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Diaphragmatic Hernias

“Transference or displacement of abdominal viscera into the thoracic cavity through the diaphragm with their serosal layer”

True diaphragmatic hernias have hernial sac, hernial contents and overlapping layers. They usually are wrapped by peritoneum and parietal pleura. Diaphragmatic hernias have two main divisions:

I. Traumatic Diaphragmatic Hernias
II. Non-Traumatic Diaphragmatic Hernias
Here we have four types of hernias:

    1. False congenital defects of diaphragm: These are the congenetal defects between thoracic and abdominal cavity in the embryogenic period.
    2. True hernias of weak zones of diaphragm: these are:
                    a. Retrosternal or Costosternal hernias (Larry Morgan type)
                    b. Posterolateral or Costolumbar hernias (Bochdalek type)
    3. True Hernias of atypical location
    4. Hernias of Native Orifice in the diaphragm:are most commonly encountered one.
                    a. Sliding or Axial or Esophagogastric hernias
                    b. Rolling or Paraesophageal hernias
Clinical Features:
Clinical features unite the science of:
  1. Gastroabdominal signs
  2. Cardiopulmonal signs
  3. Common signs
Pain is the prominent sign and some cases nausea and vomiting occurs
In gastric axial strangulation Paradoxical Dysphagia occurs, which can be illustrated as “when the hard food passes through the oesophageal gastric junction, there is no evidence of passing liquids through the cardiac region after on”.

Acute pain occurs in the epigastric and thoracic region, which radiates to the scapular region and back. It is also a characteristic sign of incarceration.

Special Investigations:
If hollow organ occurs in the thoracic cavity, percussion reveals characteristic tympanic sound.

X-Ray with barium enema is a method of choice. If the horizontal level of barium occurs in the thoracic cavity, it indicates gastric dislocation.

Surgical Treatment:
In case of dextrapositional diaphragmatic hernia, right intercostal incision in the fourth intercostal space should be applied. In case of left sided diaphragmatic hernias, left intercostal incision should in the seventh intercostal space is done.

The herniated organs should be turned back into the abdominal cavity and after the hernial sac removal; plastic of diaphragm should be performed with naked duplicature. The latter should be sutured with donates type of stitches.

Sliding Hernias

When the cardia of the ventricle slides from its place through its longitudinal axis into the thoracic cavity the sliding or axial hernias occur. Types of sliding hernias are:
  • Oesophageal
  • Cardial
  • Cardiofundal
  • Subtotal and
  • Total
In addition, congenital or acquired oesophageal shortening should be considered as sliding hernias.

Etiology:
  • Tractional
  • Via pulling
  • Mixed mechanism
Clinical Features:
are defined by:
  • Cardial insufficiency
  • Gastroesophageal reflux disease
  • Peptic esophagitis
  • Pain is prominent sign aggravated in the supine position
Due to Gastroesophageal reflux, pH in oesophagus increases up to 4. Later peptic esophagitis leads to peptic strictures of the oesophagus and concomitant Dysphagia occurs. Peptic erosions and ulcers are causes for occult bleeding.

Paraoesophageal Hernias

Here cardiac part of ventricles remains at its normal position below the diaphragm and the other parts of ventricle and other organs can be transpositioned into thoracic cavity i.e. paraoesophageal hernias should be defined as:
  • Fundal
  • Antral
  • Intestinal
  • Gastrointestinal and
  • Omental
There is no evidence of gatrooesophageal reflux but incarceration occurs. Relaxation of diaphragm should be defined as the weakening of muscular fibrotic fibres of the diaphragm, which leads to the organ translocation from the abdomen into the thoracic cage. Relaxation of the diaphragm can be congenital or acquired and can also be total or partial. Thus it has the same signs as diaphragmatic hernias do.

Treatment:
Plasty of Diaphragm the treatment of choice.

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This article has been written by Dr. M. Javed Abbas.
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21:06 21/12/2002