Diaphragmatic hernia By Dr Khaled M Abdel Aal

Diaphragmatic hernia By Dr. Khaled M. Abdel Aal MD Cardiothoracic surgery Sohag University

Definition • Diaphragmatic hernia is a defect or hole in the diaphragm that allows the abdominal contents to move into the chest cavity.

Anatomy of the diaphragm

Anatomy of the diaphragm • The diaphragm is a dome-shaped musculofibrous septum. • separates the thoracic from the abdominal cavity • Its peripheral part is muscular and • converge to be inserted into a central tendon.

Anatomy of the diaphragm • The muscular fibers may be grouped according to their origins into three parts: • Sternal: two muscular slips from the back of the xiphoid process. • Costal: the inner surfaces of the cartilages and adjacent portions of the lower six ribs. • lumbaraponeurotic arches: named the lumbosacral arches, and • Lumber vertebrae by two pillars or crura.

Anatomy of the diaphragm

Anatomy of the diaphragm

Anatomy of the diaphragm

Anatomy of the diaphragm

Anatomy of the diaphragm Nerve supply: --phrenic nerve. --lower 5 ICNs &subcostal nerve. Blood supply.

opening level Caval opening T 8 structures inferior vena cava , and some branches of the right phrenic nerve Oesophageal hiatus T 10 esophagus , the anterior and posterior vagal trunks, and some small esophageal arteries Aortic hiatus T 12 the aorta , the azygos vein , and the thoracic duct two lesser aperture of right crus greater and lesser right splanchnic nerves three lesser aperture of left crus greater and lesser left splanchnic nerves and the hemiazygos vein behind the diaphragm, under the medial lumbocostal arches Synpathetic trunk

Definition • Diaphragmatic hernia is a defect or hole in the diaphragm that allows the abdominal contents to move into the chest cavity.

types 1. Congenital diaphragmatic hernia: --bochdalek hernia --morgagni‘s hernia 2. Hiatal hernia 3. aquired diaphragmatic hernia: either iatrogenic or traumatic 4. Diaphragmatic eventration

I. Congenital diaphragmatic hernia (CDH) • CDH is a term applied to a variety of congenital birth defects that involve abnormal development of the diaphragm. • The term is used most commonly in reference to Bochdalek hernia. • however it can also apply to: 1. Morgagni's hernia 2. Diaphragm Eventration and 3. Central tendon defects of the diaphragm.

Bochdalek hernia • Called a postero-lateral diaphragmatic hernia. • The most common of CDH (95% ). • characterized by a hole in the postero-lateral corner of the diaphragm which allows passage of the abdominal viscera into the chest cavity. • The majority (80 -85%) occur on the left side of the diaphragm.

Pathophysiology • It involves three major defects: 1. A failure of the diaphragm to completely close during development. 2. herniation of the abdominal contents into the chest. 3. pulmonary hypoplasia.

Presentation • Infants born with diaphragmatic hernia experience respiratory distress and failure due to both : pulmonary hypertension and pulmonary hypoplasia.

Diagnosis • This condition can often be diagnosed before birth (u/s). • X- ray chest • CT chest • Contrast study of the GIT

Treatment • It should be noted that: 1. CDH is considered a medical emergency not a surgical emergency 2. Optimization of the baby condition is very important before surgery 3. ECMO may be used for patient stabilization

Treatment • Technique: 1. Reduction of the hernial contents 2. Excision of the sac if present 3. Surgical closure of the defect either primarily or by a mesh

II. Morgagni's hernia • This rare anterior defect of the diaphragm. • About 2% of all CDH cases. • Other names: retrosternal H. . parasternal H. .

Morgagni's hernia • Herniation through the foramina of Morgagni which are located immediately adjacent to the xiphoid process of the sternum. • The majority of hernias occur on the right side of the body

Morgagni's hernia • C/P: • are generally asymptomatic; • However newborns may present with respiratory distress at birth similar to Bochdalek hernia. • recurrent chest infections and gastrointestinal symptoms have been reported.

• Diagnosis: 1. X- ray 2. CT chest 3. Contrast study • Treament: Surgical closure even in asymptomatic cases as there Is a possibility for gangrene in the herniated bowel

III. Diaphragm eventration • The diagnosis of congenital diaphragmatic eventration is used when there is abnormal displacement (i. e. elevation) of part or all of an otherwise intact diaphragm into the chest cavity. • This rare type of CDH occurs because in the region of eventration the diaphragm is thinner, allowing the abdominal viscera to protrude upwards.

• This thinning is thought to occur a. congenitally: because of incomplete muscularisation of the diaphragm, and can be found unilaterally or bilaterally b. aquired : in cases of phrenic nerve paralysis

Clinical picture • Minor forms of diaphragm eventration are asymptomatic. • however in severe cases infants will present with respiratory distress similar to Bochdalek hernia.

Treatment • Diaphragm eventration is typically repaired by a technique called plication of the diaphragm. • Plication basically involves folding of the eventrated diaphragm which is then sutured in order to “take up the slack” of the excess diaphragm tissue.

IV. Other diaphragmatic hernias • Traumatic diaphragmatic hernia • Hiatal hernia

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