**8. Surgical treatment of catamenial pneumothorax**

Surgical treatment is the gold standard in treatment of catamenial pneumothorax, not only for its better results but less recurrences after treatment as well. Surgery has better results compared with medical treatment [1–20].

Korom et al. [7] reviewed 195 cases of CPX among 229 cases and reported that 154 cases (78%) were treated surgically. Among surgically treated patients, diaphragmatic repair (38%), pleurodesis (81%), and lung wedge resection (20%) were performed.

There is common consensus in the literature that the appropriate approach to CPX has to be minimally invasive so video-assisted thoracoscopic surgery (VATS) is the choice of treatment. VATS not only provides magnification but complete visualization of diaphragm as well [23].

Video-assisted thoracoscopic surgery (VATS) has been mainly in use since 2000 in the treatment of thoracic diseases with several advantages over conventional thoracotomy. Incision may be extended when extensive diaphragmatic repair is required, and also a muscle-sparing thoracotomy may offer better access in such cases. Thoracotomy may be an option especially in recurrent interventions or in reoperations [4–28, 30].

The lung examination for bullae, bleb, and air leakage is very important, but the diaphragm should also be carefully examined for fenestrations and spots or nodules. In addition, it is critical to examine the parietal pleura, lung, and pericardium in terms of spots and nodules.

Bagan et al. recommended the use of surgical treatment during menstruation. Thus, they stated that endometriotic lesions may be better visualized during menstrual period [22]. Slasky et al. used the pneumoperitoneum method to reveal unseen diaphragmatic fenestrations [42]. Identification of the lesions within the thorax is made easier by the magnification provided by VATS [4–28, 30]. The tissue samples from these lesions make it easy to diagnose thoracic endometriosis [10].

Resection of all visible lesions such as bullae or bleb and also resection of endometriosis-induced thoracic lesions have been recommended by Alifano et al. Limited wedge resection of the diseased lung tissue, limited parietal pleurectomy, and partial diaphragmatic resection were suggested surgical techniques for the elimination of intrathoracic lesions [4].

Excision and wedge resection of bullae and blebs [7, 12, 23, 30], along with pleurodesis or pleurectomy, has been mainly performed in the literature [7, 8, 12, 23, 30, 47]. Pleurodesis was found to be the most common intervention [29]. The majority of pleurodesis performed was mechanical pleurodesis (abrasion or pleurectomy), which has been found to be more successful in comparison to chemical pleurodesis [6].

Addressing the diaphragmatic pathology is of paramount importance. Diaphragmatic plication and/or resection of the diseased area have been reported [7, 12, 23, 24, 30, 49] (**Figure 1c** and **d**).

## *Pneumothorax*

Recurrence is the most common complication of CPX, and there are reported recurrence rates of 20–40% [4, 7, 41, 51]. Alifano et al. suggested that diaphragmatic resection with removal of endometrial implants is the preferred method compared to single diaphragmatic plication because plication has an disadvantage of leaving endometrial implants untreated [29, 38]. Still, recurrences may develop even after diaphragmatic resection [29].

Fewer recurrences after diaphragmatic coverage with a polyglactin mesh were reported by Bagan et al. To prevent recurrences, they suggested a systematic diaphragmatic covering, including the normal appearance of diaphragms, treating ocular defects, strengthening the diaphragm, and inducing adhesions to the lung [7].

There are also reports on diaphragmatic coverage with a polyglactin or polypropylene mesh [8], a polytetrafluoroethylene (PTFE) mesh [15], or a bovine pericardial patch [24], which has been reported with good mid-term results.
