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.