Transcript Diaphragm
Diaphragm anatomy hernias treatment Anatomy of the diaphragm A dome-shaped anatomical structure consisting of a muscular and tendineous part Diaphragmatic attachments: posterior: the first, second and third lumbar vertebra anterior: the inferior part of the sternum lateral: the costal arch It separates abdominal and thoracic cavities from each other Anatomy of the diaphragm Xyphoid process Cartilaginous part of a rib Central lobe Central tendon Foramen of the caval vein Left lobe Right lobe Esophageal hiatus Right crus Aortic hiatus Left crus XII rib Lumbar quadrate muscle Diaphragmatic hernias Etiology Numerous hiatuses and foramina in the diaphragm Complex embryology Difference of pressure over and beneath the diaphragm Diaphragmatic hernias Classification General classification: congenital acquired posttraumatic Akerlund’s classification: caused by congenital short esophagus paraesophageal sliding Paraesophageal hernia Esophagus Normal position of gastroesophageal junction. Protrusion of the stomach alongside the esophagus. Protrusion of the stomach into a hernia sac Cardia Phrenoesophageal membrane Bending of the parietal peritoneum Diaphragm Diaphragm Part of the stomach localized within the abdominal space Paraesophageal hernia good function of the lower esophageal sphincter asymptomatic clinical course- frequently air eructation postprandial fulness Complications: bleeding incarceration acute dysphagia strangulation Treatment - surgical management Sliding hernia Esophagus Most common. Gastroesophageal junction above the diapragm. Cardia Bending of the parietal peritoneum Diaphragm Phrenoesophageal membrane Bending of the parietal peritoneum Protrusion of the stomach into a hernia sac Diaphragm Phrenoesophageal membrane Part of the stomach localized within the abdominal space Sliding hernia dysfunction of the lower esophageal sphincter heartburn frequently made worse when a patient lies down typical picture on x-ray examination decreased resting pressure of the lower esophageal sphincter Complications esophagitis esophageal strictures Sliding hernia Treatment Medical treatment Surgical 1. 2. Abdominal approach Chest approach Aims of surgical management: Reduction of hernia Closure of a hernial ring Reconstruction of the Hiss’s angle Congenital hernias Morgagni’s and Bochdalek’s hernia frequently asymptomatic diagnosed accidentally paroxysmal or constant epigastric pain respiratory and circulatory disturbances ileus Treatment- surgical management. Congenital hernias Morgagni’s and Bochdalek’s hernia Parasternal diaphragmatic hernia (Morgagni) Posterolateral diaphragmatic hernia (Bochdalek) Posttraumatic diaphragmatic hernia Traumatic rupture of the diaphragm may result from penetrating or blunt traumas Diaphragmatic rupture occurs usually within the central tendon more frequently on its left side Viscera can immediately translocate into the pleural space through the diaphragmatic rupture or their displacement may be gradual and it can last months or even years. Posttraumatic diaphragmatic hernia Clinical presentation of the hernia depends on the part and amount of viscera that displaced into the pleural space. We can observe: bleeding ileus Circulatory and respiratory failure Posttraumatic diaphragmatic hernia Surgical approach through the abdominal cavity is advocated if: recent trauma injuries of viscera are suspected or diagnosed. Surgical approach through the chest is advocated if diagnosis is substantially delayed and intra-abdominal injuries are excluded.