Classification of diaphragmatic hernia

Gabriel

There are two main types 1.congenital diaphragmatic herniasEventration Bochdalek hernia Morgagni hernia 2.AcquiredTraumatic diaphragmatic rupture hiatus herniaiatrogenic

CDHsBochdalek hernia: failure of

fusion of pleuroperitoneal canal leaving a direct communication between pleura and peritoneum on left side

Makes up about ninety percent of all cases.

Occurs in one out of every 2,200 to 5,000 live births.

Morgagni hernia makes up 2% of all cases.

The defect lies between the sternal and costal attachments of the diaphragm and is situated in front and towards right.

Bochdalek hernia - A Bochdalek hernia involves an opening on the left side of the diaphragm. The stomach and intestines usually move up into the chest cavity.

Morgagni hernia - A Morgagni hernia involves an opening on the right side of the diaphragm. The liver and intestines usually move up into the chest cavity.

Clinical features Bochdalek presents with acute

respiratory distress in neonatal period.

In adults most cases are asymptomatic, few present with digestive symptoms due to herniation of stomach or bowels.

Morgagni presents with pain and tenderness in the right subcostal region, intermittent obstructive symptoms.

ADHsTraumatic diaphragmatic ruptureBlunt or penetrating trauma to

the abdomen and chest.In most cases the rupture is on the left side of the diaphragm; tendinonous portion.

Hiatus herniaThe most common type of DHs. classification• Type I hiatus hernia – It is the cephalad displacement of the gastrooesophageal junction through the hiatus into the mediastinum. It is usually small, asymptomatic and reducible. It is commonest type• Type II hiatus hernia – It is superior migration of the fundus of the stomach along side the GE junction and oesophagus into the mediastinum with GE junction in normal intraabdominal location. It is rolling hernia• Type III hiatus hernia – It is combination of type I and type II• Type IV hiatus hernia – It is the hernia containing other abdominal viscera as content like transverse colon and omentum.

Types• Sliding hernia (85%).commonly associated with GORD.• Rolling hernia (10-12%). (paraesophageal)Combined

Clinical Features• Common in elderly.• Abdominal pain and chest pain.• Hiccough, early satiety.• Regurgitation, post prandial bloating.• Cardiac abnormality (arrhythmia).• Dysphagia dyspnoea.• 40% presents as acute features with perforation/gangrene/bleeding.

diagnosis• Plain X-ray - lateral and PA erect view showing retro cardiac air-fluid level.• Barium meal study very useful.• 3D CT scan is useful.

Post traumatic hernia; dilated bowel in left hemithorax.

CT-scan; collasped bowel loops with omentum within the left hemithorax

Displacement of the large intestine into the left hemithorax

Indicationn for surgeryCDH is not an emergency

situation.Gangrene of the stomachThreatening perforation into the

mediastinum or peritonuemPerforation Gastric volvolus

CDH/ADH is often treated with mini invasive thoracoscopy.

Excision of sac and repair of the defect.If it is gangrenous, gastrectomy is

required.Either abdominal or thoracic laparoscopyapproach can be used in treating rolling

hernia surgically.Mesh reinforcement to hiatus to close the

defect may be needed.