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DIAPHRAGMATIC HERNIAS

“Transference or displacement of abdominal viscera into the thoracic cavity through the diaphragm with their serous layer”
True diaphragmatic hernias have hernial sac, hernial contents and overlapping layers, usually are wrapped by peritoneum and parietal pleura. Diaphragmatic hernias have two main divisions.

  • Traumatic diaphragmatic hernias
  • Non-traumatic diaphragmatic hernias
    These include:
    • False congenital defects of hernias
    • True hernias of weak zones of diaphragm
    • True hernias of atypical locations
    • Hernias of the native orifices in diaphragm
  • False congenital defects of hernias
    These are the congenital defects between thoracic and abdominal cavity in the emryogenic period.
  • True hernias of weak zones of diaphragm
    These are:
    • Retrosternal/Costosternal hernias (Larry Morgan Type)
    • Posterolateral/Costolumbar hernias (Bochdalek Type)
  • Hernias of the native orifices in diaphragm
    These are most commonly encountered type of diaphragmatic hernias:
    • Sliding/Axial/esophagogastric hernias
    • Rolling/paraesophageal hernias
Clinical Features:
Clinical features unite the science of:
  • Gastroabdominal
  • Cardiopulmonal
  • Common signs
Pain is the prominent sign, in 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”.

Acute pain in the epigastrium and thoracic region radiating to scapular region and back is characteristic sign for incarceration. If hollow organ occurs in the thoracic cavity, percussion reveals characteristic tympanic sounds.

Special investigations:
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 hernias, right intercostals incisions in the fourth intercostals space should be applied. In case of left sided diaphragmatic hernias, left intercostals incision in seventh intercostal space is done.
The herniated organs should be turned into abdominal cavity and after 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, sliding/axial hernias occur. Types of sliding hernias are:
  • Oesophageal hernias
  • Cardial hernias
  • Cardiofundal hernias
  • Subtotal hernias and
  • Total hernias
In addition, congenital or acquired oesophageal shortenism should also be considered as sliding hernias.

Etiology:
These hernias occur by the following mechanisms:
  • Tractional
  • Pulsional and
  • Mixed mechanism
Clinical Features:
Clinical features are divided by:
  • Cardial insufficiency
  • Gastroesophageal reflux disease
  • Peptic oesophagitis usually occurs
  • Pain is the prominent sign which is aggravated in the supine position
Due to gastroesophageal reflux, pH in the oesophagus increases up to 4.0. Later peptic oesophagitis lead 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 the ventricle remains at its normal position below the diaphragm while other parts of the ventricle and other organs can be traspositioned into thoracic cavity i.e. paraoesophageal hernias should be defined as:
  • Fundal
  • Antral
  • Intestinal
  • Gastrointestinal and
  • Omental ones
There is no evidence of gastroesophageal reflux but incarceration occurs. Relaxation of diaphragm should be defined as the weakening of muscular fibrotic fibers of the diaphragm, which leads to the organ traslocation from the abdomen into thoracic cavity. Relaxation of the diaphragm is congenital / acquired and total / partial. It has the same signs as the diaphragmatic hernias do.

Treatment:
Plasty of diaphragm is the only treatment of choice.

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This article has been written by Dr. M. Javed Abbas.
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00:55 06/02/2003