diaphragm (d) is seen adjacent to the area of resection. (G), Case 2: After resection of the diaphragm, the laparoscope can be advanced into the chest cavity, observing a rib, the lung and intercostal muscles (icm). No pleural endometriosis was seen. (H), Case 2: The pleural surface of the resected diaphragm shows hemorrhagic nodularity and adjacent ecchymotic changes. Redwine. Diaphragmatic endometriosis. Fertil Steril 2002. Fertility and Sterility 2002 77, 288-296DOI: (10.1016/S0015-0282(01)02998-3)

FIGURE 2 (A), Low-power view of endometriosis of the diaphragm, Case 3. A nodular lesion of endometriosis, which is thicker than the normal diaphragm, has disrupted the normal musculature of the diaphragm (arrows). The pleural and diaphragmatic surfaces were not marked at surgery, so the orientation of this view is unknown; (B), High-power view showing well-differentiated glands of endometriosis straddling a bundle of muscle fibers (asterisk); and (C), High-power view of well-differentiated glands surrounded by slightly edematous stroma with interstitial capillary hemorrhage. Redwine. Diaphragmatic endometriosis. Fertil Steril 2002. Fertility and Sterility 2002 77, 288-296DOI: (10.1016/S0015-0282(01)02998-3)