Robot-assisted resection of diaphragmatic and hepatorenal recess peritoneal endometriosis: Two cases and a narrative review

Xiaoming Guan: Data curation, Conceptualization, Methodology, Supervision, Project administration, surgeon, Writing – original draft, Writing – review & editing, Validation; Qiannan Yang: Data curation, Visualization, Writing – original draft, Writing – review & editing, Validation; Daniel Y. Lovell: Writing – review & editing, Validation; Chunhua Zhang: Writing – review & editing, Validation. All authors have read and agreed to the published version of the manuscript.

This study was institutional review board approved from Baylor College of Medicine on March 8, 2022, under approval number H‐51429.

A 45‐year‐old G1P1 White woman with a history of uterine didelphys and prior cesarean delivery presented with chronic pelvic pain and abnormal uterine bleeding (AUB). She underwent a hysterectomy for AUB in December 2022, during which Stage IV endometriosis involving the bowel was incidentally discovered. Intraoperatively, a robot‐assisted laparoscopic excision of pelvic nodules, extensive lysis of adhesions, and partial‐thickness proctorrhaphy with primary repair were performed by colorectal surgery. A cecal and small bowel mass was identified but not resected at that time. The patient continued to experience right lower quadrant (RLQ) and right upper quadrant (RUQ) pain postoperatively, which was associated with dyspareunia and intermittent dyschezia, prompting further evaluation. Computed tomography (CT) on February 16, 2024, revealed a 3.7‐cm indeterminate lesion in the left pelvis. A subsequent pelvic MRI identified a 1.1‐cm T1 hyperintense lesion along the posterior, basal right hemidiaphragm, without enhancement or diffusion restriction, suggestive of diaphragmatic endometriosis (Figure  1 ). Magnetic resonance imaging (MRI) findings in Case  1 . (a) The red arrow indicates the presence of diaphragmatic endometriosis. (b) MRI demonstrating the renal region. The patient underwent a robot‐assisted resection of diaphragmatic endometriosis, peritoneal resection of the hepatorenal recess, excision of residual pelvic implants, and completion of adhesiolysis on June 11, 2025. Final pathology confirmed diaphragmatic and hepatorenal recess peritoneal endometriosis with extensive pelvic disease. A 32‐year‐old G1P1001 Hispanic woman with a history of cesarean delivery presented with a 10‐day history of sudden‐onset lower pelvic pain. The pain was described as sharp, continuous, aching, and pressure‐like, fluctuating in intensity from 5 to 9 out of 10. Associated symptoms included deep dyspareunia, constipation, dyschezia, and dysuria with intermittent hematuria during urinary tract infections. Pain was worsened by menstruation and ovulation and partially relieved with heat and over‐the‐counter non‐steroidal anti‐inflammatory drugs. The patient expressed a desire for future fertility and her primary goal of care was pain relief. She did not have cyclical RUQ pain. Her menstrual history was notable for irregular cycles with dysmenorrhea and menorrhagia lasting 7 to 9 days. Physical exam was significant for 4/10 tenderness to the posterior fornix, but negative for tenderness to the pelvic floor. MRI demonstrated a retroverted uterus with mild posterior junctional zone asymmetry suggestive of adenomyosis and potential adhesions between the right ovary, anterior uterine wall, and adjacent bowel loops. No endoluminal bowel endometriosis was identified with rectal contrast. She was referred for a multidisciplinary evaluation, with a planned minimally invasive surgery to treat her presumed endometriosis and pelvic adhesive disease. A robot‐assisted laparoscopic approach was used for both cases. For Case 1, a Veress needle was inserted through the umbilicus, and pneumoperitoneum was established. Four 8‐mm robotic trocars were placed (Figure  S1 ), including an AirSeal (Conmed; Largo, Florida) trocar in the left upper quadrant. At the beginning of each procedure, a thorough and systematic survey of both the upper and lower abdomen was performed, including inspection of the liver, diaphragm, hepatorenal recess peritoneum, appendix, bowel, bladder, pelvic sidewalls, uterus, and adnexa. Exploration beyond the pelvis was undertaken to identify potential extrapelvic endometriosis, even in the absence of specific preoperative symptoms, given the known risk of occult diaphragmatic and upper abdominal disease in patients with advanced pelvic endometriosis. Any lesions suspicious for endometriosis were excised. For both patients, the presence of diaphragmatic endometriosis guided the decision to excise the diaphragmatic lesions as the initial surgical step. Patients were positioned in the supine position. The da Vinci Xi (Intuitive; Sunnyvale, California) robot was then docked for upper abdominal dissection, targeting the diaphragm and right upper quadrant. For Case 2, a Hassan entry was made through the umbilicus with a single‐incision da Vinci Xi port placed. Due to the complexity of the procedure, two additional 8‐mm robotic ports were placed lateral to the umbilicus. For both procedures, dense adhesions between the liver and diaphragm were lysed using cold scissors. Diaphragmatic endometriosis implants were sharply excised with bipolar graspers and scissors, elevating the lesions away from the diaphragm before en bloc removal, which means healthy underlying tissue was visualized. Additional excision of endometriotic nodules over the hepatorenal recess peritoneum was performed using the same technique (Figures  2 and 3 ). All resection sites were confirmed to be superficial, without evidence of transdiaphragmatic penetration, and hemostasis was achieved upon inspection. The robot was subsequently undocked and re‐docked toward the pelvis to complete the procedure. Intraoperative findings in Case  1 . (a) Dense adhesion between the diaphragm and liver (green arrows). (b) Endometriotic lesion (yellow arrows) with the hepatorenal recess highlighted (blue area). (c–e) Resection of endometriotic lesions (blue arrow and line‐ peritoneal reflection). (f) Complete excision of endometriotic lesions (yellow area). Intraoperative findings in Case  2 . Yellow arrows: Endometriotic lesion. Green arrows: Adhesion between the diaphragm and liver. Yellow area: Complete excision of endometriotic lesions. Blue area: Hepatorenal recess. Blue arrow and line: Peritoneal reflection. At the end of the procedure, all robotic instruments were removed, and the abdomen was desufflated. The robot was undocked. In Case 1, a 2‐cm endometriotic lesion was incidentally identified at the umbilical incision site during closure and excised; this lesion had not been detected on preoperative imaging. For both cases, the umbilical incision was closed in a similar fashion. The umbilical fascial incision was closed using interrupted figure‐of‐eight sutures with 0‐Polyethelene terephthalate and 0‐Polyglactin. The subcutaneous layer was approximated with interrupted 0‐Polyglactin sutures, and the skin was closed in a subcuticular fashion with 4–0 Poliglecaprone. The umbilical skin was tacked to the fascia with 0‐Polyglactin suture. A total of 10 mL of liposomal bupivacaine (Exparel) was injected into the incision, and Dermabond was applied to all skin closure sites. Case 1 procedures: Robotic multi‐port resection of endometriosis. Resection of diaphragmatic endometriosis. Bilateral retroperitoneal dissection and ureterolysis. Left ovarian cystectomy. Left temporary ovarian suspension. Right oophorectomy. Enterolysis and adhesiolysis. Resection of umbilical endometriosis. Low anterior resection with cecal end‐to‐end anastomosis, hepatorenal recess peritoneal endometriosis resection performed by a colorectal surgeon. Robotic multi‐port resection of endometriosis. Resection of diaphragmatic endometriosis. Bilateral retroperitoneal dissection and ureterolysis. Left ovarian cystectomy. Left temporary ovarian suspension. Right oophorectomy. Enterolysis and adhesiolysis. Resection of umbilical endometriosis. Low anterior resection with cecal end‐to‐end anastomosis, hepatorenal recess peritoneal endometriosis resection performed by a colorectal surgeon. Case 2 procedures: Robotic multi‐port resection of endometriosis. Resection of diaphragmatic endometriosis. Resection of hepatorenal recess peritoneal endometriosis. Enterolysis. Left ovarian cystectomy. Bilateral temporary ovarian suspension. Appendectomy. Robotic multi‐port resection of endometriosis. Resection of diaphragmatic endometriosis. Resection of hepatorenal recess peritoneal endometriosis. Enterolysis. Left ovarian cystectomy. Bilateral temporary ovarian suspension. Appendectomy. A narrative literature review was conducted to contextualize our case findings. We searched PubMed from database inception to June 2025. Search terms included “diaphragmatic endometriosis,” “thoracic endometriosis,” “hepatorenal recess endometriosis,” “pararenal peritoneum,” and “perirenal peritoneum,” as well as combinations of these keywords. Reference lists of retrieved articles were also screened to identify additional relevant publications. Inclusion criteria comprised case reports, case series that described extrapelvic endometriosis involving the diaphragm, thoracic cavity, hepatorenal recess peritoneum, or renal endometriosis. Exclusion criteria included review articles, conference abstracts without full‐text availability, articles not in English, and reports unrelated to endometriosis of these anatomical regions. Data from eligible studies were extracted and synthesized qualitatively to generate summary Tables  1 and 2 , which present clinical characteristics, operative details, and outcomes. This approach ensured a comprehensive yet methodologically transparent review consistent with the narrative review framework. Summary of previous reports of diaphragmatic endometriosis. Abbreviations: AppE, appendiceal endometriosis; CT, computed tomography; DE, diaphragmatic endometriosis; MRI, magnetic resonance imaging; RATS, robotic‐assisted thoracic surgery; TED, thoracic/diaphragmatic endometriosis; VATS, video‐assisted thoracoscopic surgery. Summary of previous reports of renal endometriosis.

The total operative times of the two patients were 344 min (case 1) and 193 min (case 2). Estimated blood loss was 50 mL (case 1) and 15 mL (case 2). At the 6‐week postoperative follow‐up, both patients demonstrated satisfactory recovery with complete symptom resolution and no complications. In Case 1, postoperative visual analog scale (VAS) pain scores were 4, 4, 2, and 2 at weeks 1, 2, 3, and 6, respectively. In Case 2, the corresponding scores were 10, 5, 3, and 0. Both patients reported discontinuation of analgesic use within the first postoperative week and were able to return to normal daily activities without restriction. At the most recent follow‐up, 4 months postoperatively, both patients remained asymptomatic with sustained pain relief. No adjuvant hormonal therapy was administered after surgery. According to the revised American Society for Reproductive Medicine (r‐ASRM) classification, Case 1 was classified as stage IV endometriosis, whereas Case 2 was classified as stage III endometriosis. Case 1 pathology resulted with endometriosis at 28 out of 46 locations including the umbilicus, diaphragm, small and large colon, hepatorenal recess peritoneum, peri‐aorta, as well as throughout the pelvic peritoneum. Similarly in case 2, pathology resulted with endometriosis at 26 out of 34 areas of resection, including the appendix, diaphragm, hepatorenal recess peritoneum, pelvic peritoneum, and large colon.

Written informed consent was obtained from each patient for publication of this case report and the accompanying clinical details and intraoperative images.

This case report presents two rare instances of right diaphragmatic endometriosis extending to the peritoneum overlying the hepatorenal recess (Figures  2b and 3g ). One patient exhibited typical symptoms of diaphragmatic endometriosis, including catamenial abdominal and shoulder pain, while the other was diagnosed incidentally during surgical exploration. In both cases, all visualized lesions were completely excised and confirmed histologically. To verify the novelty of our findings, we conducted a structured literature search using PubMed from database inception through June 2025. Search terms included combinations of “diaphragmatic endometriosis,” “thoracic endometriosis,” “hepatorenal recess endometriosis,” “pararenal peritoneum,” “perirenal peritoneum,” and “renal endometriosis.” Reference lists of relevant articles were also manually screened. Reports describing renal parenchymal endometriosis were identified 7 , 34 , 35 , 36 , 37 ; however, no prior publications were found that documented robotic‐assisted minimally invasive resection of concurrent diaphragmatic and hepatorenal recess peritoneal endometriosis. This structured search supports the conclusion that, to our knowledge, the present cases represent the first such report in the literature. A comprehensive literature review identified 28 publications of diaphragmatic endometriosis, which we analyzed and summarized in Table  1 , with statistical findings and clinical recommendations presented in Table  S1 . Diaphragmatic endometriosis often coexists with pelvic disease and commonly presents with catamenial upper abdominal, chest, or shoulder pain. MRI is the preferred diagnostic modality, although it frequently underestimates the extent of endometriotic lesion. In patients with thoracic symptoms or advanced pelvic endometriosis, thoracic imaging or thoracoscopy should be considered for accurate assessment. Management of diaphragmatic endometriosis requires careful patient selection, MRI‐based preoperative assessment, multidisciplinary surgical planning with robotic or combined approaches for complex lesions, adjunctive postoperative hormonal therapy, and prospective research to clarify long‐term outcomes and recurrence. Surgical excision remains the cornerstone of management, with laparoscopy as the preferred approach. Robot‐assisted techniques are increasingly utilized, especially for deep infiltrating disease. Full‐thickness or extensive diaphragmatic lesions might require combined laparoscopic and thoracoscopic excision. Multidisciplinary collaboration involving gynecologic, thoracic, and general surgeons is crucial in complex cases to optimize outcomes. Postoperative symptom relief is typically substantial, particularly when complete excision is achieved. Hormonal therapy is commonly used adjunctively but does not appear superior to surgery, when used alone. In asymptomatic cases, conservative management might be appropriate. However, depending on the size and location of the lesion (e.g., on the bowel), shared decision‐making with the patient should be considered. Regarding renal involvement, a literature review revealed only five case reports of kidney endometriosis, which is intrarenal parenchymal involvement (summarized in Table  2 ). Renal endometriosis should be considered in reproductive‐age women with renal masses, as symptoms and imaging are often inconclusive, histopathology remains essential for diagnosis, and minimally invasive robotic or laparoscopic approaches are preferred when the diagnosis is uncertain. These findings underscore the need for increased awareness of renal endometriosis, particularly in evaluating atypical renal masses. Menstrual history and known endometriosis should be considered before proceeding with radical interventions. Notably, no reports were found describing hepatorenal recess peritoneal endometriosis. Thus, the clinical significance and management strategies for this presentation remain unknown. Based on our findings, we recommend thorough intraoperative inspection and excision of peritoneal lesions overlying abdominal organs, particularly when diaphragmatic endometriosis is present or when upper abdominal quadrant pain is reported, even in the absence of overt symptoms. Whenever feasible, minimally invasive surgery should be the preferred approach, as it facilitates complete lesion removal while minimizing patient morbidity.

These two cases highlight an exceptionally rare presentation of diaphragmatic endometriosis with extension to the hepatorenal recess. While diaphragmatic endometriosis is increasingly recognized, no prior reports have described contiguous involvement of the hepatorenal recess peritoneum. Our findings emphasize the importance of comprehensive abdominal inspection when diaphragmatic lesions are present, even in asymptomatic patients. Complete surgical excision confirmed by pathology can be safely achieved using minimally invasive techniques, offering both diagnostic clarity and symptomatic relief. Given the scarcity of data on renal or perirenal peritoneal endometriosis, increased clinical awareness and further case accumulation are warranted to guide diagnosis and management strategies in this subset of extrapelvic endometriosis.

Extrapelvic endometriosis is a rare yet increasingly recognized manifestation of the disease, with diaphragmatic endometriosis being among the more frequently reported forms. Diaphragmatic endometriosis can be superficial on the peritoneal surface of the abdominal diaphragm or be a full thickness lesion extending through the diaphragm into the thoracic cavity. 1 , 2 , 3 , 4 The prevalence of diaphragmatic endometriosis ranges from approximately 0.67% to 4.7% of all endometriosis cases, with most studies citing an incidence around 1.5%–1.86%. 1 , 2 , 3 Patients often present with catamenial right upper quadrant pain, referred shoulder pain, or chest discomfort, with symptoms varying based on the proximity of the lesions to the phrenic nerve. 5 Magnetic resonance imaging (MRI) remains the most sensitive non‐invasive diagnostic modality. The advantages include a detailed delineation of lesion depth and anatomical extent and is essential for preoperative planning. However, histopathologic confirmation following surgical excision remains the gold standard for diagnosis and management. 6 While urinary tract endometriosis has traditionally been regarded as rare (afflicting approximately 1%–2% of patients with endometriosis), renal involvement is exceedingly uncommon, accounting for <1% of all cases. Kidney endometriosis typically presents with nonspecific or “silent” symptoms, such as catamenial flank or back pain, hematuria, or urinary tract obstruction, and is often misdiagnosed as a renal tumor. Hepatorenal recess peritoneal endometriosis refers to ectopic endometrial implants involving the parietal peritoneum of the right posterior subhepatic space (Morison's pouch), without invasion of the renal parenchyma. Reports of hepatorenal recess peritoneal endometriosis are extremely limited, and to date, no case studies have described isolated hepatorenal recess peritoneal endometriosis coexisting with right diaphragmatic disease. 7 , 8 Robot‐assisted surgery offers unique advantages in managing complex extrapelvic endometriosis. These include enhanced dexterity with multi‐jointed instruments, three‐dimensional visualization, and superior access to anatomically challenging regions, such as the diaphragm or the upper abdominal wall. According to both the American College of Obstetricians and Gynecologists and the Society of Gynecologic Surgeons recommendations, robotic platforms may be preferential in cases where extensive adhesions, deep infiltrating endometriosis, or patient factors like obesity, may complicate conventional laparoscopic approaches. 9 These advantages are particularly beneficial in resecting diaphragmatic lesions with or without concurrent hepatorenal recess peritoneum involvement. In this report, we present two unique cases of right‐sided diaphragmatic endometriosis accompanied by hepatorenal recess peritoneum involvement. To our knowledge, this is the first report describing robot‐assisted resection of both diaphragmatic and hepatorenal recess peritoneal endometriosis via a minimally invasive approach.

The authors have no conflicts of interest declare to declare.

Data S1