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Diaphragmatic hernia

  • Herniation of abdominal content through diaphragm into the chest

Anatomy – foramina of the diaphragm

Classification of diaphragmatic hernias

Congenital

  • Bochdalek hernia – most common congenital type
  • Morgagni hernia
  • Diaphragm eventration

Acquired

  • Traumatic
  • Hiatus hernia – most common type of diaphragmatic hernia
  • Iatrogenic

Bochdalek Hernia

  • Defect is more common on the left hand side, posteriorly

Pathogenesis

  • It is a developmental defect which occurs due to failure of fusion of pleuroperitoneal canal leaving a direct communication between pleura and peritoneum – allows herniation of abdominal contents into the chest cavity
    • Abdominal contents can be – colon, small intestine, stomach
  • Leads to decreased total lung mass and pulmonary hypoplasia
  • 80% cases do not have hernia sac

Clinical features

  • Symptoms usually present in the newborn period
  • Respiratory issues, cyanosis, tachycardia
  • Scaphoid abdomen
  • Bowel sounds in the left hand side of chest
  • Mediastinal shift to the right hand side
  • Intestinal obstruction

Investigations

  • CXR, barium enema/meal, ABG

Treatment

  • Respiratory support
  • Laparotomy and dissection of the sac with closure of the defect in diaphragm

Hernia through Foramen of Morgagni

  • Defect is more common on the right hand side, anteriorly
  • Contents – omental fat or colon
  • It usually asymptomatic, but can present with respiratory problems and recurrent chest infections
  • Can be treated with laparoscopic repair if asymptomatic

Eventration

  • Weakening of diaphragm due to atrophy and loss of muscle with fibrous tissue formation
  • Diaphragm is attenuated and inactive
  • Classification of eventration
    • Congenital – marked decrease in the muscle fibres in the diaphragm
    • Acquired – (a) phrenic nerve palsy due to trauma (b) viral i.e. polio, HZV, influenza (c) neoplasia (d) autoimmune neuropathy (d) iatrogenic
  • Often present in infancy and childhood
  • The thin diaphragm is raised higher and immobile – it is not actually a true herniation but features mimic hernia

Clinical features

  • Can be asymptomatic
  • Wheezing, recurrent lower respiratory tract infections, extreme respiratory distress, V/Q mismatch

Investigations

  • CXR/CT/MRI
  • Pulmonary function tests

Treatment

  • Diaphragmatic plication

Traumatic diaphragmatic hernia

  • Can occur either on the left and right hand side
  • Etiology – road traffic accident, crush injuries, penetrating injuries or blunt injuries
  • Most commonly herniated organs – stomach and colon
  • Patient is pale, has respiratory distress, guarding and rigidity over the abdomen

Oesophageal hiatus hernia

  • Hiatus – hole through diaphragm where oesophagus passes through into stomach

Etiology

  • Idiopathic
  • Increasing age
  • Increase pressure in the abdomen from – pregnancy, obesity, coughing, straining, ascites
Types
  • Sliding hernia – type I
    • Upward dislocation of the cardia through the oesophageal hiatus
    • Gastro-oesophageal junction (GOJ) protrudes into chest
    • Most common type of hiatal hernia
  • Rolling hernia/paraoesophagel hernia (PEH) – Type II
    • Upward dislocation of the gastric fundus alongside a normally positioned cardia
    • GOJ is in its normal location, but the fundus passes/bulges into chest beside the oesophagus
  • Mixed type – has both a sliding and rolling component

Clinical features

  • Most cases are asymptomatic
  • Symptoms of GORD – heartburn, epigastric pain
  • Vomiting, weight loss
  • Severe cases – bleeding, dysphagia, chest pain

Investigations

  • Oesophagogastroduodenoscopy – gold standard
  • Barium swallow
  • CT, MRI

Treatment

  • Conservative – omeprazole (PPI), weight loss, diet modification, smoking cessation
  • Surgical – indicated when there is increased risk of strangulation/volvulus
    • Cruroplasty – hernia is reduced from the thorax into the abdomen; may require mesh
    • Fundoplication – fundus is wrapped around and sutured to the lower oesophagus, to strengthen the lower oesophageal sphincter

Internal hernias

  • Protrusions of the viscera through the peritoneum or mesentery but remaining within the abdominal cavity
  • Acute small bowel obstruction is the most common presentation

Etiology – pathologic defects of the mesentery and visceral peritoneum

  • Congenital maldevelopment of mesenteries
  • Iatrogenic – surgery

Types

  • Paraduodenal hernias
  • Lesser sac (foramen of Winslow) hernias
  • Pericaecal hernia
  • Sigmoid mesocolon hernia
  • Falciform ligament hernia

Investigations

  • CT – gold standard; shows encapsulation of distended bowel loops within an abnormal location
  • Barium studies

Treatment

  • Surgery to release the constricting agent by division
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