Unexpected coexistence of diaphragmatic and abdominal wall endometriosis in a case of bilateral ovarian endometriomas: a case report

Introduction: Extra-pelvic endometriosis is a rare and complex condition characterized by endometriotic implants located outside the pelvis. It commonly poses significant diagnostic challenges and considerable surgical management difficulties. Case presentation: A 32 year-old primiparous woman presented with severe abdominal pain, deep dyspareunia and right-sided shoulder pain. Laparoscopic excision of deep infiltrating endometriosis on the anterior abdominal wall, under the ovaries and uterosacral ligaments was completely performed as well as pre-vesical shaving and ovarian cystectomy. However, resection of diaphragmatic endometriotic lesion was not performed due to multiple limitations, the procedure was conducted in a gynecology clinic without a multidisciplinary team, including thoracic surgeons and the lack of specialized equipment. The patient received hormone therapy for 5 months, including 2 GnRH agonist injections followed by 3 months of dienogest 2 mg. Abdominal pain resolved completely, however, right-sided shoulder pain became mild and tolerable.

This case emphasizes the diagnostic and surgical challenges of extra-pelvic endometriosis and highlights the need of a multidisciplinary and individualized approach.

Endometriosis is a benign disorder characterized by abnormal growth of endometrial tissue outside the uterus (1). It affects approximately 190 millions of reproductive age women globally (2). Debilitating symptoms comprise dysmenorrhea, dyspareunia, and infertility (3). While endometriosis frequently affects pelvis, it can rarely occur in extra-pelvic sites, which makes it a complex condition, difficult to diagnose and to treat (4). Extra-pelvic endometriosis refers to a rare type of endometriosis, which occurs in distant sites from gynecological organs (5). Despite its rarity, extra-pelvic endometriosis can involve clinically significant sites such as abdominal wall, diaphragm, gastrointestinal tract, and brain (5, 6). In this paper, we present a case of a patient with severe abdominal pain, deep dyspareunia, and right-sided shoulder pain. Laparoscopic exploration revealed, in addition to pelvic endometriosis, both diaphragmatic and abdominal wall endometriosis (AWE). Through this case, we also aim to highlight diagnostic and surgical challenges associated with extra-pelvic endometriosis. Case presentation History On November 11, 2024, a 32 year-old primiparous woman with an ongoing illness, sought medical attention after being seen by many physicians for incapacitating abdominal pain related to menstruation. The patient was married for 8 years and had 1 live birth from a spontaneous pregnancy, delivered by cesarean section 6 years ago. Menarche was at 15 years of age, with regular menstrual cycles every 28–30 days and a duration of 3 to 5 days. She had no personal history of endometriosis as well as no documented relevant family history of endometriosis or other diseases. Her chief complains were dysmenorrhea, with abdominal pain was reported with a maximum intensity of 10 out of 10 on the Numerical Rating Scale (NRS), coupled with deep dyspareunia, and vaginismus, as well as right-sided shoulder pain. During gynecological examination, Vaginal speculum examination and bimanual palpation were extremely painful, to the point of being nearly impossible. Transvaginal ultrasound exam was also very limited by patient pain, showing two cystic ovaries in a kissing ovaries configuration, with the obliteration of the pouch of Douglas by adhesions. Laboratory tests performed on the third day of menstrual cycle are summarized in Table 1. Table 1 | Follicle-stimulating hormone (FSH) mUI/ml | Luteinizing hormone (LH) mUI/ml | Estradiol (E2) pg/ml | Prolactin (PRL) ng/ml | Anti-Mullerian hormone (AMH) ng/ml | Cancer antigen 125 (CA125) U/ml | |---|---|---|---|---|---| | 28 | 8 | 40,87 | 10 | 0,16 | 50 | Laboratory tests conducted on the third day of menstrual cycle. Pelvic Magnetic Resonance Imaging (MRI) for endometriosis mapping revealed bilateral ovarian endometriomas, with 46 mm right endometrioma, and 34 mm left endometrioma. It also showed features suggestive of deep infiltrating endometriosis, including thickening of the torus uterinus and uterosacral ligaments. The patient’s detailed clinical course is summarized in Figure 1. Figure 1 Intraoperative findings Under general anesthesia, hysteroscopic examination identified cervical stenosis, which was carefully dilated using the hysteroscope tip. An endometrial biopsy was then obtained for histopathological evaluation. Video-assisted laparoscopy revealed a uterus enveloped by the vesico-parietal fold, with multiple adhesions. The uterovesical pouch showed florid endometriosis. A frozen pelvis was observed with kissing ovaries adherent to the posterior surface of an inflamed uterus (Figure 2). Ovarian endometriotic cysts were evacuated, followed by bilateral ovarian cystectomy by blunt mechanical dissection, carefully preserving the surrounding ovarian tissue. The excision of deep infiltrating endometriosis of the anterior abdominal wall was successfully performed. Careful dissection of the left and right pararectal spaces, and deep infiltrating endometriotic nodules involving the uterosacral ligaments and the torus uterinus were excised, followed by pre-vesical shaving. Unexpectedly, a diaphragmatic lesion was identified in the supra-hepatic region (Figure 3). Figure 2 Figure 3 Histo-pathology Histopathology confirmed a deep infiltrating wall, pre-vesical, uterosacral ligaments and ovarian endometriosis, with absence of features suggestive of malignancy (Figure 4). Figure 4 Postoperative management and outcomes Postoperative management consisted of hormone therapy for 5 months, including 2 injections of GnRH agonist followed by 3 months of dienogest. After 12 months follow-up her abdominal pain has markedly improved, as she was no longer experiencing any pain. Nevertheless, right-sided shoulder pain became mild and tolerable. The patient opted for conservative management of diaphragmatic endometriosis, as long as the pain remains asymptomatic and does not impact her quality of life, allowing her to continue her normal daily activities.

In the present case, diaphragmatic and AWE were identified intraoperatively, while surgery was planned for pelvic deep infiltrating endometriosis, highlighting limitations of preoperative assessment. In contrast to previously reported cases, diaphragmatic lesion excision was not performed, however, parietal lesions were successfully resected. This decision was carefully guided by intraoperative assessment and the absence of dedicated thoracic expertise and specific equipment, reflecting a wise and individualized surgical strategy. It also underscores the effectiveness of hormone therapy in managing diaphragmatic endometriosis. Diaphragmatic endometriosis is often misdiagnosed and can be overlooked in differential diagnosis due to its low prevalence ranging from 0.67 to 4.7%, and non-specific clinical manifestations (4, 7). Even usually asymptomatic, diaphragmatic endometriosis can be associated with non-specific pain localized in the thorax, shoulder, or periscapular region (4). Previously reported cases of diaphragmatic endometriosis predominantly describe right-sided referred pain involving shoulder, back and chest (8). It may also present as isolated right hypochondrial pain without other associated symptoms leading to misdiagnosis as cholelithiasis (9). This aligns with our case, where the patient reported right-sided shoulder pain without any accompanying respiratory symptoms. Furthermore, non-specific symptoms explain why diaphragmatic endometriosis was missed and overlooked in favor of cholelithiasis in our case. While diaphragmatic endometriosis pathogenesis remains unclear, the prevailing theory, called retrograde menstruation, suggests that viable endometrial cells are transported through the clockwise flow of peritoneal fluid from the left pelvis to the right diaphragm, allowing their implantation (5, 7). In our case, surgical resection of diaphragmatic endometriosis was not performed as the lesion was discovered accidentally during surgery and thoracic intervention was not planned initially, surgical intervention was done in a gynecology clinic with absence of thoracic surgeon at the clinic and non-availability of specialized equipment. Intraoperative assessment revealed a small diaphragmatic lesion with no definite signs of deep invasion. However, extent of the lesion could not be fully assessed due to the absence of thoracic MRI. The surgeon elected not to treat the lesion using bipolar electrocoagulation, as this technique is not universally recommended and may be associated with potential risks and complications. This decision is consistent with recommendations in the literature emphasizing caution with thermal energy on the diaphragm, supported by a reported case of phrenic nerve paralysis following bipolar electrocoagulation for diaphragmatic endometriosis (10). Management of superficial diaphragmatic endometriosis includes hydro-dissection followed by excision or CO2 laser vaporization and cauterization using bipolar cautery (11). CO2 laser is preferred for its precision, limited tissue penetration and minimal thermal injury, reducing the risk of local ischemia and tissue necrosis. Moreover, it allows access to difficult areas (11). However, surgery is not required in asymptomatic patients (12). Transabdominal robotic-assisted resection of the diaphragmatic lesions has shown good clinical outcomes, with symptom relief in about 80% of patients at 3 months (13). The unusual sites and manifestations of endometriotic lesions make the management challenging for gynecologic surgeons. In agreement with this, it has been documented that diaphragmatic endometriosis present several challenges making its management difficult. First of all, the diaphragm is a complex muscle with unique anatomy, notably the right hemidiaphragm is shielded from direct view by the right hepatic lobe making lesions difficult to detect and requiring liver mobilization (14, 15). A further drawback is the lack of a standardized surgical technique, and no consensus has been reached yet regarding the most effective surgical approach, whether abdominal, thoracic, or a combined modality (4). Patient positioning remains a subject of debate and represents a critical aspect of diaphragmatic endometriosis (4). Regarding AWE, also known as parietal endometriosis, most reported cases were associated with gynecologic or obstetric surgery, notably caesarean section (16, 17). Consistent with this, our patient had a history of cesarean section performed 6 years prior to the diagnosis of AWE. However, rare cases have also been described in women with no previous abdominal surgery (18). The most widely accepted mechanism is iatrogenic implantation of endometrial cells during caesarean section, due to extensive tissue manipulation providing a highly vascularized environment (19). Another proposed mechanism involves lympho-vascular dissemination, especially in deep infiltrating pelvic endometriosis (20). Thus, several intraoperative strategies have been suggested to minimize the risk of endometrial cell implantation in the abdominal wall during gynecologic and obstetric surgeries. Among these, the use of wound protectors or retractors during cesarean section may be beneficial, as caesarean section is considered the principal risk factor for AWE (21). It should also be considered during segmental bowel resection to reduce surgical site infections and prevent abdominal wall endometriotic cell contamination. In laparoscopic endometriosis surgery, the use of an endobag for specimen retrieval is recommended (21). For procedures involving both uterine and abdominal wall suturing, a new needle and suture should be used for abdominal closure to reduce the risk of iatrogenic endometrial implantation (21).

Extra-pelvic endometriosis remains a challenging condition requires a comprehensive and personalized approach to diagnosis, treatment, and management. Diaphragmatic endometriosis should be suspected when a woman of reproductive age reports symptoms such as chest or shoulder pain. Asymptomatic diaphragmatic endometriosis is more difficult to diagnose and requires prolonged monitoring and potential surgical intervention. In the other hand, when a woman with a history of gynecologic or obstetric surgery reports cyclic abdominal scar pain, clinicians should strongly suspect AWE to ensure timely diagnosis and treatment. Statements Data availability statement The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author. Ethics statement The studies involving humans were approved by the Biomedical Research Ethics Committee of UM6SS. The studies were conducted in accordance with the local legislation and institutional requirements. The human samples used in this study were acquired from a by- product of routine care or industry. Written informed consent was obtained from the participant/patient(s) for the publication of this case report. Author contributions HE: Formal analysis, Writing – original draft, Software, Methodology, Conceptualization, Data curation, Investigation, Validation. MZ: Methodology, Writing – review & editing, Data curation, Investigation. FE: Formal analysis, Data curation, Writing – review & editing. NL: Formal analysis, Writing – review & editing, Investigation. BG: Investigation, Validation, Supervision, Conceptualization, Writing – review & editing, Project administration. Funding The author(s) declared that financial support was not received for this work and/or its publication. Conflict of interest The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Generative AI statement The author(s) declared that Generative AI was not used in the creation of this manuscript. Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us. Publisher’s note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Abbreviations AMH, Anti-Mullerian hormone; AWE, Abdominal Wall Endometriosis; CA125, Cancer Antigen 125; FSH, Follicle-Stimulating Hormone; GnRH, Gonadotropin-Releasing Hormone; LH, Luteinizing hormone; MRI, Magnetic Resonance Imaging; NRS, Numerical Rating Scale; PRL, Prolactin.

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extra-pelvic endometriosis, diaphragmatic endometriosis, abdominal wall endometriosis, laparoscopy, case report Citation Erraji H, Zarqaoui M, El Mansouri F, Louanjli N and Ghazi B (2026) Unexpected coexistence of diaphragmatic and abdominal wall endometriosis in a case of bilateral ovarian endometriomas: a case report. Front. Med. 13:1839110. doi: 10.3389/fmed.2026.1839110 Received 25 March 2026 Revised 11 June 2026 Accepted 22 June 2026 Published 23 July 2026 Volume 13 - 2026 Edited by Zheng Liu, Guilin Medical University, China Updates Copyright © 2026 Erraji, Zarqaoui, El Mansouri, Louanjli and Ghazi. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. *Correspondence: Bouchra Ghazi, [email protected] Disclaimer All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.