Diaphragmatic endometriosis: a practical radiologic guide to diagnosis, mapping, and multidisciplinary surgical...

Diaphragmatic endometriosis (DiaE) is a frequently underdiagnosed manifestation of deep endometriosis (DE), typically occurring in patients with advanced pelvic disease. Accurate preoperative detection remains challenging, as standard laparoscopy may overlook posterior diaphragmatic lesions due to their subhepatic location. In this context, magnetic resonance imaging (MRI) plays a central role by enabling lesion detection, precise mapping, and comprehensive assessment of disease extent. This review synthesizes diaphragmatic anatomy, pathophysiology, and clinical presentation, delivering a practical framework for MRI evaluation. We propose an abbreviated diaphragm-focused MRI protocol, acquired within an abdominal field of view in conjunction with standard pelvic MRI. This combined approach emphasizes high-resolution fat-suppressed T1-weighted sequences to detect hemorrhagic lesions, alongside a systematic evaluation of non-hemorrhagic features on fat-suppressed T2-weighted images, allowing simultaneous assessment of the pelvis and abdominal extrapelvic sites. Finally, we provide a structured reporting template designed to improve radiologist-surgeon communication. Combining a targeted imaging protocol with standardized anatomic reporting enhances preoperative planning, reduces intraoperative uncertainty, and facilitates complete disease excision, potentially reducing the need for repeat surgical interventions. The proposed abbreviated diaphragm-focused MRI protocol and structured reporting template represent the central practical contributions of this review.