Diaphragmatic endometriosis: a practical radiologic guide to diagnosis, mapping, and multidisciplinary surgical planning

Diaphragmatic endometriosis (DiaE) is a frequently underdiagnosed manifestation of deep endometriosis (DE), typically occurring in patients with advanced pelvic disease. Accurate preoperative detection remains challenging, as standard laparoscopy may overlook posterior diaphragmatic lesions due to their subhepatic location. In this context, magnetic resonance imaging (MRI) plays a central role by enabling lesion detection, precise mapping, and comprehensive assessment of disease extent. This review synthesizes diaphragmatic anatomy, pathophysiology, and clinical presentation, delivering a practical framework for MRI evaluation. We propose an abbreviated diaphragm-focused MRI protocol, acquired within an abdominal field of view in conjunction with standard pelvic MRI. This combined approach emphasizes high-resolution fat-suppressed T1-weighted sequences to detect hemorrhagic lesions, alongside a systematic evaluation of non-hemorrhagic features on fat-suppressed T2-weighted images, allowing simultaneous assessment of the pelvis and abdominal extrapelvic sites. Finally, we provide a structured reporting template designed to improve radiologist-surgeon communication. Combining a targeted imaging protocol with standardized anatomic reporting enhances preoperative planning, reduces intraoperative uncertainty, and facilitates complete disease excision, potentially reducing the need for repeat surgical interventions. The proposed abbreviated diaphragm-focused MRI protocol and structured reporting template represent the central practical contributions of this review. Similar content being viewed by others Data availability No datasets were generated or analysed during the current study. Abbreviations - DE: - Deep endometriosis - DiaE: - Diaphragmatic endometriosis - TES: - Thoracic endometriosis syndrome - T1W: - T1-weighted - T2W: - T2-weighted - DWI: - Diffusion-weighted imaging - FS: - Fat-suppressed

Naem A, Roman H, Martin DC, Krentel H. A bird-eye view of diaphragmatic endometriosis: current practices and future perspectives. Front Med (Lausanne). 2024 Nov 15;11:1505399. https://doi.org/10.3389/fmed.2024.1505399 Naem A, Andrikos A, Constantin AS, Khamou M, Andrikos D, Laganà AS, et al. Diaphragmatic endometriosis-A single-center retrospective analysis of the patients’ demographics, symptomatology, and long-term treatment outcomes. J Clin Med. 2023 Oct 11;12(20):6455. https://doi.org/10.3390/jcm12206455 Pagano F, Schwander A, Vaineau C, Knabben L, Nirgianakis K, Imboden S, et al. True prevalence of diaphragmatic endometriosis and its association with severe endometriosis: A call for awareness and investigation. J Minim Invasive Gynecol. 2023 Apr;30(4):329–34. https://doi.org/10.1016/j.jmig.2023.01.006 Tong A, VanBuren WM, Chamié L, Feldman M, Hindman N, Huang C, et al. Recommendations for MRI technique in the evaluation of pelvic endometriosis: consensus statement from the Society of Abdominal Radiology endometriosis disease-focused panel. Abdom Radiol (NY). 2020 Jun;45(6):1569–86. https://doi.org/10.1007/s00261-020-02483-w Xiao L, White D, Kruger LF, Alwatari Y, Blackmon S, Burnett T, et al. Thoracic endometriosis syndrome: imaging findings and the value of a dedicated MRI protocol. Abdom Radiol (NY). 2025 Sep;50(9):4423–36. https://doi.org/10.1007/s00261-025-04835-w Ceccaroni M, Roviglione G, Farulla A, Bertoglio P, Clarizia R, Viti A, et al. Minimally invasive treatment of diaphragmatic endometriosis: a 15-year single referral center’s experience on 215 patients. Surg Endosc. 2021 Dec;35(12):6807–17. https://doi.org/10.1007/s00464-020-08186-z Vercellini P, Abbiati A, Viganò P, Somigliana ED, Daguati R, Meroni F, et al. Asymmetry in distribution of diaphragmatic endometriotic lesions: evidence in favour of the menstrual reflux theory. Hum Reprod. 2007 Sep;22(9):2359–67. Andres MP, Arcoverde FVL, Souza CCC, Fernandes LFC, Abrão MS, Kho RM. Extrapelvic endometriosis: a systematic review. J Minim Invasive Gynecol. 2020 Feb;27(2):373–89. https://doi.org/10.1016/j.jmig.2019.10.004 Servidoni ACP, Castel C, Martin GCC, Armstrong BBS, Amador WFO, Yousif A, et al. Diaphragmatic endometriosis: clinical features and surgical outcomes — a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2026 Feb;317:114863. https://doi.org/10.1016/j.ejogrb.2025.114863 Piriyev E, Römer T. Diaphragm endometriosis: Random localization or extended form of pelvis endometriosis. A large comparative analysis of 202 cases. Eur J Obstet Gynecol Reprod Biol. 2024 Mar;294:117–22. https://doi.org/10.1016/j.ejogrb.2024.01.020 Piccus R, Mann C, Sutcliffe RP. Diagnosis and treatment of diaphragmatic endometriosis: results of an international patient survey. Eur J Obstet Gynecol Reprod Biol. 2021 May;260:48–51. https://doi.org/10.1016/j.ejogrb.2021.03.003 Redwine DB. Diaphragmatic endometriosis: diagnosis, surgical management, and long-term results of treatment. Fertil Steril. 2002 Feb;77(2):288–96. https://doi.org/10.1016/S0015-0282(01)02998-3 Rousset P, Gregory J, Rousset-Jablonski C, Hugon-Rodin J, Regnard JF, Chapron C, et al. MR diagnosis of diaphragmatic endometriosis. Eur Radiol. 2016 Nov;26(11):3968–77. https://doi.org/10.1007/s00330-016-4226-5 Keyes S, Spouge RJ, Kennedy P, Rai S, Abdellatif W, Sugrue G, et al. Approach to acute traumatic and nontraumatic diaphragmatic abnormalities. Radiographics. 2024 Jun;44(6):e230110. https://doi.org/10.1148/rg.230110 Maish MS. The diaphragm. Surg Clin North Am. 2010 Oct;90(5):955–68. https://doi.org/10.1016/j.suc.2010.07.005 Bordoni B, Zanier E. Anatomic connections of the diaphragm: influence of respiration on the body system. J Multidiscip Healthc. 2013 Jul 25;6:281–91. https://doi.org/10.2147/JMDH.S45443 Nason LK, Walker CM, McNeeley MF, Burivong W, Fligner CL, Godwin JD. Imaging of the diaphragm: anatomy and function. Radiographics. 2012 Mar;32(2):E51–70. https://doi.org/10.1148/rg.322115127 du Plessis M, Ramai D, Shah S, Holland JD, Tubbs RS, Loukas M. The clinical anatomy of the musculotendinous part of the diaphragm. Surg Radiol Anat. 2015 Nov;37(9):1013–20. https://doi.org/10.1007/s00276-015-1481-0 Boriek AM, Rodarte JR. Inferences on passive diaphragm mechanics from gross anatomy. J Appl Physiol. 1994 Nov;77(5):2065–70. https://doi.org/10.1152/jappl.1994.77.5.2065 Soares T, Oliveira MA, Panisset K, Habib N, Rahman S, Klebanoff JS, et al. Diaphragmatic endometriosis and thoracic endometriosis syndrome: a review on diagnosis and treatment. Horm Mol Biol Clin Investig. 2021 Feb 18;43(2):137–43. https://doi.org/10.1515/hmbci-2020-0066 Pagano F, Dedes I, Imboden S, Mueller MD. Connecting the dots: Exploring appendiceal endometriosis in women with diaphragmatic endometriosis. Eur J Obstet Gynecol Reprod Biol. 2024 Nov;302:134–40. https://doi.org/10.1016/j.ejogrb.2024.08.045 Chamié LP, Ribeiro DMFR, Tiferes DA, Macedo Neto AC de, Serafini PC. Atypical sites of deeply infiltrative endometriosis: Clinical characteristics and imaging findings. Radiographics. 2018 Jan;38(1):309–28. https://doi.org/10.1148/rg.2018170093 Nezhat C, Seidman DS, Nezhat F, Nezhat C. Laparoscopic surgical management of diaphragmatic endometriosis. Fertil Steril. 1998 Jun;69(6):1048–55. https://doi.org/10.1016/s0015-0282(98)00056-9 Gil Y, Tulandi T. Diagnosis and treatment of catamenial pneumothorax: a systematic review. J Minim Invasive Gynecol. 2020 Jan;27(1):48–53. https://doi.org/10.1016/j.jmig.2019.08.005 Hosseiny M, Khoshpouri P, Cledera T, Brun-Vergara ML, Avalos F, Bartlett DJ. Endometriosis of the diaphragm. Radiographics. 2024 Nov;44(11):e240153. https://doi.org/10.1148/rg.240153 Gui B, Valentini AL, Ninivaggi V, Miccò M, Zecchi V, Grimaldi PP, et al. Shining light in a dark landscape: MRI evaluation of unusual localization of endometriosis. Diagn Interv Radiol. 2017 Jul;23(4):272–81. https://doi.org/10.5152/dir.2017.16364 Nezhat C, Lindheim SR, Backhus L, Vu M, Vang N, Nezhat A, et al. Thoracic endometriosis syndrome: A review of diagnosis and management. JSLS. 2019 Jul;23(3):e2019.00029. https://doi.org/10.4293/JSLS.2019.00029 Chamié LP. Ultrasound evaluation of deeply infiltrative endometriosis: technique and interpretation. Abdom Radiol (NY). 2020 Jun;45(6):1648–58. https://doi.org/10.1007/s00261-019-02322-7 Thomassin-Naggara I, Dolciami M, Chamie LP, Guerra A, Bharwani N, Freeman S, et al. ESUR consensus MRI for endometriosis: protocol, lexicon, and compartment-based analysis. Eur Radiol. 2025 Nov;35(11):7272–86. https://doi.org/10.1007/s00330-025-11611-3 Ceccaroni M, Roviglione G, Giampaolino P, Clarizia R, Bruni F, Ruffo G, et al. Laparoscopic surgical treatment of diaphragmatic endometriosis: a 7-year single-institution retrospective review. Surg Endosc. 2013 Feb;27(2):625–32. https://doi.org/10.1007/s00464-012-2505-z Ohashi K, Kurihara M, Tsuboshima K. Dynamics of diaphragmatic endometriosis with thoracic endometriosis-related pneumothorax. J Thorac Dis. 2026 Feb;18(2):82. https://doi.org/10.21037/jtd-2025-838 Bobbio A, Carbognani P, Ampollini L, Rusca M. Diaphragmatic laceration, partial liver herniation and catamenial pneumothorax. Asian Cardiovasc Thorac Ann. 2007 Jun;15(3):249–51. https://doi.org/10.1177/021849230701500317 Triponez F, Alifano M, Bobbio A, Regnard JF. Endometriosis-related spontaneous diaphragmatic rupture. Interact Cardiovasc Thorac Surg. 2010 Oct;11(4):485–7. https://doi.org/10.1510/icvts.2010.243543 Thomassin-Naggara I, Dolciami M, Chamie LP, Guerra A, Bharwani N, Freeman S, et al. ESUR consensus MRI for endometriosis: indications, reporting, and classifications. Eur Radiol. 2025 Nov;35(11):7260–8. https://doi.org/10.1007/s00330-025-11579-0 Feldman MK, VanBuren WM, Barnard H, Taffel MT, Kho RM. Systematic interpretation and structured reporting for pelvic magnetic resonance imaging studies in patients with endometriosis: value added for improved patient care. Abdom Radiol (NY). 2020 Jun;45(6):1608–22. https://doi.org/10.1007/s00261-019-02182-1 Vigueras Smith A, Cabrera R, Kondo W, Ferreira H. Diaphragmatic endometriosis minimally invasive treatment: a feasible and effective approach. J Obstet Gynaecol. 2021 Feb 17;41(2):176–86. https://doi.org/10.1080/01443615.2019.1702934 Nezhat C, Nicoll LM, Bhagan L, Huang JQ, Bosev D, Hajhosseini B, et al. Endometriosis of the diaphragm: Four cases treated with a combination of laparoscopy and thoracoscopy. J Minim Invasive Gynecol. 2009 Sep;16(5):573–80. https://doi.org/10.1016/j.jmig.2009.06.012 Ceccaroni M, D'Ancona G, Roviglione G, Choi S, Capezzuoli T, Puppo A, et al. Tailoring radicality in diaphragmatic surgery for deep endometriosis: a matter of choice. Best Pract Res Clin Obstet Gynaecol. 2024 Jul;95:102499. https://doi.org/10.1016/j.bpobgyn.2024.102499 D'Ancona G, Merlot B, Chanavaz-Lacheray I, Braund S, Kade S, Dennis T, et al. Robotic-assisted laparoscopy excision of a severe form of diaphragmatic endometriosis: a retrospective study of 60 patients. J Minim Invasive Gynecol. 2024 Oct;31(10):847–54. https://doi.org/10.1016/j.jmig.2024.06.002 Wetzel A, Philip CA, Golfier F, Bonnot PE, Cotte E, Brichon PY, et al. Surgical management of diaphragmatic and thoracic endometriosis: a French multicentric descriptive study. J Gynecol Obstet Hum Reprod. 2021 Oct;50(8):102147. https://doi.org/10.1016/j.jogoh.2021.102147 Rousset P, Rousset-Jablonski C, Alifano M, Mansuet-Lupo A, Buy JN, Revel MP. Thoracic endometriosis syndrome: CT and MRI features. Clin Radiol. 2014 Mar;69(3):323–30. https://doi.org/10.1016/j.crad.2013.10.014 Author information Authors and Affiliations Contributions J.J.S. and F.A.F.F. share first authorship, having contributed equally to writing the main manuscript text. A.L.D.M. and L.C.B. selected the MRI cases and prepared imaging Figs. 7–11. T.S.R. provided the intraoperative surgical images. F.A.F.F. worked with an illustration artist to create Figs. 1, 3, and 5. J.J.S. prepared Figs. 2, 4, and 6, reviewed all figures and illustrations, and drafted the figure legends. F.A.F.F. and A.C.C.B.S. conceptualized the MRI protocol recommendation table, with critical review by J.J.S. and L.P.C. F.A.F.F. created the surgical anatomy table, with contributions from C.A.S. and review by J.J.S. Sectional writing contributions included: I.P.F. (Introduction), A.L.D.M. (Anatomy), L.C.B. (Structured Reporting Template), and M.A.P.O., T.S.R., and C.A.S. (Surgical Considerations and Treatment). A.C.C.B.S., L.P.C., J.J.S., and F.A.F.F. curated the literature and references. All authors critically reviewed and approved the final manuscript. Corresponding authors Ethics declarations Conflict of interest The authors declare no competing interests. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary Information Below is the link to the electronic supplementary material. Rights and permissions Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. About this article Cite this article Jabbur Stern, J., Ferreira Francisco, F., di Mango, A. et al. Diaphragmatic endometriosis: a practical radiologic guide to diagnosis, mapping, and multidisciplinary surgical planning. Abdom Radiol (2026). https://doi.org/10.1007/s00261-026-05616-9 Received: Revised: Accepted: Published: Version of record: DOI: https://doi.org/10.1007/s00261-026-05616-9