{"paper_id":"b4932627-21ba-4549-ad09-3193368a4ed8","body_text":"Review began\n 09/22/2012 \nPublished\n 11/20/2012\n© Copyright \n2012\nBuescher et al. This is an open access\narticle distributed under the terms of the\nCreative Commons Attribution License\nCC-BY 3.0., which permits unrestricted\nuse, distribution, and reproduction in any\nmedium, provided the original author and\nsource are credited.\nEndometriosis: Diagnosis and Treatment: From\nFingernails to the Robot\nElizabeth A.. Buescher\n, \nCamran Nezhat\n1.\nCorresponding author: \nElizabeth A.. Buescher, \nlizziebuescher@hotmail.com\nAbstract\nEndometriosis, the presence of endometrial glands and stroma outside of the endometrial cavity, is a disease\nthat causes pelvic pain and infertility. Unfortunately, this disease is often undiagnosed for years, resulting in\na delay in treatment. Therefore, the clinician must maintain a high index of suspicion to minimize the\nmorbidity of the disease. In recent years, there have been many advances in the treatment of endometriosis,\nwith video-assisted laparoscopic surgery (VALS) at the forefront of these changes. Because endometriosis\ncan affect many organ systems, an interdisciplinary approach is often needed to treat these patients. This\nreview will address diagnosis, work-up, and management of this complex disease.\nCategories:\n Obstetrics/Gynecology, General Surgery\nKeywords:\n laparoscopy, extra-genital, pathogenesis, robotics, chronic pelvic pain, endometriosis\nIntroduction And Background\nThe classic triad of endometriosis is dysparunea, dysmenorrhea, and infertility. However, this triad often\noversimplifies a complex disease that has been causing chronic pain and infertility for millennia.\nPathologically, endometriosis is characterized by the presence of endometrial cells outside of the\nendometrial cavity. Most commonly, it is located on the peritoneal surface or other pelvic organs, but\nendometriosis has been found in every organ of the body except for in the spleen \n[1-2]\n. The endometrial\ntissue is activated by estrogen, which can cause the endometrial tissue to spread and cause pain for the\npatient \n[3]\n.\nReview\nPathogenesis of Endometriosis\nThe pathogenesis of endometriosis remains unclear. Sampson is generally credited with the most popular\ntheory in 1927 \n[4-5]\n. However, retrograde menstruation was actually suggested in the 1690’s by both Schroen\nand Ruysch \n[6]\n. They suggested that retrograde menstruation caused the menstrual blood to spill out of the\nfallopian tubes and into the pelvic cavity, causing implants of endometriosis. Another theory is the coelomic\nmetaplasia theory, which suggests that peritoneal tissue undergoes metaplastic change to endometrial\ntissue before endometriosis can implant. This theory is supported by the fact that both endometrial tissue\nand peritoneal tissue have a common precursor: coelomic tissue \n[5, 7]\n. There is some thought that stem cells\nmay play a role through this mechanism. The third theory is the theory of lymphatic or hematologic spread.\n This theory helps explain the presence of endometriosis in areas remote from the pelvis \n[5, 8-9]\n. The final \ntheory is that of direct transplantation. This explains the presence of endometriosis in surgical scars. In\nvivo, this is referred to as autotransplantation \n[5, 10-15]\n. We believe that the hematologous/lymphatic\nspread theory likely exacerbates the disease, but is not the entity that initially starts the disease. Retrograde\nmenstruation, metaplastic change, and direct transplantation likely play a role as well, but may not be the\ninciting event that starts the chain reaction of endometriosis.\nPrevalence\nThe prevalence of the disease is uncertain as this disease is under diagnosed and patients are often\nmisdiagnosed for years before they are correctly diagnosed with endometriosis. Most clinicians consider\nendometriosis to have a prevalence of 6-10% prevalence in the general population, with that prevalence\nrising to 35-50% in women with pain and/or infertility \n[3]\n. A diagnosis of endometriosis should also be\nconsidered in unexplained infertility. In our practice, which specializes in endometriosis, infertility, and\nchronic pelvic pain, we have noted a prevalence of over 90% of pathology-proven endometriosis.\nIt is important to note that the clinician must have a high index of suspicion to diagnose endometriosis.\nPatient evaluation\nWhen a patient presents with pelvic pain, the clinician must first work to determine which organ systems\nare involved. During the history, the patient should be asked:\n \n Open Access Review\nArticle\n \nDOI:\n 10.7759/cureus.68\nHow to cite this article\nBuescher E A., Nezhat C (November 20, 2012) Endometriosis: \nDiagnosis and Treatment: \nFrom Fingernails to the Robot. Cureus 4(11): e68. \nDOI\n10.7759/cureus.68\n\n1. When did the pain start?\n2. Is the pain associated with ovulation or menses?\n3. Does the patient have dysparunea?\n4. Are there any GI symtoms: nausea, vomiting, diarrhea, constipation?\n5. Are there any GU symptoms: dysuria, urgency, frequency?\n6. Has the patient ever been sexually abused?\n7. How long is the patient’s menstrual cycle?\n8. How heavy is the patient’s menstrual cycle?\n9. Does the patient have unexplained infertility?\nThese questions are important, but one should also be aware that endometriosis can cause pain that is not\nassociated with menstrual cycle.  In addition, a large number of patients with “unexplained infertility” who\ndo not have dysmenorrhea are found to have endometriosis at laparoscopy. Again, one must maintain a high\nindex of suspicion.\nOnce the history has been taken, the patient should undergo a complete physical exam, including a pelvic\nexam and a speculum exam. The best time to examine a patient is during the luteal phase or at the time of\nher menses because the endometriotic lesions are enlarged and more easily palpable. During the pelvic\nexam, the provider should feel for the presence of nodularity on the uterosacral ligaments, which is\nconsistent with endometriosis. The physician should also see if the uterus is fixed or mobile, and assess for\nadnexal fullness, cervical motion tenderness, and the presence of levator ani spasm.\nAfter the exam, the patient should have a transvaginal ultrasound to look for the presence of ovarian cysts. If\nan ovarian cyst has a ground glass appearance due to low level homogenous echoes on ultrasound, that is\nconcerning for an endometrioma \n[16]\n. However, it is important to note that sonographic findings alone\ncannot rule out malignancy.\nThe ultrasound should include a color Doppler ultrasound to look at the blood flow to the uterus, tubes, and\novaries. The presence of hypervascularity in the uterus is suggestive of adenomyosis, which is essentially\nendometriosis of the uterus. Other signs of adenomyosis include dimensions that show a globular uterus,\nnon-symmetric anterior-posterior uterine measurements, a heterogenous myometrium, and the presence of\ntiny endometrial cysts in the myometrium \n[16]\n.\nDepending on the results of the above evaluation, lab tests may or may not be indicated. If a patient has GI\nsymptoms, consider stool cultures, colonoscopy, and a complete metabolic panel. If a patient has GU\nsymptoms, consider a urinalysis, a urine culture, and a cystoscopy. If the patient has a history of sexual\nabuse, unprotected intercourse, or abnormal vaginal discharge, consider cervical cultures.\nTreatment of endometriosis\nDepending on the severity of symptoms and the patient’s desires, one can proceed with either medical or\nsurgical treatment. In our practice, when patients present with severe pain refractory to medical\nmanagement or infertility in spite of treatment with assisted reproduction techniques, we proceed with\nsurgical treatment and then use medical treatment to keep the endometriosis at bay, provided the patient\ndoes not desire immediate fertility. For young infertile patients with endometriosis, we recommend natural\nconception after surgery provided the partner has a normal sperm count. For older patients, IVF may be\nnecessary for fertility \n[17]\n.\nVideo-assisted laparoscopic treatment of endometriosis\nLike the pelvic exam, video-assisted laparoscopy is also best performed during the luteal phase so that the\nlesions are larger and more easily seen. Laparoscopic treatment of extensive endometriosis including\nendometriosis of the bladder, bowel, and ureter was first reported in the 1980’s \n[18-20]\n. Laparoscopic\ndiagnosis and eradication of all forms of endometriosis are effective and may now be considered the gold\nstandard of clinical care for women with endometriosis-related pain and infertility. The recognized\nadvantages of video-assisted laparoscopy include faster patient recovery, smaller scars, lesions adhesions,\nbetter results, and reduced cost \n[21]\n.\nHistorically, excision of endometriosis dates back to a time when surgeons used their fingernails to excise\nendometriosis \n[6]\n. Modern surgical tools have expanded the gynecologic surgeons ability to treat\nendometriosis. These include the CO2 laser, scissors with monopolar electrocautery, bipolar electrocautery,\nHarmonic Ace ultrasonic energy (Ethicon, Somerville, NJ), the PlasmaJet (Plasma Surgical, Inc., Roswell,\nGA), and the da Vinci robot (Intuitive Surgical, Inc, Sunnyvale, CA) all of which allow\nresection, cauterization, or vaporization of endometriosis. In a recent prospective study, laparoscopic\nexcision of endometriosis significantly reduced pain and improved quality of life for up to five years \n[22]\n.\nThere may be a continuing role for hysterectomy in the management of endometriosis, but the evidence for\nconcomitant oophorectomy is less convincing. In general, conservative surgery should be considered first.\nIn spite of the current prevalence and acceptance of endoscopy, the pioneers of minimally invasive surgery\n2012 Buescher et al. Cureus 4(11): e68. DOI 10.7759/cureus.68\n2\n of \n12\n\ninitially had to prove that laparoscopy was equivalent, if not superior to laparotomy. It is a matter of\nacademic interest to understand the history of laparoscopy and how it relates to the surgical treatment of\nendometriosis, and see the rejection that laparoscopists had to overcome to gain acceptance \n[23-24]\n. The\nresults of endoscopy and laparotomy are judged by many factors \n[25]\n. Studies comparing adhesion formation\nafter laparotomy versus laparoscopy have repeated shown laparoscopy to have less adhesion formation \n[26-\n35]\n.  Results from general surgery studies have also supported the fact that laparoscopy causes less\nadhesions than laparotomy. In 2001, Polymeneas compared adhesion formation in laparoscopic\ncholecystectomy versus open cholecystectomy. The investigators found that 100% of patients with a prior\nopen cholecystectomy had dense adhesion formation, whereas 45% of those patients who underwent\nlaparoscopic cholecystectomy had loose or minimal adhesions at repeat surgery \n[36]\n.\nOnce it was established that laparoscopy was superior to laparotomy, it was compared to vaginal surgery. A\n2005 study from Nascimeno comparing morphine requirements in patients with vaginal hysterectomy versus\nlaparoscopic hysterectomy found that those patient who underwent laparoscopic hysterectomy required less\nmorphine and were on NSAIDs for fewer days following surgery \n[37]\n.\nAppearance of Endometriosis\nVideo-assisted laparoscopic assessment in combination with histologic examination of the treated lesions\nremains the gold standard for diagnosis of endometriosis. Knowledge of the most common locations of\nendometriosis is required for accurate visual inspection of the pelvic and abdominal cavities. Several\ndifferent forms of endometriosis must be considered during laparoscopic visualization: peritoneal implants,\nendometriomas, deep infiltrating lesions of the rectovaginal septum, and extragenital endometriosis. An\nincreased awareness of the variations in the appearance of endometriotic lesions has resulted in an almost\ntwo-fold increase in the diagnosis of endometriosis at laparoscopy \n[38]\n.\nPeritoneal implants are most commonly localized to the uterosacral ligaments, cul-de-sac, ovarian fossa, and\nadjacent pelvic sidewalls (Figure \n1\n). Less frequently, implants may also be found in the upper abdomen as\nwell as on the surface of the ovary, bladder and  the bowel (predominantly rectum, sigmoid colon, appendix,\nand cecum (Figure \n2\n).\nFIGURE\n 1: Dark “powder burn” lesions\nEndometriosis is commonly seen at video-assisted laparoscopy as the dark “powder burn” lesions on the\npelvic sidewall as shown here\n2012 Buescher et al. Cureus 4(11): e68. DOI 10.7759/cureus.68\n3\n of \n12\n\nFIGURE\n 2: Dark lesion on ovary\nEndometriosis can be seen as the dark lesion on this ovary during video-assisted laparoscopy.\nHence, careful and close inspection of the entire peritoneal cavity should be performed. In addition, the\ncamera should be turned towards the diaphragm and liver to look for signs of endometriosis there.\nMagnification obtained during laparoscopy depends on the distance between the laparoscope and the area\ninspected, as the closer the laparoscope is to the tissue, the greater the magnification.\nEndometriomas\nEndometriomas, commonly referred to as “chocolate cysts,” are one of the most common manifestations of\nendometriosis (Figure \n3\n).\nFIGURE\n 3: Endometrioma immediately prior to resection. The suction-\nirrigator can be used to drain the endometrioma without spilling its\ncontents.\n2012 Buescher et al. Cureus 4(11): e68. DOI 10.7759/cureus.68\n4\n of \n12\n\nNezhat, et al. \n[39-40]\n, classified endometriomas as Types I or Type II. Type I endometriomas are primary\nendometriomas. They are small, usually less than 5 cm in size, and contain dark fluid. They develop from\nsurface endometriotic implants and are difficult to excise surgically. Microscopically, endometrial glands\nand stroma are always present. These endometriomas are thin endometrial glands and stroma, which adhere\nto the surface of the ovary and invaginate into the ovary and are difficult to remove. Their video-assisted\nlaparoscopic removal requires an expert surgeon. In less experienced hands, the ovarian stroma could be\ncompromised. Type I endometriomas can be treated by either vaporization or a combination of vaporization\nand excision. If the surgeon is unable to remove the cyst wall without compromising ovarian stroma, then\nthe endometrioma should be aspirated, biopsies should be taken, and the cyst wall should be vaporized. This\ntechnique has recently become more popular as it is surgically simpler and less time consuming\nthan excising the cyst wall in its entirety \n[41]\n. Type II endometriomas are primarily functional cysts that have\nbeen invaded by endometriosis \n[39-40]\n. Type II endometriomas are much easier to remove than Type II\nendometriomas. Regardless of the type of endometrioma encountered at surgery, they will not resolve\nspontaneously and should be surgically excised and the cyst wall sent for pathologic evaluation.\nComputer-enhanced technology: the robot\nWith the introduction of the da Vinci Surgical System (Intuitive Surgical, Inc. Sunnyvale, CA), commonly\nreferred as “the robot” in 1999, surgical treatment of endometriosis has become more accessible for both\npatients and physicians. As physicians and hospitals work to integrate the robot into their patient care, most\nhave noted that having a dedicated team for the robot greatly reduces operating time as docking the robot\ncan be time consuming for those who are not proficient at it. Studies have shown that robotic surgeries take\nlonger to complete than their laparoscopic counterparts, but the operating time does decrease as more cases\nare performed \n[42]\n.  The da Vinci robot has articulating instruments that more closely resemble the\nmovements that the human wrist can perform at laparotomy as opposed to the movements that can be done\nby laparoscopy (Figure \n4\n).\nFIGURE\n 4: The da Vinci robot is used to surgically treat severe\nendometriosis\nThe da Vinci robot is used to surgically treat severe endometriosis\nThis articulation makes suturing and other surgical procedures easier with the robot than with traditional\nlaparoscopy. The primary advantage of the robot over laparoscopy is that the robot is easier to master.\nTherefore, it makes minimally invasive surgery easier for the physician, meaning more physicians are able to\nprovide their patients with a minimally invasive surgical treatment.\nMedical management of endometriosis\nBecause endometriosis is hormonally responsive, postoperatively it is important to regulate the patient’s\nhormone levels. We generally start the patients who do not desire immediate fertility on continous oral\ncontraceptive pills. Studies show that both continuous use and cyclic use have beneficial results, and the\ndecision to use one or the other should be made on a patient-by-patient basis \n[43]\n.\nGnRH agonists can also be used in the short-term for patients with chronic pelvic pain to induce a medical\nmenopause since endometriosis is estrogen-dependent. The combination of anastrozole plus goserelin can\nbe used to reduce pain and reduce recurrences \n[44-45]\n. Similarly, letrozole has been reported to decrease\n2012 Buescher et al. Cureus 4(11): e68. DOI 10.7759/cureus.68\n5\n of \n12\n\npelvic pain and decrease dysparunea \n[44, 46]\n.\nIn addition, pelvic floor physical therapy and acupuncture are helpful to treat the muscle spasms of chronic\npain. Pelvic floor physical therapy requires dedication and patience on the part of the physician and the\npatient, as it often takes two to three months of treatment for the patient to achieve the full benefit.\nExtra-genital endometriosis\nAlthough endometriosis is generally limited to the pelvic peritoneum and pelvic organs, endometriosis can\nalso be found throughout the body. Endometriosis may spread to the urinary system in  1% to 2% of women\nwith symptomatic endometriosis. Endometriosis of the urinary tract tends to be superficial but may be\ninvasive and cause complete ureteral obstruction \n[47]\n. Clinicians should consider endometriosis in cases of\nrefractory and unexplained urinary complaints. If urinary tract endometriosis is suspected, an intravenous\npyelogram (IVP) or CT with IV contrast and delayed images to evaluate the ureters, ultrasound of the\nkidneys, and a routine blood and urine work-up may be indicated. In selected cases of recurrent hematuria,\ncystoscopy is suggested (Figure \n5\n). When bladder or ureteral endometriosis is suspected, urologic consult\nmay be helpful.\nFIGURE\n 5: A lesion of bladder endometriosis\nA lesion of bladder endometriosis is seen at cystoscopy.\nGastrointestinal endometriosis was described in 1901 by Cullen \n[6]\n and in 1922 by Sampson \n[48]\n during the\nhistologic examination of resected sigmoid colon that had been diagnosed intraoperatively as a carcinoma.\nThe gastrointestinal tract is believed to be involved in 3% to 37% of women with endometriosis \n[49-\n50]\n. However, in a specialized practice, the number of patients with bowel involvement may be as high as\n50% if patients with serosal and subserosal lesions are included. Endometriotic implants may be found\nbetween the small intestine and the anal canal. Intestinal endometriosis involves  the rectum and sigmoid\ncolon in 76% of cases (Figure \n6\n), the appendix in 18% (Figure \n7\n), and the cecum in 5%. The clinical\npresentation varies from an incidental finding at laparoscopy or laparotomy to bowel obstruction \n[51]\n.\nOperative laparoscopy is performed to treat endometriotic implants on the intestinal wall, appendix, and\nrectovaginal space \n[20]\n. The surgery performed varies depending on the patient but can include\nappendectomy \n[52]\n, disk excision, or bowel resection. Bowel resection should be reserved for those patients\nwho continue to have symptoms despite more conservative forms of treatment \n[20]\n.\n2012 Buescher et al. Cureus 4(11): e68. DOI 10.7759/cureus.68\n6\n of \n12\n\nFIGURE\n 6: Endometriosis\nThe bubbles on the rectum of this patient are endometriosis.\nFIGURE\n 7: Endometriosis\nEndometriosis appears as black and red spots on this appendix.\nThe diaphragm is rarely a reported site of endometriosis \n[53]\n. Women should be asked about pleuritic,\nshoulder, or upper abdominal pain occurring with menses because they do not make the connection between\nthese distant anatomic landmarks. The laparoscope is excellent for diagnosing and possibly treating\nendometriosis on the diaphragm, which is difficult to reach by laparotomy \n[2]\n.  Endometriosis of the liver is\neven more rare than diaphragmatic endometriosis, but can cause cyclic right upper quadrant pain \n[54]\n.\nIn patients who present with catamenial pneumothorax, catamenial hemoptysis, catamenial hemothorax, or\nlung nodules, thoracic endometriosis must be considered. Catamenial pneumothorax is the most common\npresenation of thoracic endometriosis \n[55]\n.\n2012 Buescher et al. Cureus 4(11): e68. DOI 10.7759/cureus.68\n7\n of \n12\n\nIf it has been determined preoperatively that the patient may have thoracic endometriosis, video-assisted\nthoracic surgery should be performed by a cardiothoracic surgeon at the time of laparoscopy. During the\nVATS procedure, any endometriotic implants should be ablated or resected (Figure \n8\n). In addition, any\nscarring of the lung to the thoracic sidewall should be treated surgically \n[2]\n.\nFIGURE\n 8: Endometriosis\nDuring a VATS procedure, endometriosis is seen on the thoracic sidewall.\nFuture directions\nAs for the “etiologic chaos” that persists, drawing from over 30 years of endometriosis research and surgical\nexperience, which includes by now approximately 14,000 surgeries, several important insights come to mind.\nThe first is that we believe it’s time to radically reevaluate how endometriosis’s four main theories of\npathogenesis are conceptualized. In our view, all four theories are partially correct. We arrived at this hybrid\ntheory after observing what we suspect to have been all four pathogeneses at play: 1) retrograde menstrual\nendometrium implanting on peritoneal surfaces and transforming into pathology; 2) a pattern of coelomic\nmetaplastic differentiation of mesothelial cells into endometrium-like tissue; 3) lymphatic and venous\nspread transporting and depositing endometriosis into areas which cannot be explained by the other\ntheories; and 4) iatrogenic or direct transplantation, which would explain the presence of endometriosis in\nsurgical scars. Rather than viewing these theories from a zero-sum standpoint, we believe that by\nconceptualizing endometriosis through the framework of an integrated model, this could potentially lead to\nsignificant improvements in preventive and treatment strategies, as well as potentially lead us more closely\ntoward a cure.\nThere is escape of endometrial glands and stroma from the fallopian tubes at the time of diagnostic\nlaparoscopy while hysteroscopy is being performed simultaneously (Figures \n9\n-\n10\n).\n2012 Buescher et al. Cureus 4(11): e68. DOI 10.7759/cureus.68\n8\n of \n12\n\nFIGURE\n 9: Endometrial glands and stroma escaping from the fallopian\ntube\nEndometrial glands and stroma escaping from the fallopian tube at the the time of hysteroscopy\nFIGURE\n 10: Endometrial glands\nImmediately after hysteroscopy, these blebs of endometrial glands and stroma are easily removed from the\npelvis and sent for pathologic evaluation. The pathology is invariably endometriosis.\nOn countless occasions over more than three decades, we have observed this phenomenon repeatedly.\nPathologic diagnosis of endometriosis has been noted 100% of the time. Additionally, we have observed\ndifferent stages of progression of these lesions attaching themselves to different organs of the pelvis (Figure\n11\n). Thus, we have no doubt that retrograde menstruation is one of the causes of endometriosis.\n2012 Buescher et al. Cureus 4(11): e68. DOI 10.7759/cureus.68\n9\n of \n12\n\nFIGURE\n 11: Endometrial glands and stroma\nEndometrial glands and stroma have attached to the posterior uterus after hysteroscopy. If left behind, this\ncan lead to obliteration of the posterior cul de sac.\nWith regard to the assumption that resection of endometriosis can be cured, we have observed over and over\nnew implants of endometriosis exactly at the center of the craters or at the periphery of previously resected\ndisease (Figure \n12\n).\nFIGURE\n 12: Endometriosis\nEndometriosis can recur even at sites of previous excision. This image clearly shows the recurrence of\nendometriosis at the left pararectal site of previous excision.\nAdditionally, on rare occasions over the past several decades we have noticed severe dissemination of\nendometriosis on repeat laparoscopy on patients with mild to moderate endometriosis at the initial\nprocedure within the three years.\n2012 Buescher et al. Cureus 4(11): e68. DOI 10.7759/cureus.68\n10\n of \n12\n\nConclusions\nAs providers of women’s health, we must always strive to provide the highest level of care for our patients.\nWomen with chronic pelvic pain or infertility often present a challenge to the clinician as they often present\nwith multiple previous diagnoses and may be frustrated with the medical system. When a patient in her\nreproductive years presents with pelvic pain or infertility, endometriosis should be considered as a diagnosis\nand treatment started. Endometriosis treatment often requires a multidisciplinary approach: pain\nmanagement to help manage chronic pain, physical therapy, and those patients with extragenital\nendometriosis may need co-management with urology, colorectal surgery, gastroenterology, and\ncardiovascular surgery. However, with appropriate care, the majority of these patients can be relieved of\ntheir symptoms and achieve fertility.\nAdditional Information\nDisclosures\nConflicts of interest:\n In compliance with the ICMJE uniform disclosure form, all authors declare the\nfollowing: \nPayment/services info:\n All authors have declared that no financial support was received from\nany organization for the submitted work. \nFinancial relationships:\n All authors have declared that they have\nno financial relationships at present or within the previous three years with any organizations that might\nhave an interest in the submitted work. \nOther relationships:\n All authors have declared that there are no\nother relationships or activities that could appear to have influenced the submitted work.\nReferences\n1\n. \nVeeraswamy A, Lewis M, Mann A, Kotikela S, Hajhosseini B, Nezhat C: \nExtragenital endometriosis\n. 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Dis Colon Rectum. 1973, 16:490-499.\n52\n. \nBerker B, Lashay N, Davarpanah R, Marziali M, Nezhat CH, Nezhat C: \nLaparoscopic appendectomy in\npatients with endometriosis\n. J Minim Invasive Gynecol. 2005, 122:206-209.\n53\n. \nNezhat C, Seidman DS, Nezhat F: \nLaparoscopic surgical management of diaphragmatic endometriosis\n. Fertil\nSteril. 1998, 69:1048-1055.\n54\n. \nNezhat C, Kazerooni T, Berker B, Lashay N, Fernandez S, Marziali M: \nLaparoscopic management of hepatic\nendometriosis: report of two cases and review of the literature\n. J Minim Invasive Gynecol. 2005, 12:196-200.\n55\n. \nJoseph J, Sahn SA: \nThoracic endometriosis syndrome: new observations from an analysis of 110 cases\n. Am J\nMed. 1996, 100:164-170.\n2012 Buescher et al. Cureus 4(11): e68. DOI 10.7759/cureus.68\n12\n of \n12","source_license":"CC0","license_restricted":false}