Diaphragmatic hernia (DH) account for 2% of all types of hernias. This disease occurs in 5-7% of patients with gastric complaints during X-ray examination.
The first description of DG belongs to Ambroise Paré (1579).
Diaphragmatic hernia should be understood as penetration internal organs through a defect in the diaphragm from one cavity to another.
It should be recalled that the development of the diaphragm occurs due to the connection on both sides of the pleuroperitoneal membrane, the transverse septum and the mesoesophagus.
Disorders arising from complicated embryonic development, can lead to a partial or complete diaphragm defect in the newborn. When developmental disorders occur before the formation of the diaphragm membrane, then the hernia does not have a hernial sac (it is more correct to talk about eventration). At later stages of development, when a membranous diaphragm has already formed and the development of the muscular part is only delayed, a hernial sac consisting of two serous films penetrates through the hernial orifice, which does not contain muscle.
The place of penetration of sternocostal hernias (sternocostal) is the muscleless area of the connection with the sternum and costal part. This place is called Larrey's sternocostal triangle, and such hernias are called Larrey's triangle hernias. In the absence of serous cover, there is a sternocostal foramen of Morgagni.
Due to the anatomical features of the location of the anterior and posterior muscles within the lumbocostal triangle of Bochdalek, a hernial protrusion may occur in this place.
Classification of diaphragmatic hernias according to B.V. Petrovsky:
I. traumatic hernias:
True;
False.
II. Non-traumatic:
False congenital hernias;
True hernias of weak areas of the diaphragm;
True hernias of atypical localization;
Hernias of the natural openings of the diaphragm:
a) esophageal opening;
b) rare hernias of the natural openings of the diaphragm.
Traumatic hernias due to wounds are mostly false, closed injuries - true and false.
In case of non-traumatic hernias, the only false one is a congenital hernia - a defect of the diaphragm, due to non-closure between the thoracic and abdominal cavities.
From the weak areas of the diaphragm - These are hernias of the area of the sternocostal triangle (Bogdalek's gap). The chest in these areas is separated from abdominal cavity a thin connective tissue plate between the pleura and peritoneum.
The area of underdeveloped sternal part of the diaphragm is a retrosternal hernia.
Rare (extremely) hernias of the sympathetic nerve fissure, vena cava, aorta. In terms of frequency, hiatal hernia (HH) is in first place; they account for 98% of all diaphragmatic hernias of non-traumatic origin.
Hiatal hernia
Anatomical features. The esophagus passes from the thoracic cavity to the abdominal cavity through the hiatus oesophagcus, formed from the muscles that make up the diaphragm. The muscle fibers that form the right and left legs of the diaphragm also form the anterior loop, which in most cases is formed from the right leg. Behind the esophagus, the legs of the diaphragm do not connect intimately, forming a Y-shaped defect. Normally, the esophageal opening has a fairly wide diameter, approximately 2.6 cm, through which food passes freely. The esophagus goes obliquely through this opening, above the opening it lies in front of the aorta, below the opening somewhat to the left of it. 11 variants of muscle anatomy in the area of the esophageal opening are described. In 50% of cases, the esophageal opening is formed from the right leg of the diaphragm, in 40% there are inclusions of muscle fibers from the left leg. Both diaphragmatic legs begin from the lateral surfaces of the I-IV lumbar vertebrae. The esophageal ring contracts slightly during inhalation, resulting in an increase in the curvature of the esophagus at the hiatus. The abdominal segment of the esophagus is small, its length is variable, on average about 2 cm. The esophagus enters the stomach at an acute angle. The fundus of the stomach is located above and to the left of the esophagogastric junction, occupying almost the entire space under the left dome of the diaphragm. The acute angle between the left edge of the abdominal esophagus and the medial edge of the fundus of the stomach is called the angle of His. The folds of the mucous membrane of the esophagus, descending into the lumen of the stomach from the top of the angle (Gubarev valve), play the role of an additional valve. When the pressure in the stomach rises, especially in the area of its bottom, the left half of the semi-ring of the esophageal-gastric junction shifts to the right, blocking the entrance to the esophagus. The cardiac part of the stomach at the junction with the esophagus is a narrow ring about 1 cm in diameter. The structure of this section is very similar to the structure of the pyloric section of the stomach. The submucosa is loose, parietal and chief cells are absent. By eye you can see the junction of the mucous membrane of the esophagus with the mucous membrane of the stomach. The junction of the mucous membranes is located next to the anastomosis, but does not necessarily correspond to it.
There is no anatomically defined valve in this area. The lower part of the esophagus and the esophagogastric junction are held in the esophagus by the phrenoesophageal ligament. It consists of leaves of the transversus abdominis fascia and intrathoracic fascia. The phrenic-esophageal ligament is attached around the circumference of the esophagus in its diaphragmatic part. The attachment of the ligament occurs over a fairly wide area - from 3 to 5 cm in length. The upper layer of the phrenoesophageal ligament is usually attached 3 centimeters above the junction of the squamous epithelium and the columnar epithelium. The lower leaf of the ligament is 1.6 centimeters below this connection. The membrane is attached to the wall of the esophagus through the thinnest trabecular bridges connecting to the muscular lining of the esophagus. This attachment allows for dynamic interaction between the esophagus and the diaphragm during swallowing and breathing as the abdominal esophagus lengthens or contracts.
Closing mechanism of the esophagus. There is no anatomically defined sphincter in the cardiac region. It has been established that the diaphragm and its legs do not participate in the closure of the cardia. Reflux of gastric contents into the esophagus is undesirable because the epithelium of the esophagus is extremely sensitive to the digestive action of acidic gastric juice. Normally, pressure would seem to predispose to its occurrence, since in the stomach it is higher than atmospheric pressure, and in the esophagus it is lower. For the first time, the work of Code and Ingeifinger proved that in the lower segment of the esophagus, 2-3 centimeters above the level of the diaphragm, there is a zone of increased pressure. When measuring pressure with a balloon, it was shown that the pressure in this zone is always higher than in the stomach and in the upper parts of the esophagus, regardless of body position and the respiratory cycle. This department has a pronounced motor function, which is convincingly proven by physiological pharmacological and radiological studies. This part of the esophagus acts as an esophagogastric sphincter; closure occurs completely over the entire area, and not in the form of contraction of individual segments. When the peristaltic wave approaches, it completely relaxes.
There are several options for hiatal hernias. B.V. Petrovsky proposed the following classification.
I. Sliding (axial) hiatal hernia
Without shortening of the esophagus With shortening of the esophagus
1. Cardiac 1. Cardiac
2. Cardiofundal 2. Cardiofundal
3. Subtotal gastric 3. Subtotal gastric
4. Total gastric 4. Total gastric
Paraesophageal hernias
1.Fundal
2. Antral
3. Intestinal
4. Gastrointestinal
5. Omental
It is necessary to distinguish : 1. Congenital “short esophagus” with intrathoracic location of the stomach; 2. Paraesophageal hernia, when part of the stomach is inserted to the side of the normally located esophagus; 3. Sliding GPO, when the esophagus, together with the cardiac part of the stomach, is retracted into the chest cavity.
A sliding hernia is so called because the posterior top part the cardiac part of the stomach is not covered by peritoneum and when the hernia is displaced into the mediastinum, it slides out like a protrusion Bladder or cecum when inguinal hernia. In a paraesophageal hernia, an organ or part of an abdominal organ passes into the esophageal hiatus to the left of the esophagus, and the cardia of the stomach remains fixed in place. Paraesophageal hernias, like sliding ones, can be congenital and acquired, but congenital hernias are much less common than acquired ones. Acquired hernias are more common over the age of 40 years. Age-related tissue involution is important, which leads to expansion of the esophageal opening of the diaphragm and weakening of the connection between the esophagus and the diaphragm.
The immediate causes of hernia formation can be two factors. Ripple factor - increased intra-abdominal pressure in severe physical activity, overeating, flatulence, pregnancy, constantly wearing tight belts. Traction factor - hypermotility of the esophagus associated with frequent vomiting, as well as a violation of the nervous regulation of motor skills.
Paraesophageal hernia
The hernia defect is located to the left of the esophagus and can be of various sizes - up to 10 centimeters in diameter. Part of the stomach prolapses into the hernial sac, lined with fibrously modified diaphragmatic peritoneum. The stomach seems to be wrapped in a defect in relation to the esophageal-gastric junction fixed in the opening. The degree of inversion may vary.
Clinic. Clinical symptoms of paraesophageal hernia are caused mainly by the accumulation of food in the stomach, partially located in the chest cavity. Patients feel pressing pain in the chest, especially intense after eating. First they avoid eating in large quantities, then in regular doses. There is weight loss. Symptoms characteristic of esophagitis occur only when a paraesophageal hernia is combined with a sliding one.
When a hernia is strangulated, progressive stretching of the prolapsed part of the stomach occurs until it ruptures. Mediastinitis develops rapidly with severe pain, signs and accumulation of fluid in the left pleural cavity. A hernia can cause the development of peptic ulcers of the stomach, since the passage of food from the deformed stomach is impaired. These ulcers are difficult to treat and are often complicated by bleeding or. The diagnosis is made mainly by X-ray examination if a gas bubble is detected in the chest cavity. A barium test confirms the diagnosis.
In order to find out the type of hernia, it is very important to determine the location of the esophagogastric anastomosis. Esophagoscopy can be used to diagnose concomitant esophagitis.
Clinic. Most typical signs are: pain after eating in the epigastric region, belching, vomiting. When the stomach remains in the hernial opening of the diaphragm for a long time, dilation of the veins may occur. distal section esophagus and cardia, manifested by bloody vomiting.
Treatment. Conservative therapy consists of a special diet. Food should be taken often and in small portions. Diet in general outline similar to antiulcer. After eating, it is recommended to take walks and never lie down. To prevent possible complications– surgical treatment is indicated for pinching and rupture of the wall. The optimal access is transabdominal. By gentle stretching, the stomach is lowered into the abdominal cavity. The hernial orifice is sutured with additional suturing of the angle of His or esophagofundoplication. Relapses are rare. After surgery, clinical symptoms decrease and nutrition improves.
sliding hernia
The cause of this hernia is the pathology of the phrenoesophageal ligament, which fixes the esophagogastric anastomosis inside the esophageal opening of the diaphragm. Part of the cardiac part of the stomach moves upward into the chest cavity. The phrenoesophaeal ligament becomes thinner and lengthens. The esophageal opening in the diaphragm expands. Depending on the position of the body and the filling of the stomach, the esophagogastric anastomosis shifts from the abdominal cavity to the thoracic cavity and vice versa. When the cardia shifts upward, the angle of His becomes obtuse, and the folds of the mucous membrane are smoothed out. The diaphragmatic peritoneum shifts along with the cardia; a well-defined hernial sac occurs only with large hernias. Fixation and narrowing by scars can lead to shortening of the esophagus and the permanent location of the esophagogastric junction above the diaphragm. In advanced cases, fibrous stenosis occurs. Sliding hernias are never strangulated. If there is compression of the cardia displaced into the chest cavity, then circulatory disturbance does not occur, since the outflow of venous blood occurs through the esophageal veins, and the contents can be emptied through the esophagus. A sliding hernia is often combined with reflux esophagitis.
An upward displacement of the cardiac region leads to a flattening of the His angle, the activity of the sphincter is disrupted, and the possibility of gastroesophageal reflux is created. However, these changes are not natural, and in a significant number of patients reflux esophagitis does not develop, since physiological function sphincter is preserved. Therefore, displacement of the cardia alone is not enough for sphincter insufficiency to develop; in addition, reflux can be observed without a sliding hernia. An unfavorable relationship between the pressure in the stomach and in the esophagus contributes to the penetration of gastric contents into the esophagus. The epithelium of the esophagus is very sensitive to the action of gastric and duodenal contents. Alkaline esophagitis due to the influence of duodenal juice is even more severe than peptic esophagitis. Esophagitis can become erosive and even ulcerative. Constant inflammatory swelling of the mucous membrane contributes to its easy trauma with hemorrhages and bleeding, which sometimes manifests itself in the form of anemia. Subsequent scarring leads to the formation of a stricture and even complete closure of the lumen. Most often, reflux esophagitis accompanies a cardiac hernia, less often a cardiofundal hernia.
Clinic. Sliding hernias without complications are not accompanied by clinical symptoms. Symptoms occur when gastroesophageal reflux and reflux esophagitis are associated. Patients may complain of heartburn, belching, and regurgitation. The appearance of these symptoms is usually associated with a change in body position; the pain intensifies after eating. Most common symptom burning sensation behind the sternum is observed in 90% of patients. The pain can be localized in the epigastric region, left hypochondrium and even in the heart area. They are not similar to ulcers, since they appear immediately after eating, are associated with the amount of food taken, and are especially painful after a heavy meal. Relief occurs after taking medications that reduce stomach acidity. Regurgitation occurs in half of the cases, especially after eating a large meal; bitterness is often felt in the larynx. Dysphagia is late symptoms and is observed in 10% of cases. It develops due to spasms of the inflamed distal end esophagus. Dysphagia occurs periodically and disappears periodically. As inflammatory changes progress, dysphagia occurs more frequently and may become permanent.
Bleeding may occur from the resulting ulcerations of the esophagus, which proceeds hidden.
Kasten syndrome– a combination of hiatal hernia, chronic cholecystitis and duodenal ulcer.
Diagnostics difficult. Patients are most often interpreted as suffering from peptic ulcer, cholecystitis, angina pectoris or pleurisy. There are known cases of erroneous puncture of the pleural cavity and puncture or even drainage of a hollow organ (in our practice, we observed how a drainage tube was installed twice in the fundus of the stomach) due to the suspicion of exudative pleurisy.
Triad Senta: hiatal hernia, cholelithiasis, colon diverticulosis.
Diagnosis is difficult. Patients are more often treated as suffering cholelithiasis or chronic colitis. It is detected more often during surgery for acute calculous cholecystitis or acute intestinal obstruction when the colon is strangulated in a hernia.
An X-ray may help. But it helped us make the correct diagnosis and choose the optimal tactics for a patient admitted with acute destructive cholecystitis. The patient underwent cholecystectomy, elimination of the irreducible hiatal hernia with resection of the transverse colon and descending colon, suturing the hernial orifice with esophagofundoplication according to Nissen.
Decisive role plays a role in making a diagnosis X-ray examination. In the diagnosis of hiatal hernia, the main diagnostic method- X-ray. Quincke position (legs above head). Direct symptoms of hiatal hernia include swelling of the cardia and vault of the stomach, increased mobility of the abdominal esophagus, flatness and absence of the His angle, antiperistaltic movements of the esophagus (“dance of the pharynx”), and prolapse of the esophageal mucosa into the stomach. Hernias up to 3 cm in diameter are regarded as small, from 3 to 8 - as medium and more than 8 cm - as large.
In second place in terms of information content they are worth endoscopic methods , which in combination with X-ray examinations allow you to increase the percentage of detection of this disease up to 98.5%. Characteristic: 1) decreasing the distance from the anterior incisors to the cardia; 2) the presence of a hernial cavity; 3) the presence of a “second entrance” to the stomach; 4) gaping or incomplete closure of the cardia; 5) transcardial migrations of the mucous membrane; 6) gastroesophageal reflux; 7) signs of hernial gastritis and reflux esophagitis (RE); 8) the presence of a contractile ring; 9) the presence of foci of epithelial ectomy – “Barrett’s esophagus”.
Intraesophageal pH-metry can detect EC in 89% of patients. Manometric method for determining the condition of the LES. For the paraesophageal type of hernia, diagnostic testing is offered.
Laboratory research play a supporting role. A significant number of patients with hiatal hernia and esophagitis also suffer from duodenal ulcers or gastric hypersecretion, characteristic of peptic ulcer disease. The more severe the esophagitis and the disorders caused by it, the more often patients have a concomitant duodenal ulcer. In order to clarify the diagnosis in doubtful cases, the Bernstein test is performed. Inserted into the lower end of the esophagus gastric tube and a 0.1% solution is poured through it of hydrochloric acid so that the patient cannot see it. The administration of hydrochloric acid causes symptoms of esophagitis in the patient.
Treatment. Conservative treatment for sliding hernia with esophagitis usually does not bring great success. It is necessary to exclude tobacco, coffee, and alcohol. Food should be taken in small portions and should contain a minimum amount of fat that remains in the stomach for a long time. Raising the head of the bed reduces the possibility of reflux. Drug antiulcer therapy is advisable, although its effectiveness is low. Antiseptics are contraindicated because they increase gastric congestion. Indications for surgery are: ineffectiveness of conservative therapy and complications (esophagitis, obstruction of the esophagus, severe deformation of the stomach, etc.).
There are many surgical methods for treating hiatal hernia. There are basically two requirements for them: 1) reposition and retention of the esophageal-gastric junction under the diaphragm; 2) restoration of a constant acute cardiofundal angle.
An interesting operation is the antelateral movement of the POD with suturing of the hernial orifice tightly.
R. Belsey in 1955 first reported transthoracic esophagofundoplication followed by fixation to the diaphragm with V-shaped sutures. Relapse in 12% of cases. Many surgeons usually sutured the stomach to the anterior abdominal wall. In 1960 L. Hill developed the posterior gastropexy procedure with cardia calibration. Some surgeons use esophagophundoraphy (suturing the fundus of the stomach with terminal department esophagus).
Transperitoneal access is preferable for uncomplicated hernias. If the hernia is combined with shortening of the esophagus due to stenosis, it is better to use transthoracic. Transabdominal access also deserves attention because some patients with eeophagitis have lesions biliary tract who need surgical correction. Approximately 1/3 of patients with esophagitis suffer from a duodenal ulcer, so it is advisable to combine the removal of a hernia with vagotomy and pyloroplasty. Common surgical method Treatment is Nissen surgery combined with closure of the angle of His. In 1963, Nissen proposed fundoplication for the treatment of hiatal hernia complicated by esophagitis. In this operation, the fundus of the stomach is wrapped around the abdominal esophagus, and the edges of the stomach are sutured together with the wall of the esophagus. If the esophageal opening is particularly wide, the legs of the diaphragm are sutured. This operation prevents cardioesophageal reflux well and does not interfere with the passage of food from the esophagus. Nissen fundoplication is equally good for treating a hernia and preventing reflux. Relapses of the disease are rare, especially in unadvanced cases. Restoring anatomical relationships with a sliding hernia leads to a cure for reflux esophagitis. For hernias combined with shortening of the esophagus due to esophagitis, the best results are obtained by the operation of B.V. Petrovsky. After fundoplication, the diaphragm is dissected in front, the stomach is sutured with separate sutures to the diaphragm and remains fixed in the mediastinum (mediastinolization of the cardia). After this operation, reflux disappears due to the presence of a valve and the stomach does not become pinched, since the hole in the diaphragm becomes wide enough. Fixation to the diaphragm prevents its further displacement into the mediastinum. Nissen, when the cardia is located in the mediastinum above 4 cm above the level of the diaphragm, recommends using fundoplication using a transpleural approach in such patients, leaving the upper part of the cardia in the pleural cavity. B.V. Petrovsky in these cases uses valve gastropplication, which can be performed transabdominally, which is very important for elderly patients.
Traumatic diaphragmatic hernia . Particular distinction should be made between diaphragmatic-intercostal hernias, when the diaphragm ruptures at the site of attachment of its fibers to the lower ribs or in the area of the sealed pleural sinus. In these cases, the hernial protrusion does not fall into the free pleural cavity, and into one of the intercostal spaces, usually on the left.
Clinical picture
There are symptoms of acute organ displacement that occurs after injury and chronic diaphragmatic hernia.
Characteristic:
1) respiratory and cardiac disorders;
2) symptoms of abdominal disorders (vomiting, constipation, bloating)
Complications
Irreducibility and infringement (30-40% of all DHs). Hernias after injuries are more prone to strangulation.
Factors contributing to infringement: small size of the defect, rigidity of the ring, heavy food intake, physical stress. Clinical picture in case of strangulation - corresponds to the clinic of intestinal obstruction. If the stomach is strangulated, it is not possible to install a gastric tube.
Differential diagnosis
between DG and diaphragm relaxation. Pneumoperitoneum.
Surgical treatment
Transpleural or transabdominal approaches.
Tasks of a general practitioner
- when complaints characteristic of gastrointestinal manifestations appear (dysphagia, nausea, vomiting, peristaltic noises in chest etc., especially after eating, lifting heavy objects) or cardiorespiratory (cyanosis, shortness of breath, attacks, under the same conditions) the patient should be referred for examination.
Correction diaphragmatic hernia in Israel, it is successfully carried out in the surgical department of the private clinic “Herzliya Medical Center”. The use of innovative laparoscopic surgery techniques allowed hospital specialists to minimize the risk of postoperative complications, as well as the duration of hospital treatment.
What is a diaphragmatic hernia?
The diaphragm is a dome-shaped muscular structure that separates the chest cavity from the abdominal cavity. Besides barrier function, the diaphragm muscles play important role during breathing. The diaphragm has a series of holes that allow the digestive and circulatory systems penetrate from the chest cavity into the abdominal cavity. Muscle around these openings there is a relatively weak link in the organ, which often causes pathological expansion and insufficiency of barrier function, called a diaphragmatic hernia or hiatal hernia.
Types of diaphragmatic hernias
One of the common manifestations of a diaphragmatic hernia is a hernia of the esophageal opening of the diaphragm - the place where the esophagus enters the abdominal cavity. Small hernias interfere with the normal functioning of the esophagogastric sphincter, being the main cause of reflux (the return of stomach contents to the esophagus). Large hiatal hernias can cause abnormal penetration of abdominal organs into the chest with serious functional impairment and severe symptoms.
In clinical practice, the most common types of diaphragmatic hernias are:
- Sliding hiatal hernia. This type of hiatal hernia is observed in 70-80% of cases. The weakness of the esophageal opening ring leads to free displacement of the posterior-superior part of the stomach, not covered by the peritoneum, into the chest cavity. In the vast majority of cases, the stomach returns unhindered to the abdominal cavity, which explains the name of this pathology. Sliding diaphragmatic hernias are not strangulated, and, as a rule, are accompanied by gastroesophageal reflux, as well as secondary changes in the mucous membrane of the esophagus (reflux esophagitis);
- Paraesophageal hiatal hernia characterized by a defect to the left of the esophagus, usually not exceeding 10 centimeters. The resulting hernial sac is covered on the side of the abdominal cavity by the peritoneum, which over time undergoes pronounced fibrous changes. Unlike a sliding hernia, the upper part of the stomach remains fixed, while the hernial sac may contain part of the body of the stomach or other abdominal organs. A paraesophageal hernia can be complicated by strangulation with the development of acute intestinal obstruction and impaired circulation in the strangulated organs.
Causes of development of diaphragmatic hernia
Diaphragmatic hernias can develop during intrauterine development and be innate in nature. Esophageal hernia has a clear hereditary predisposition and is often observed in family members over several generations. Acquired hernias can be the result of trauma, injury, as well as surgical interventions on the abdominal organs and diaphragm. Less likely to develop due to systemic diseases connective tissue and disturbances in the innervation of the diaphragm (most likely, there is an increase in a previously existing small hernia that did not previously cause clinical manifestations).
Symptoms of diaphragmatic hernia
The clinical manifestations of a diaphragmatic hernia depend mainly on the size of the defect. Large congenital hernias can cause the newborn's stomach and part small intestine located in the chest, causing serious respiratory and hemodynamic disturbances. In adulthood, the main complaints of patients with diaphragmatic hernia are:
- Chest pain that occurs periodically and is usually associated with eating. Differential diagnosis with coronary heart disease, diseases of the lungs and mediastinum is often required;
- Breathing disorders, as well as signs of chronic oxygen deficiency. Collapse and atelectasis of one of the lungs, caused by external pressure, is often observed;
- Symptoms of heart failure. Violation of the relationship between the mediastinal organs leads to displacement of the heart and great vessels, often leading to severe functional disorders from the cardiovascular system;
- Sounds and sensation of peristalsis in the chest;
- Symptoms of gastroesophageal reflux (epigastric pain, heartburn, burning sensation in the chest, bad smell from mouth;
- Symptoms of intestinal obstruction in case of strangulation.
Diagnosis of diaphragmatic hernia
The private clinic “Herzliya Medical Center” uses all modern methods diagnostics that allow timely determination of the presence of a diaphragmatic hernia, including:
- Ultrasound examination, including intrauterine ultrasound of the fetus;
- X-ray using contrast agent. This method allows you to accurately determine the penetration of organs gastrointestinal tract into the chest cavity;
- Tomographic scanning (CT and MRI);
Based on the data obtained, the clinic’s specialists will determine the type and severity of the disease, choosing the optimal and most effective treatment in Israel.
Correction of diaphragmatic hernia at the Herzliya Medical Center clinic
Large congenital diaphragmatic hernias, accompanied by movement of the abdominal organs into the chest, require emergency surgical intervention in the first days of the child’s life. During the correction of a diaphragmatic hernia in a newborn, the displaced organs are repositioned, the stomach and intestines are returned to the abdominal cavity, and the diaphragm defect is sutured. Emergency surgery due vital signs and age of patients is performed using an open method.
Surgical treatment of late manifestations and acquired diaphragmatic hernias is carried out mainly using the laparoscopic method. Surgeons at the Herzliya Medical Center clinic prefer access to the diaphragm from the abdominal cavity. During the operation, the integrity of the diaphragm is reconstructed and the displaced organs of the gastrointestinal tract are returned to the abdominal cavity. Often the procedure is performed in conjunction with fundoplication, an operation to eliminate gastroesophageal reflux. Laparoscopic procedures are easily tolerated by patients and do not require prolonged hospitalization.
For many years our private clinic is a leading center for abdominal, endoscopic and minimally invasive surgery in Israel. Doctors of the Herzliya Medical Center hospital underwent training in the best surgical clinics USA, Europe and Canada, specializing in modern laparoscopic procedures, which have gradually replaced the classical methods of open surgery. Hospital patients are guaranteed individual approach, highly professional post-operative care, excellent service, as well as a warm and humane attitude from a multidisciplinary team.
Congenital diaphragmatic hernia
Congenital diaphragmatic hernia is a malformation of the diaphragm, leading to disruption of the separation of the abdominal cavity and chest, as well as to displacement of the stomach, spleen, intestines and liver into the chest cavity.
Causes
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Congenital diaphragmatic hernia can be an isolated defect, or it can also be combined with malformations of other organs and systems. Most cases of congenital diaphragmatic hernia are sporadic.
With a congenital diaphragmatic hernia, at 8-10 weeks of pregnancy, a diaphragm defect occurs as a result of disruption of the closure of the pleuroperitoneal canal, and the abdominal organs can ventrate through the defect into the pleural cavity during the entire period after the intestines return to the abdominal cavity (9-10 weeks of gestation). The presence of abdominal organs in the chest limits the growth and development of the lungs, which leads to pulmonary hypoplasia with decreased total number branches of bronchi and arteries. On the side of the hernia there is significant lung damage, however, the contralateral lung, as a rule, also has an abnormal structure and less weight compared to the norm.
Incidence rate 1 in 4000 live births, sex ratio 1:1
Diaphragmatic hernia can be combined with heart defects, which account for about 20%. Combinations with defects of the central nervous system and urinary system account for 10.7% each. About 10-12% of congenital diaphragmatic hernias diagnosed prenatally are part of various hereditary syndromes (Cantrell pentad, Frinze, Lange, Marfan, Ehlers-Danlos syndromes, etc.) or a manifestation of chromosomal abnormalities and gene disorders. The average incidence of chromosomal abnormalities is 16%. Once again, it should be emphasized that chromosomal abnormalities are often detected only in cases where congenital diaphragmatic hernia is combined with other developmental defects. Consequently, prenatal karyotyping is indicated in all cases of concomitant pathology to clarify the genesis of the defect.
Regarding the affected side, all congenital diaphragmatic hernias are divided into:
- Left-handed about 80%
- Right-sided about 20%.
- Bilateral less than 1%.
Clinical manifestations
Most newborns with congenital diaphragmatic hernia develop a picture of respiratory failure directly in the delivery room immediately after birth. Acute respiratory failure progresses very quickly. On examination, attention is drawn to the asymmetry of the chest with bulging of the affected side (usually on the left) and the absence of chest excursion on this side. A very characteristic symptom is a sunken navicular abdomen.
Diagnostics
The main method of prenatal detection of congenital diaphragmatic hernia is echography. During ultrasound examination, suspicion of this defect arises from an abnormal image of the chest organs. One of the main echographic signs is the displacement of the heart, as well as the appearance of the stomach and loops of the small intestine in the chest. Prenatal ultrasound can detect the presence of abdominal contents in the chest as early as 12 weeks of pregnancy. However, diagnosis is usually made at 16 weeks of pregnancy.
Early diagnosis of CDH makes it possible to perform karyotyping to exclude a combined chromosomal abnormality. Also, according to ultrasound data in the first and second trimester of pregnancy, it is possible to determine the need for fetal interventions to stabilize a fetus with CDH.
After birth, the diagnosis of CDH is confirmed after comprehensive ultrasound and radiography of the chest and abdominal cavity.
Treatment methods
When a child is born with a diaphragmatic hernia, doctors must be prepared to perform an extended cardiopulmonary resuscitation. Tracheal intubation and mechanical ventilation are indicated from the first minute of life. Already in the delivery room, a child with CDH may require administration medicines, stabilizing the work of the heart. Only after reaching a stable condition is it possible to transport the child from the delivery room; this is performed in a transport incubator on a ventilator with monitoring of vital functions.
In the intensive care unit of the department, intensive therapy continues, aimed at stabilizing the condition and preparing for surgery: selection of methods and parameters of mechanical ventilation, cardiotonic support, sedative and analgesic, antibacterial therapy.
As the condition stabilizes, the question of the possibility of surgical treatment is decided.
In case of instability, our department has the opportunity to use the extracorporeal method of supporting the functioning of the heart and lungs - ECMO.
Surgical treatment of children with CDH is carried out primarily using a minimally invasive endoscopic method. Through minimal punctures of the chest (3 mm), the contents are carefully immersed from the chest cavity into the abdominal cavity. After which the diaphragm defect is assessed: in the case of a sufficiently developed native diaphragm, the defect is repaired using its own tissues, and in case of severe tissue deficiency, the defect is replaced by an implant (synthetic material Gore-Tex is used and biological material Permacol).
IN postoperative period Intensive therapy continues, aimed at correcting deficits that persist until the hypoplastic lung recovers.
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Hiatal hernia is one of the most common anatomical and topographical defects of the gastrointestinal tract, accompanied by gastroesophageal reflux disease.
Currently, a fairly extensive analysis of the effectiveness of primary antireflux interventions has been carried out, and methods for selecting fundoplications have been determined.
Nikolay Sivets, head of the surgical department6th City Clinical Hospital of Minsk, Professor of the Department of Military Field Surgery of BSMU,doctor med. sciences
The essence of the operation is to correct the esophageal opening of the diaphragm and form a cuff from the fundus of the stomach around the abdominal esophagus and cardia. Interventions for hiatal hernia (HHH), as a rule, are performed using laparoscopic access, which reduces trauma, shortens the period of disability and speeds up rehabilitation.
Surgical treatment of hiatal hernia in the late postoperative period is accompanied by a fairly high percentage of relapses (from 11% to 30%). Good and excellent results are in the range of 84-86%. According to a number of authors, the relapse rate after laparoscopic correction of giant hiatal hernias (with a surface area of the esophageal opening of the diaphragm more than 20 cm 2) is 25-40%.
A characteristic feature of the operation: sutures are applied to the diaphragmatic legs that have already been separated from the fibers and have undergone degeneration. As a result, the diaphragm tissue erupts, creating conditions for the migration of the applied fundoplication cuff into the posterior mediastinum with the development of recurrent pathology. An attempt to apply sutures to intact tissue, while involving a large number of diaphragmatic crura, can lead to persistent postoperative dysphagia due to excessive narrowing of the esophageal opening of the diaphragm.
Specific mechanisms and types of relapses are well known: slipping of the fundoplication cuff, or telescope syndrome, displacement of the cuff into the chest cavity above the diaphragm, cutting through the sutures of the cuff or the sutures of the legs of the diaphragm, the formation of a paraesophageal hernia. Sliding of the fundoplication cuff above the diaphragm is most often observed when the crurorrhaphic suture fails. In second place is relapse due to rupture and disintegration of the diaphragmatic pedicle. The literature describes mechanical (manifested by dysphagia) and functional (manifested by heartburn) forms of relapse.
To improve the results of surgical treatment, plasty of the esophageal opening of the diaphragm is performed using a mesh implant. Many authors believe that the use of a mesh is advisable only for large sizes of the esophageal opening of the diaphragm, atrophy of the diaphragmatic legs and in old age. The attitude towards polypropylene mesh is currently very restrained. The limited use of them in plasty of the esophageal opening of the diaphragm is explained by frequent complications (long-term dysphagia in the postoperative period, cicatricial strictures, erosion of the esophagus by the implant and migration of the implant). At the same time, the indications for placing the mesh have not been worked out.
When repeated operations for recurrent hiatal hernias are performed, Nissen fundoplication is used in approximately 70% of cases, and Toupet fundoplication is used in 17-20% of cases. Indications for re-intervention: recurrent hiatal hernia, especially if there is recurrent development of reflux, reflux esophagitis or other manifestations of gastroesophageal reflux disease (heartburn, dysphagia, vomiting, chest pain). It has been proven that with repeated operations their effectiveness decreases, and the greater the number of previously performed interventions, the lower the effectiveness of each subsequent one. This fact requires a careful approach to determining indications for refundoplication. To accurately determine whether reoperation is feasible, it is necessary to conduct a comprehensive clinical and X-ray endoscopic examination.
Patient V., 69 years old, resident of Polotsk, was hospitalized in the surgical department of the 6th City Clinical Hospital of Minsk on May 29, 2017 with a recurrent hiatal hernia.
From the anamnesis: in 2009 she was operated on in one of the clinics in Vitebsk. Completed endoscopic surgery in the scope of posterior crurorrhaphy with installation of a polypropylene mesh behind the esophagus, fundoplication according to Nissen. A year later, a recurrence of the hiatal hernia occurred, and the patient was operated on again in the same clinic. A left-sided thoracotomy and plasty of the esophageal opening of the diaphragm by suturing it were performed. About four years after the second operation I felt satisfactory. The deterioration of the condition has been noted over the past two years. I began to experience chest pain, bitterness in my mouth, and belching.
In April 2017, the patient was consulted at surgical department 6th City Clinical Hospital of Minsk. Additional examination was recommended for differential diagnosis. Comprehensive clinical, endoscopic and x-ray examination, as a result of which it is installed clinical diagnosis: recurrent hernia esophageal opening of the diaphragm. On May 29, the patient was hospitalized and operated on the next day. Reconstructive surgery was performed on the esophagus and stomach: laparotomy, hernia repair, anterior crurorrhaphy, Nissen refundoplication. The duration of the operation is 3 hours 40 minutes.
FROM THE OPERATION RECORD:
upper-median laparotomy with bypass of the umbilicus on the left. An audit of the abdominal organs revealed that there was a moderate adhesive process in the abdominal cavity after the previous operation. The greater omentum is soldered to the anterior abdominal wall, to the liver, and to the bed of the gallbladder. In the subhepatic space on the left, in the area of the esophageal opening of the diaphragm, there is a massive adhesive process.
Upon further inspection, it was determined that there was a recurrence of the hiatal hernia. The adhesions are separated, and the hernial orifice is isolated (diameter about 5 cm). Behind the esophagus, a mesh implant is palpated, which is fixed to the legs of the diaphragm. The area of the esophagogastric junction on the lower right is tightly fixed to the implant. An attempt to remove the mesh implant was accompanied by tissue trauma and moderate diffuse bleeding.
Two metal brackets removed. The mesh implant was left in its original place. The parietal peritoneum was dissected in the area of the hernial orifice along the left wall of the esophageal opening of the diaphragm. The stomach in the cardiac region was mobilized along the lesser curvature, two short gastrosplenic branches were crossed along the greater curvature. The abdominal part of the esophagus is isolated. The thoracic esophagus was mobilized down to 3 cm. The esophagus was displaced downward. There were no signs of the presence of a Nissen fundoplication cuff formed during the first operation. Self-destruction of the cuff occurred, apparently, due to resorption suture material or cutting seams.
Considering the above, an esophageal opening of the diaphragm up to 2.5 cm in diameter was formed by placing two sutures on the legs of the diaphragm in front of the esophagus. A Nissen fundoplication was performed with cuff formation using four sutures. The stomach, together with the esophagus, is fixed to the right leg of the diaphragm with one suture. On the left, the cuff is fixed to the diaphragm with one seam. Hemostasis control. Drainage tube into the subhepatic space to the plastic area, the second - above the spleen. Instruments were removed from the abdominal cavity. Layered suture of the wound with a mechanical skin suture. Bandage.
In the first days after surgery, severe dysphagia was observed. The patient could only take liquid food in small portions. On the 9th day after surgery, a control FEGDS was performed.
ENDOSCOPIC IMAGE :
The esophagus is freely passable, the mucous membrane is pink, with curdled mycotic deposits on it. The cardia closes. The cuff is formed in the area of the cardia and is passable without effort for endoscopes sequentially 5.2 mm and 8.0 mm in diameter. Empty contents with copious admixture of bile. The gastric mucosa is focally hyperemic, edematous, the relief is preserved. The pylorus, bulb and cavity of the duodenum are without features.
CONCLUSION :
condition after hernioplasty with fundoplication according to Nissen. Erythematous gastropathy of the 1st degree. Mycosis of the esophagus.
Over the next four days, conservative therapy was continued. Two weeks after the operation, on June 13, the patient was discharged in satisfactory condition for outpatient treatment.
conclusions
1. In modern conditions, the use of a minimally invasive endoscopic method of surgical treatment of hiatal hernia is a promising direction in esophageal surgery.
2. To prevent recurrence of the hernia, it is necessary to observe the basic principle of surgical treatment: not only to eliminate the hernia, narrow the hernial orifice, but also to restore normal interaction between the stomach and the esophagus.
3. In case of failure of crurorrhaphy sutures, cutting of sutures or dissection of the diaphragmatic leg, the task of reoperation is to restore the usefulness of the plastic and the size of the esophageal opening of the diaphragm.
4. The use of synthetic mesh endoprostheses for surgical correction of the hernia is considered a convenient immediate solution to the problem, but in case of recurrence of the hernia, this may interfere with the quality of the reconstructive operation. Mesh implants can only be considered as an option when surgical treatment giant hiatal hernia.
This is an extremely rare type of hernia that occurs in only one in 2000-5000 newborns. It should not be confused with other, more common types of hernia.
The diaphragm is a muscle formation that separates the chest cavity from the abdominal cavity and helps to breathe. A diaphragmatic hernia occurs in utero when an abnormal formation causes a hole to form in the hernia.
Through this hole, abdominal organs can penetrate into the chest and flatten the baby's lungs, preventing them from developing properly. The hole can form on any side of the baby's diaphragm, but more often it occurs on the left.
How do I know if my baby has a diaphragmatic hernia?
Diaphragmatic hernia can be diagnosed using ultrasound echography from 12 weeks of pregnancy until birth.
How will this affect my child?
Shortly after birth, your baby may have serious breathing difficulties or other problems related to the heart, kidneys, or spinal cord(neural tube defect) such as spina bifida.
Keep in mind that if you have a baby with a diaphragmatic hernia, the risk of the situation repeating in subsequent pregnancies is very small - only 2%.
Is it possible to treat a diaphragmatic hernia during pregnancy?
If the baby has a severe form of diaphragmatic hernia, then it may be treated while the baby is in the womb. This treatment technique is called percutaneous fetoscopic correction of fetal tracheal occlusion (FETO).
FETO refers to surgeries that are performed through a small hole in the tissue. The procedure is performed between 26 and 28 weeks of pregnancy, when a special balloon is inserted into the baby's windpipe. It stimulates the development of the baby's lungs. The balloon is later removed - during pregnancy, during childbirth or after the baby is born.
FETO is performed only in specialized surgical centers. Unfortunately, a diaphragm or rupture may occur during surgery. The procedure is prescribed if the child is unlikely to survive without surgery. But even with the use of FETO, the baby’s chances of survival are 50%.
In the case of a moderate diaphragmatic hernia, it is better to wait until surgery and just watch how the baby develops.
How is a diaphragmatic hernia treated after birth?
To help your baby breathe, he will be ventilated for the first few hours after birth. Soon after this, the baby will need surgery under general anesthesia, so he will sleep during the procedure.
During the operation, surgeons will replace the abdominal organs and sew up the hole in the diaphragm. This may take from one to two hours, depending on whether the baby's intestines are damaged. Sometimes a flap is needed to repair the diaphragm synthetic fabric. In this case, later, when the child is older, he will undergo another operation to replace the flap.
After the operation, the baby will again need help breathing, so he will continue to be ventilated. This is the most exciting time for parents. It's so hard to see your child connected to so many medical devices. But intensive therapy is designed to help the baby. Therefore, the child will be carefully monitored during recovery.
The duration of ventilation of the lungs depends on how badly these organs were damaged while they were being compressed by the hernia. It will take some time for the baby’s intestines to begin to function properly, so the baby will need special nutrition. Some children develop with age (when food is thrown back from the stomach into the esophagus).
What are my baby's chances of survival?
A diaphragmatic hernia can be life-threatening for your baby, especially if it is severe or your baby has other serious complications. To understand what the baby’s chances of survival are, the so-called pulmonary-head ratio (LHR) is calculated. This is done in the process ultrasound examination during pregnancy.
With a diaphragmatic hernia, the chances of survival range from 60 to 80%. But the outcome depends on which side the hernia is located on, as well as how serious the defect is.
The doctor will tell you which treatment will be most effective for the baby.
You can discuss diaphragmatic hernia with other members of our communities.
