This is extremely rare view hernia, which 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 surgical operations, which are passed through a small hole in the fabric. 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 without surgical intervention the child most likely will not survive. 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.
Description:
Diaphragmatic hernia is a surgical pathology that represents the movement of organs from the abdominal cavity to the thoracic cavity through some parts of the diaphragm.
For any hernia, 2 components are required: the hernial orifice and the hernial sac. In the case of this pathology, the entrance gates are natural openings or pathological defects of the diaphragm. When a pressure gradient occurs, the esophagus (abdominal part), stomach, intestinal loops, liver, and spleen penetrate into the chest cavity. They will be the content hernial sac.
In infants with a congenital diaphragmatic hernia, the picture is different. The child's condition has been severe since birth, due to respiratory failure. Skin cyanotic, an increase in the dynamics of the respiratory rate with the participation of auxiliary muscles, impaired consciousness as a result.
Diagnostics:
The diagnosis algorithm includes:
1. Collection of complaints and medical history.
2. Objective examination. Allows you to identify retraction of the abdomen, bowel sounds over the lung area, impaired participation chest in the act of breathing, a shift in the boundaries of the heart to the healthy side.
3. Instrumental examination. The “gold standard” for diagnosis is the chest organs. The picture of the overview image will depend on the contents of the hernial sac. A dense liver appears as a darkening of the lung fields, and a hollow stomach or intestines appears as a clearing. In some cases, they resort to the X-ray contrast method using a barium suspension. This procedure will allow you to most accurately identify the location and size of the defect.
Other studies - fibrogastroduodenoscopy, ECG. They are used to differentiate from inflammatory pathologies of the gastrointestinal tract and cardiovascular diseases.
Important! Newborns have a diaphragmatic hernia, unlike others birth defects, is not detected on prenatal ultrasound. This is due to the appearance of a hernial protrusion only at the moment of the first breaths.
Treatment:
A patient with a diaphragmatic hernia often requires surgery. The essence surgical correction- relegation of the organ to abdominal cavity followed by suturing the defect. At large sizes holes and their inconsistencies are repaired with a synthetic mesh.
Important! Strangulated hernia- absolute indication for emergency surgery.
Conservative drug treatment is symptomatic. Antacids and antispasmodics are prescribed. Required condition treatment is to normalize the diet. Food portions should be small, the intake should be fractional, and the consistency should be puree.
Diaphragmatic hernia with timely and adequate treatment has a favorable prognosis for life and health.
There are 3 types of diaphragmatic hernia - posterolateral (Bochdalek hernia), parasternal (Morgagni hernia) and central (phrenopericardial hernia). Bochdalek's hernia is the most common option, it occurs in 80% of cases. Due to a posterolateral defect of the diaphragm, the intestine moves into the chest, the lung is compressed and its hypoplasia develops.
2. What is the clinical picture of congenital diaphragmatic hernia?
The main symptom of congenital diaphragmatic hernia is breathing problems. From birth or in the first hours of life, the newborn experiences severe shortness of breath, retraction of the intercostal spaces during inspiration, and cyanosis. An objective examination reveals a sharp weakening of respiratory sounds on the affected side. It is better to listen to the sounds of the heart on the opposite side. Due to the fact that the newborn breathes with effort, air enters the intestines. The latter expands and further disrupts breathing.
Left to its natural course, a diaphragmatic hernia leads to mediastinal displacement, impaired venous return and cardiac output.
3. What confirms the diagnosis of diaphragmatic hernia?
The diagnosis of a diaphragmatic hernia is confirmed by the detection on a chest x-ray in a direct projection of multiple intestinal loops filled with gas on the side of the hernia. However, if x-rays are taken before air has entered the intestines, only a displaced mediastinum, an unusual position of the heart, and darkening of one side of the chest are revealed.
To confirm the diagnosis, radiography is repeated after the introduction of air or a contrast agent through a gastrogastric tube.
4. What developmental defects accompany congenital diaphragmatic hernia?
In 50% of cases of diaphragmatic hernia there are associated developmental defects. With multiple severe concomitant defects, less than 10% of patients survive. In cases where a congenital diaphragmatic hernia is detected in the prenatal period (before 25 weeks of pregnancy), the malformations are often potentially fatal.
In addition to incomplete intestinal rotation and pulmonary hypoplasia, heart defects are especially common (63%), followed in frequency by defects of the urinary tract and genital organs (23%), gastrointestinal tract(17%), central nervous system(14%) and additional lung defects (5%).
5. What therapeutic measures should precede transportation of the child and surgery?
Perhaps the simplest and most effective palliative measure is gastric decompression by inserting a gastrogastric tube. It prevents further distension of the intestine and improves pulmonary ventilation. Endotracheal intubation ensures adequate pulmonary ventilation and oxygenation. In addition, it also prevents further distension of the intestine.
Since pulmonary hypoplasia predisposes to barotrauma, inspiratory pressure should not exceed 30 mmHg. Adequacy of mechanical ventilation is ensured by increasing the respiratory rate to 40-60 per minute. In addition, it is necessary to ensure venous access, adequate fluid administration and correction of acidosis.
6. What is a period of imaginary well-being?
While 65% of children with congenital diaphragmatic hernia are stillborn or die shortly after birth, 25% are diagnosed with this malformation after 28 days of life. Children who develop symptoms of a congenital diaphragmatic hernia after the first 24 hours of life have an almost 100% survival rate. The severity of breathing problems depends on the degree of pulmonary hypoplasia. The absence or mild severity of respiratory disorders in a newborn indicates a sufficient lung volume compatible with life.
The period of apparent well-being is the period of time during which the newborn's ventilation and oxygenation remain adequate without intensive care. Despite subsequent decompensation, the presence of this period indicates pulmonary function compatible with life.
7. What are the principles of surgical correction of congenital diaphragmatic hernia?
Before surgery, it is necessary to stabilize the child's condition. Optimal time operation is not installed. Congenital causes physiological disorders in the lungs, which by themselves do not eliminate the restoration of the integrity of the diaphragm, so there is no need to perform it urgently. In cooperative research current state problems of surgical correction of congenital diaphragmatic hernia Clark et al found that average age, in which it was produced, exceeded 1 day of life.
In cases where extracorporeal membrane oxygenation was used, the age was 170 hours, in the rest - 73 hours. Used as transabdominal or transthoracic access. Transabdominal access is preferred for the following reasons:
(1) it makes it easier to return internal organs into the abdominal cavity;
(2) allows you to eliminate the diaphragm defect with sufficient visibility and without tension;
(3) facilitates the identification and correction of concomitant malformations, including those that impair intestinal patency and
(4) if the initial dimensions of the abdominal cavity are insufficient to accommodate the internal organs, it allows them to be enlarged or a hernial sac is created abdominal wall using a prosthetic flap.
Transthoracic access is used mainly for recurrent diaphragmatic hernia and in children over 1 year of age.
8. What is the most dangerous complication of congenital diaphragmatic hernia? Is it removable, and how?
With a congenital diaphragmatic hernia, one or both lungs are hypoplastic. Their circulatory system underdeveloped. The arteries are thickened muscle layer and have increased reactivity. Without correction of congenital diaphragmatic hernia, the child quickly develops a persistent fetal type of blood circulation, which is the most dangerous complication.
Persistence of fetal fluid in the blood circulation is caused by a prolonged increase in pressure in pulmonary artery. Blood is discharged, bypassing the lungs (right-left shunt). Unoxygenated blood returns to big circle blood circulation through open ductus arteriosus and a patent foramen ovale. Persistence of the fetal type of blood circulation leads to hypoxemia, deep acidosis and shock. The trigger mechanism for its formation is acidosis, hypercapnia and hypoxia, which affect blood vessels lungs sharp vasoconstrictor effect.
To prevent the development of persistent fetal circulation, the following measures are used:
a) Blood oxygenation monitoring or sampling arterial blood on the preductal (from the arteries right hand) and postductal (from the arteries of the legs) level, revealing the discharge of non-oxygenated blood into the systemic circulation.
b) The optimal ventilation mode for preventing hypercapnia is with a high respiratory rate and low inspiratory pressure; sufficient introduction sedatives, if necessary, the use of muscle relaxants.
c) Adequate artificial ventilation of the lungs with a gas mixture with a high, usually 100%, oxygen content, to avoid hypoxemia.
d) Restoring tissue perfusion by sufficient administration of electrolyte solutions or blood, inotropes and sodium bicarbonate, eliminating metabolic acidosis.
If these measures do not produce an effect, they are supplemented with the introduction of drugs that dilate the arteries of the pulmonary circulation (nitric oxide by inhalation, intravenous priscoline or prostaglandin E2); high frequency artificial ventilation lungs and, finally, resort to extracorporeal membrane oxygenation. In addition, complications include pulmonary barotrauma and pneumothorax and bleeding, especially when extracorporeal membrane oxygenation is used.
9. What is the survival rate for congenital diaphragmatic hernia?
The overall survival rate is 60%. The survival rate is determined mainly by the degree of pulmonary hypoplasia and the presence of severe accompanying defects development. In children who did not have in the first days of life severe violations breathing, the survival rate is approaching 100%. In those clinics that use intensive care methods such as extracorporeal membrane oxygenation or inhaled nitric oxide, the survival rate is no higher than in others.
"Hello! I can’t find material anywhere about erosion of the esophagus (as a result of a hernia hiatus). This is exactly the diagnosis I was given more than a year ago. I had prosthetic surgery in May last year. hip joint, and the erosion worsened. From medications special effect I don't receive it. From mouth - bad smell, which I can’t drown out with anything. In addition, I experience pain when swallowing. Maybe there is folk remedies from this misfortune? I really hope for your help in . Sincerely, Irina Evgenievna, Tambov region, Petrovsky district.”
We asked the doctor, Ph.D., to respond. Selivanov A.D.:
Let's start, perhaps, with the most important thing: what are the reasons for the appearance of such hernias? The main points in the development of hernias can be: increased intrauterine pressure; shortening of the esophagus (scarring-inflammatory process, tumor, etc.); decreased muscle tone; atrophy of the left lobe of the liver; complete disappearance of adipose tissue under the diaphragm; stretching of the esophageal opening in the diaphragm; rachiocampsis thoracic(kyphosis) in the elderly and old age and others. These factors most often lead to the development of axial (axial, sliding) hernias.
The disease is often vague and asymptomatic. However, burning, sharp and dull pain in the chest, in the abdominal cavity with various irradiations, often provoking angina pain. Unpleasant painful sensations usually associated with food, a sudden change in body position, accompanied by a feeling of fullness, decreases significantly in vertical position. Frequent symptoms also include belching, hiccups, regurgitation, vomiting, dysphagia (swallowing disorder), increased salivation, oral bad smell. In particular, for our reader, a complication of the disease was the development of esophageal erosion.
The diagnosis is usually made after a thorough x-ray examination in the clinic, which allows you to quickly identify the hernia and confirm gastrointestinal reflux (reflux). Moreover, the examination is carried out not only in a vertical position, but also in a horizontal position of the patient. Esophagogastroscopy allows you to assess the level of esophagitis (inflammation of the esophagus) and diagnose an axial hernia. Besides, specific diagnostics axial hernias are carried out using the method of graphic recording inside the esophageal and gastric pressure - esophagotonocymography. Biochemical and general analysis blood, general urine analysis, stool blood test, etc.
We were asked about folk methods treatment, in this regard I can recommend treatment herbal infusions. This topic is large and I would like to dwell on it in more detail, but in the next posts. In the meantime, take advantage of one more piece of advice - buy a comfortable and healing mattress, which you can choose from the Matras-Inter online store - the manifestation of the disease being considered today depends on the position of the body in sleep. And prepare the following plants for collection, we will prepare them - knotweed root, crushed calamus rhizome, stinging nettle flowers, crushed dandelion roots, oregano, corn silk and crushed blood-red hawthorn fruits.
Diaphragmatic hernia- movement of the abdominal organs into the chest cavity through congenital or acquired defects. There are congenital, acquired and traumatic hernias.
False hernias do not have a peritoneal hernial sac. They are divided into congenital and acquired. Congenital hernias are formed as a result of non-closure in the diaphragm of the communications existing in the embryonic period between the thoracic and abdominal cavities. Traumatic acquired false hernias are much more common. They occur with injuries to the diaphragm and internal organs, as well as with isolated ruptures of the diaphragm measuring 2-3 cm or more in both the tendon and muscle parts.
True hernias have a hernial sac covering the prolapsed organs. They occur when intra-abdominal pressure increases and the abdominal organs protrude through existing openings: through the sternocostal space (parasternal hernias - Larrey, Morgagni) or directly in the area of the underdeveloped sternal part of the diaphragm (retrosternal hernia), Bochdalek's diaphragmatic hernia - through the lumbocostal space. The contents of the hernial sac, both acquired and congenital hernia there may be an oil seal, transverse colon, preperitoneal fatty tissue(parasternal lipoma).
True hernias of atypical localization are rare and differ from relaxation of the diaphragm by the presence of a hernial orifice, and therefore the possibility of strangulation.
Hiatal hernias are classified as a separate group, as they have a number of features
Clinical picture and diagnosis. The severity of symptoms of diaphragmatic hernia depends on the type and anatomical features displaced abdominal organs in pleural cavity, their volume, degree of filling with contents, compression and bending in the area of the hernial orifice, degree of lung collapse and mediastinal displacement, size and shape of the hernial orifice.
Some false hernias (prolapse) may be asymptomatic. In other cases, symptoms can be divided into gastrointestinal, pulmonary-cardiac and general.
Patients complain of a feeling of heaviness and pain in the epigastric region, chest, hypochondrium, shortness of breath and palpitations that occur after a heavy meal; gurgling and rumbling in the chest on the side of the hernia and increased shortness of breath in a horizontal position are often noted. After eating, vomiting of ingested food occurs. When gastric volvulus is accompanied by a bend in the esophagus, paradoxical dysphagia develops (solid food passes better than liquid food).
When a diaphragmatic hernia is strangulated, sharp paroxysmal pain occurs in the corresponding half of the chest or in the epigastric region and symptoms of acute intestinal obstruction. Infringement of a hollow organ can lead to necrosis and perforation of its wall with the development of pyopneumothorax.
A diaphragmatic hernia can be suspected if there is a history of trauma, the complaints listed above, decreased mobility of the chest and smoothing of the intercostal spaces on the affected side. Also characteristic are retraction of the abdomen with large, long-standing stools, dullness or tympanitis over the corresponding half of the chest, changing intensity depending on the degree of filling of the stomach and intestines. During auscultation, peristaltic bowel sounds or splashing sounds in this area are heard with simultaneous pain or complete absence breathing sounds. There is a shift of mediastinal dullness to the unaffected side.
The final diagnosis is made when x-ray examination and more informative computed tomography. When the stomach prolapses into the pleural cavity, a large horizontal level of fluid is visible in the left half of the chest. When loops fall out small intestine against the background of the pulmonary field, individual areas of clearing and darkening are determined. Movement of the spleen or liver produces darkening in the corresponding part of the pulmonary field. In some patients, the dome of the pragma and the abdominal organs located above it are clearly visible.
During a contrast study of the digestive tract, the nature of the prolapsed organs is determined (hollow or parenchymal), the location and size of the hernial orifice are specified based on the pattern of compression of the prolapsed organs at the level of the hole in the diaphragm (symptom of the hernial orifice). In some patients, to clarify the diagnosis, it is advisable to perform thoracoscopy or apply pneumoperitoneum. With a false hernia, air can pass into the pleural cavity (the picture of pneumothorax is determined by x-ray).
Treatment. Due to the possibility of strangulation of the hernia, surgery is indicated. If the hernia is located on the right side, the operation is performed through a transthoracic approach in the fourth intercostal space; for parasternal hernias better access is the upper median laparotomy; for left-sided hernias, transthoracic access is indicated in the seventh-eighth intercostal spaces.
After dividing the adhesions and freeing the edges of the defect in the diaphragm, the displaced organs are brought down into the abdominal cavity and the hernial orifice (defect in the diaphragm) is sutured with separate interrupted sutures to form a duplicate. If the diaphragm defect is large, it is covered with a synthetic mesh (lavsan, Teflon, etc.).
In case of parasternal hernias (Larrey's hernia, retrosternal hernia), the displaced organs are removed from the chest cavity, the hernial sac is everted and cut off at the neck. U-shaped sutures are applied and sequentially tied to the edges of the diaphragm defect and the posterior layer of the sheath of the abdominal muscles, the periosteum of the sternum and ribs.
In case of hernias of the lumbocostal space, the diaphragm defect is sutured with separate sutures to form a duplicate.
For strangulated diaphragmatic hernias, transthoracic access is performed. After dissection of the strangulating ring, the contents of the hernial sac are examined. If the viability of the prolapsed organ is preserved, it is replaced into the abdominal cavity; if the changes are irreversible, it is resected. The defect in the diaphragm is sutured.
