Expanding the Gynecologic Surgeon’s Toolbox: Liver Mobilization for Complete Excision of Diaphragmatic Endometriosis

INTRODUCTION: Diaphragmatic endometriosis represents an uncommon yet challenging subtype of extrapelvic disease. Beyond its impact on quality of life through chronic pain and infertility, this condition may lead to severe complications, including recurrent pleural effusions, diaphragmatic hernias, and catamenial pneumothorax. Owing to its relative rarity and anatomical location, which necessitates familiarity with hepatobiliary structures often outside the routine scope of gynecologic practice, achieving the gold standard of complete surgical excision is particularly difficult. OBJECTIVE: This video aims to illustrate key anatomical landmarks relevant to hepatic mobilization in order to facilitate safe and thorough excision of diaphragmatic and Morrison’s pouch endometriosis. Techniques for achieving hemostasis and a discussion of instrumentation that aids in resection of endometriosis involving the liver surface are also presented. METHODS: We demonstrate the surgical steps required for division of the coronary, triangular, and falciform ligaments to achieve complete hepatic mobilization. The case involves a 41-year-old patient with stage IV endometriosis complicated by recurrent ascites and pelvic effusions, resulting in multiple hospitalizations attributed to extrapelvic disease. RESULTS: Hepatic mobilization permitted comprehensive resection of endometriosis from Morrison’s pouch and a full-thickness excision of the right hemidiaphragm. Hemostasis was successfully maintained, and exposure to previously inaccessible disease was optimized. CONCLUSIONS: Division of the coronary, triangular, and falciform ligaments enables effective liver mobilization, thereby providing access to difficult anatomical regions such as Morrison’s pouch and the right hemidiaphragm. Mastery of these techniques expands the gynecologic surgeon’s operative capacity and is critical for achieving complete excision of advanced extrapelvic endometriosis.