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    Add as FriendDiaphragmatic Hernia

    by: Dr Amarnath Reddy

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    1 : Diaphragmatic Hernia Apollo BGS Hospitals, Mysore Dr Amarnath Reddy Enja DNB General Surgery Resident Apollo BGS Hospitals Mysore
    2 : Diaphragm The diaphragm is a thin dome-shaped musculo membranous partition between thoracic and abdominal cavity. Chief respiratory muscle.
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    5 : Diaphragm No muscle in the human body, apart from the heart muscle, is more associated with life than the diaphragm. -Hugo Devlieger
    6 : Origin: sternal – xiphoid, aponeurosis of transversus Costal – 7th, 8th – cartilages 9th – cartilage & bony portions 11th, 12th - distal bony portions Lumbar – crura, arcuate ligaments Insertion: central tendon
    7 : Attachments
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    9 : Parts - Diaphragm
    10 : Embryogenesis Composite organ Septum transversum Pleuro-peritoneal membranes Dorsal mesentery Mesoderm of adjacent body walls - Mastery of surgery
    11 : Descent of diaphragm during development
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    15 : GEJ 1. Anatomist 2. Surgeon 3. Radiologist 4. Endoscopist
    16 : Blood supply Arterial Internal thoracic artery Musculo-phrenic Pericardio-phrenic Aorta Superior phrenic artery Inferior phrenic artery
    17 : Blood supply Venous Superior surface Musculo-phrenic vein internal thoracic Pericardio-nephric vein brachio-cephalic veins Posterior - Azygos, hemi-azygos Inferior surface Right inferior phrenic - IVC Left inferior phrenic – supra renal vein or IVC
    18 : Lymphatic drainage All nodes on superior surface 3 groups Anterior – para-sternal, mediastinal Middle - mediastinal Posterior – mediastinal, brachio-cephalic Nerve supply: Right & left phrenic nerves (C1 – C3) Peripheral portion – 7th to 12th intercostal nerves
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    21 : Diaphragmatic hernia Abnormal protrusion of abdominal viscera in to the thoracic cavity through a defect in the diaphragm. Male > female
    22 : Types Congenital Acquired Bochdalek hernia Morgagni hernia Central tendon hernia Eventeration Hiatal – sliding, paraesophageal Traumatic
    23 : Etiology Defect/ weakness in the diaphragm Congenital/ acquired
    24 : Traumatic -Penetrating – thorax/ abdomen -Blunt injury abdomen High index of suspicion Usually associated with poly-trauma Clinically Dyspnoea – progressive Lower thoracic pain Dullness, diminished BS
    25 : Investigations CXR – -Elevation/ irregularity of the diaphragm -extraneous shadows above the diaphragm -Hourglass sign USG abdomen/thorax Contrast CT if no contra indication
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    27 : Traumatic
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    29 : Treatment Do not heal spontaneously Semi-urgent – hemodynamically stable Laparotomy/thoracotomy Horizontal mattress sutures – non absorbable
    30 : Eventration Extreme elevation of the abnormally thin diaphragm Congenital -failure of muscularization -left side common, male preponderance - associated malrotation, inversion, lung collapse -moderate respiratory distress -medical management occasionally successful -Diaphragmatic plication -dependent on respirator > 5 days
    31 : Eventeration
    32 : Acquired eventration - secondary to damage or entrapment of phrenic nerve -asymptomatic – observation -respiratory distress - plication
    33 : Congenital hernias Bochdalek hernia 1 in 4400 live births Usually associated with anomalies – early fetal loss/still birth Left sided – 80% - 90% Right sided – 10% - 15% M:F = 1:1.36
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    35 : Bochdalek hernia
    36 : Clinically Dyspnoea scaphoid abdomen Barrel chest Right sided cardiac impulse Investigations Chest X-ray CT thorax/ abdomen
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    38 : Management Asymptomatic symptomatic -avoid mask ventilation -Intubation – mandatory, 30cmH2O, 60-120/min NG decompression Pulmonary hypoplasia prevents normal chest excursion.
    39 : Management IVF Correct acidosis – NaHCO3 0.5 – 2 meq/kg/hr Immediate operative reduction does not improve mortality rate Stabilization Predictors of survival -radiographic criteria -level of acidosis -arterial CO2 -ventilatory index (respi rate X mean airway pressure)
    40 : Surgical correction After stabilization Sub-costal incision Reduce hernia Local tissue repair if sufficient - 2 layer closure – preferred -non absorbable suture large defect - Prosthetic mesh - thin Gore-Tex - Muscular flaps can be used
    41 : Associated non rotation of the GI tract -left sided hernia -Ladd’s procedure – division of duodenal bands (to open small bowel mesentery) Post operative care Ventilator minimize the onset of pulmonary hypertension - alkalinizing agents – NaHCCO3, tolazoline Persistent pulmonary hypertension -High frequency jet ventilation - oscillatory ventilation
    42 : Medical therapy failure - extracorporial oxygenation indication Prolonged AaO2 gradient > 78 over 12 hr Oxygenation index >40 Evidence of severe barotrauma Future direction Intra uterine intervention -Intra thoracic stomach -poly hydromnias
    43 : Morgagni’s hernia Remnant of pericardio-peritoneal canal Retro-sternal space of Larrey Usually incidental Associated pentalogy of Cantrell epigastric omphalocele distal sternal cleft ectopia cardis VSD Surgical repair to avoid potential complication – gastric volvulus, incarcitarion
    44 : Hiatal hernia Hernia of a part of the stomach through the esophageal hiatus of the diaphragm. Types - Type I (sliding) - Type II (para-esophageal) -Type III (combined) Clinically Usually asymptomatic – 80%- Incidental 20% - symptomatic – related to esophageal reflux
    45 : Hiatal Hernia
    46 : Normal Sliding hiatal hernia Para esophageal Combined Congenital short esophagus
    47 : Paraesophageal -engorgement of entrapped gastric mucosa -chronic blood loss -fatigue malaise Treatment Asymptomatic – observation Symptomatic – esophageal reflux -antacids, H2 receptor antagonists -prokinetics -simethicone
    48 : Surgical repair -unsuccessful medical management -large paraesophageal hiatus hernia even asymptomatic -complicated -esophageal ulcer/ stricture/ stenosis -Barrets esophagitis Nissan fundoplication Belsey – Mark IV fundoplication Hill gastropexy Emergency – incarciration/ strangulation/ hemorrhage
    49 : Take home message Penetrating/ blunt trauma – chest / abdomen High index of suspicion for diaphragmatic hernia Unless otherwise proved
    50 : Hour glass sign
    51 : Reference
    52 : Thank You

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