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

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