SURGERY OF THE DIAPHRAGM Professor Karam Mosallam Introduction

SURGERY OF THE DIAPHRAGM Professor : Karam Mosallam

Introduction Anatomy of Diaphragm: -Fibromuscular. -Normal anatomical openings. - Blood sypply & Innervation.

Definition a A diaphragmatic hernia is defined as an abnormal communication between the abdominal and thoracic caviti with or without abdominal contents. b. A Diaphragmatic eventration is abnormal elevation of th diaphragm due to paralysis or weakness of muscles of the diaphragm.

Types&Etiology 1 -Congenital: * Morgagni(anterior or retrosternal). * Buchdalek(posteriolateral). 2 -Traumatic: *Accidental trauma. *Iatrogenic. . during surgery. 3 - Hiatus Hernia

Congenital Diaphragmatic Hernia • • • Epidemiology; 1/200 -1/5000 live births. M: F- 1: 2. Left side more common (85%). Usually associated with other anomalies. Usually sporadic may be familial.

Symptoms &Signs • • • Respiratory Distress. Scaphoid Abdomin. Increased Chest wall diameter. Bowel sounds heared in the chest. Decreased or absent breath sounds on side of hernia. • Contralateral shift of the heart and mediastinum.

Delayed presentation May be: Regurgitation, vomiting, intestinal obstruction Rarely shock and sepsis due to hernial incarcination.

DIAGNOSIS Prenatal ultrasound; can diagnose many cases. After delivery: Chest X ray may need insertion of nasogastric tube. Gatrografin or barium studies. CT&Echocardiography may be needed in some cases.

Prognosis Overall survival 67%. Intrauterine fetal death around 8%. Poor prognosis if symptoms appear at the first 24 hours. Severe pulmonary hyperplasia. Need for ECMO. . poor prognosis.

Prognostic imaging features • Lung to head ratio. . LHR. If LHR less than 1. . poor prognosis. If LHR 1 -4. . improved prognosis. • Liver in thorax. . poor prognosis.

Differential diagnosis • Diaphragmatic eventration. • Brochogenic cyst. • Cystic lung diseases: cystic adenoid malformation & Pulmonary sequestration. • Tumors ; Neurogenic&sarcoma

Treatment • Initial management: Aggressive respiratory care. Nasogastric tube &urinary catheter. • Ventilatory support may be needed in some patients; - Conventional mechanical ventilation. -ECMO (Extracorporeal membane oxygenation). • Nitric oxide inhalation(selective pulmonary vasodilator).

SURGERY Usually after 48 hours after stabilization of respiratory Distress and improvement of pulmonary hypertension. • Reduction of the content of hernia and closure of the defect either direct if a small defect or by use of a patch( native tissue or synthetic patch.

Surgical approach • Subcostal; most common. Rerely thoracotomy. • Laparoscopic • Thoracoscopic

Complications • • • GERD in 50% Recurrence. Intestinal obstruction. Delayed growth. Pectus excavatum. Scoliosis.