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

Cartilaginous part of a rib

Xyphoid process

Central lobe

Central tendon

Left lobe

Esophageal hiatus

Aortic hiatus

Left crus

Right lobe

Right crus

Foramen of the
caval vein

Lumbar quadrate
muscle

XII rib

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

Normal position

of

gastroesophage

al junction.

Protrusion of the

stomach

alongside the

esophagus.

Phrenoesophageal
membrane

Bending of
the parietal
peritoneum

Diaphragm

Diaphrag
m

Protrusion of the stomach
into a hernia sac

Part of the stomach localized within the
abdominal space

Esophagu
s

Cardia

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

Most common.
Gastroesophageal
junction above the
diapragm.

Esophagu
s

Protrusion of the
stomach into a hernia
sac

Phrenoesophageal
membrane

Cardia

Diaphragm

Bending of
the parietal
peritoneum

Part of the stomach localized within the
abdominal space

Phrenoesophage
al membrane

Bending of
the parietal
peritoneum

Diaphragm

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

1.

Medical treatment

2.

Surgical



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.