Catamenial Pneumothorax: Robotic-Assisted Surgical Treatment

Catamenial pneumothorax (CP) is defined as a spontaneous pneumothorax occurring in women of reproductive age during the perimenstrual period. This period generally includes the day before to three days after the onset of menstruation, with some authors extending this time frame until 5-7 days after. Catamenial pneumothorax is the most frequent manifestation of thoracic endometriosis, which is defined as the presence of ectopic endometrial glands and/or stroma outside the uterus. Endometriosis can cause small holes or openings (fenestrations) in the diaphragm, which can allow air and fluid to pass through into the pleural space. 

As evidence of this disease mostly relies on surgical exploration, minimally invasive approaches in particular, diagnostic and therapeutic procedures are often combined. Complete intrathoracic exploration should be performed, including visualization of the parietal and visceral pleura, the lung, and above all, the diaphragm. Diaphragmatic lesions are frequently observed in series of patients treated minimally invasively with thoracoscopy, allowing the magnification of lesions presenting as small brown, red, purple, or violet nodules and/or subsequent perforations, usually surrounding the central tendon of diaphragm. An appropriate parenchymal inspection is also recommended for the diagnosis and treatment effectiveness, to rule out potential endometrial implants, or to assess the presence of other lung defects which could have caused the pneumothorax.

Case Report

A 44-year-old patient with a previous medical history of endometriosis, who during the last year presented with four episodes of right apical spontaneous pneumothorax 72 hours after menstruation that was associated with intense pleuritic pain, required right pleural drainage. On chest computed tomography (CT), no significant alterations or pathological findings were observed. Due to reiterative symptoms and radiological findings, robot-assisted thoracoscopic surgery was decided.

Surgical Technique

The patient was placed in the lateral decubitus position and single-lung ventilation was achieved via a double-lumen endotracheal tube. The da Vinci system Xi (4-arm robot) was draped and docked from the side of the patient’s head, and three robotic ports and one assistance port were placed. Carbon dioxide was insufflated through the assistance port.

The pleural cavity was explored, and a small apical bullous complex was found. When inspecting the diaphragm, multiple subcentimeter violet lesions were observed, suggestive of diaphragmatic fenestrations and endometriosis. A mechanical endostapler was introduced through the assistance port and wedge resection of apical bullae was performed. The robotic forceps were then used to elevate the central tendon of the diaphragm where the fenestrations were found. The mechanical endostapler was again introduced through the assistance port, and partial diaphragm resection was performed and sent for pathological analysis. Mechanical pleural abrasion was performed. One pleural drainage tube was introduced, and complete pulmonary expansion was confirmed.

The immediate postoperative chest X-ray showed an expanded lung. The pleural drainage tube was removed 24 hours after surgery, and the patient was discharged on the third postoperative day. The pathological analysis reported multiple diaphragmatic foci of endometriosis, of sizes between 1 and 2 mm, with immunohistochemistry demonstrating estrogen receptors and CD10 positive tissue. The chest X-ray at two weeks showed a well-expanded lung and the patient has not experienced a recurrence.

References

1. Visouli AN, Zarogoulidis K, Kougioumtzi I, Huang H, Li Q, Dryllis G, et al. Catamenial pneumothorax. J Thorac Dis. 2014;6(Suppl 4):S448-S460.
2. Peikert T, Gillespie DJ, Cassivi SD. Catamenial pneumothorax. Mayo Clin Proc. 2005;80(5):677–680.
3. Tulandi T, Sirois C, Sabban H, Cohen A, Murji A, Singh SS, et al. Relationship between catamenial pneumothorax or non-catamenial pneumothorax and endometriosis. J Minim Invasive Gynecol. 2018;25(3):480-483.