Diaphragm disordersDiaphragm disordersBy:Dr seyed Mostafa ShiryazdiBy:Dr seyed Mostafa Shiryazdi

Associate professor of surgeryAssociate professor of surgery

Clinical AnatomyClinical Anatomy

-musculotendinous membrane-musculotendinous membrane -central:tendinous-central:tendinous -peripheral:muscular-peripheral:muscular

HIATUSHIATUS

-Aorta:T12 azygus vein-thoracic -Aorta:T12 azygus vein-thoracic ductduct

-Esophagus:T10 vagus nerves-Esophagus:T10 vagus nerves -IVC:T8 -IVC:T8

BLOOD SUPPLYBLOOD SUPPLY

-abdominal aorta:RPA-LPA-abdominal aorta:RPA-LPA -thoracic aorta:SPA-thoracic aorta:SPA -internal mamary artery-internal mamary artery

VENOUS DRAINAGEVENOUS DRAINAGE

-left phrenic vein-left phrenic vein -right phrenic vein-right phrenic vein

-Both drain to IVC-Both drain to IVC

INNERVATIONINNERVATION

-Right phrenic nerve:motor -Right phrenic nerve:motor innervationinnervation

-Left phrenic vein:motor innervation-Left phrenic vein:motor innervation

-Intercostal nerve:sensory -Intercostal nerve:sensory innervationinnervation

Diaphragm develops between the 4Diaphragm develops between the 4thth and 8and 8thth weeks of gestation weeks of gestation

Failure closure of the pericardio Failure closure of the pericardio peritoneal canal cause CDH(bochdalek peritoneal canal cause CDH(bochdalek

hernia)hernia)

The crura develop from The crura develop from the mesentery of the mesentery of

esophagusesophagus

Higher position of Higher position of diaphragmdiaphragm

LIVER in rightLIVER in right

HEART in leftHEART in left

Diaphragm developsDiaphragm developsTransverse septumTransverse septum

Pleuroperitoneal membranePleuroperitoneal membraneDorsal and lateral body wallDorsal and lateral body wall

Mesentery of esophagusMesentery of esophagus

CONGENITAL DIAPHRAGMATIC CONGENITAL DIAPHRAGMATIC HERNIAHERNIA

_BOCHDALEK HERNIA_BOCHDALEK HERNIA -MORGAGNI HERNIA-MORGAGNI HERNIA -ESOPHAGEAL HIATAL HERNIA-ESOPHAGEAL HIATAL HERNIA

BOCHDALEK HERNIABOCHDALEK HERNIA

Male:female 2/1Male:female 2/1 Left sided 90%Left sided 90% Right sided 10%Right sided 10%

Clinical FindingClinical Finding

Rsepiratory dystressRsepiratory dystress Absence of breath soundsAbsence of breath sounds Bowel sound in chestBowel sound in chest Scaphoid abdomenScaphoid abdomen

Bochdalek hernia occurs in Bochdalek hernia occurs in 1:4000-5000 live birth1:4000-5000 live birth

Morgagni hernia occurs <2% of all Morgagni hernia occurs <2% of all diaphragmatic herniadiaphragmatic hernia

Usually CDH discovered Usually CDH discovered prenataly on routine prenataly on routine

ultrasoundultrasound

After birthAfter birth

CXRCXR BARIUM SWALLOWBARIUM SWALLOW

Long term problems in CDHLong term problems in CDH

Gastroesophageal refluxGastroesophageal reflux Chronic lung diseaseChronic lung disease Hearing lossHearing loss Pectus excavatumPectus excavatum seizureseizure

Contained sac in Contained sac in morgagnimorgagni

OmentumOmentumColonColon

StomachStomachLiverLiver

Small intestineSmall intestine

treatmenttreatment

Nasogastric tubeNasogastric tube Fluid and electrolyteFluid and electrolyte PEEP or ECMOPEEP or ECMO surgerysurgery

Right Right side:thoracotomyside:thoracotomy

Left side:laparotomyLeft side:laparotomy

Mortality 30-50% in Mortality 30-50% in 24 hours24 hours

MORGAGNI HERNIAMORGAGNI HERNIA

Larrey hernia or retrosternalLarrey hernia or retrosternal Rarely symptomaticRarely symptomatic Symptomatic after 40 yearsSymptomatic after 40 years

HIATAL HERNIAHIATAL HERNIA

SlidingSliding ParaesophagealParaesophageal mixedmixed

GERGER

MedicalMedical SurgicalSurgical

FTT-repeated respiratory infection-FTT-repeated respiratory infection-anemia-recurrentanemia-recurrent

Diaphragm tumorsDiaphragm tumors

Primary(rare):fibrosarcoma-hydatid Primary(rare):fibrosarcoma-hydatid cyst-TBcyst-TB

secondarysecondary

Eventration of diaphragmEventration of diaphragm

Congenital(non paralysed)Congenital(non paralysed)

Acquired(paralysed)Acquired(paralysed)

Trauma to diaphragmTrauma to diaphragm

90% left sided90% left sided

Early diagnosis:laparotomyEarly diagnosis:laparotomy

Late diagnosis:thoracotomyLate diagnosis:thoracotomy