1. anatomy hernias treatment
Diaphragm
anatomy
hernias
treatment

2. Anatomy of the diaphragm
A dome-shaped anatomical structure consisting of a muscular and tendineous part
Diaphragmatic attachments:
posterior: the first, second and third lumbar vertebra
anterior: the inferior part of the sternum
lateral: the costal arch
It separates abdominal and thoracic cavities from each other

3. Anatomy of the diaphragm
Xyphoid process
Cartilaginous part of a rib
Central lobe
Central tendon
Foramen of the caval vein
Left lobe
Right lobe
Esophageal hiatus
Right crus
Aortic hiatus
Left crus
XII rib
Lumbar quadrate muscle

4. Diaphragmatic hernias Etiology
Numerous hiatuses and foramina in the diaphragm
Complex embryology
Difference of pressure over and beneath the diaphragm

5. Diaphragmatic hernias Classification
General classification:
congenital
acquired
posttraumatic
Akerlund’s classification:
caused by congenital short esophagus
paraesophageal
sliding

6. Paraesophageal hernia
Esophagus
Normal position of gastroesophageal junction. Protrusion of the stomach alongside the esophagus.
Protrusion of the stomach into a hernia sac
Cardia
Phrenoesophageal membrane
Bending of the parietal peritoneum
Diaphragm
Diaphragm
Part of the stomach localized within the abdominal space

7. Paraesophageal hernia
good function of the lower esophageal sphincter
asymptomatic clinical course- frequently
air eructation
postprandial fulness
Complications:
bleeding
incarceration
acute dysphagia
strangulation
Treatment - surgical management

8. Sliding hernia Most common. Gastroesophageal junction above the
Esophagus
Most common.
Gastroesophageal
junction above the
diapragm.
Bending of the parietal peritoneum
Cardia
Bending of the parietal peritoneum
Protrusion of the stomach into a hernia sac
Diaphragm
Diaphragm
Phrenoesophageal membrane
Phrenoesophageal membrane
Part of the stomach localized within the abdominal space

9. Sliding hernia dysfunction of the lower esophageal sphincter
heartburn frequently made worse when a patient lies down
typical picture on x-ray examination
decreased resting pressure of the lower esophageal sphincter
Complications
esophagitis
esophageal strictures

10. Sliding hernia Treatment
Medical treatment
Surgical
Abdominal approach
Chest approach
Aims of surgical management:
Reduction of hernia
Closure of a hernial ring
Reconstruction of the Hiss’s angle

11. Congenital hernias Morgagni’s and Bochdalek’s hernia
frequently asymptomatic
diagnosed accidentally
paroxysmal or constant epigastric pain
respiratory and circulatory disturbances
ileus
Treatment- surgical management.

12. Congenital hernias Morgagni’s and Bochdalek’s hernia
Parasternal diaphragmatic hernia (Morgagni)
Posterolateral diaphragmatic hernia (Bochdalek)

13. Posttraumatic diaphragmatic hernia
Traumatic rupture of the diaphragm may result from penetrating or blunt traumas
Diaphragmatic rupture occurs usually within the central tendon more frequently on its left side
Viscera can immediately translocate into the pleural space through the diaphragmatic rupture or their displacement may be gradual and it can last months or even years.

14. Posttraumatic diaphragmatic hernia
Clinical presentation of the hernia depends on the part and amount of viscera that displaced into the pleural space.
We can observe:
bleeding
ileus
Circulatory and respiratory failure

15. Posttraumatic diaphragmatic hernia
Surgical approach through the abdominal cavity is advocated if:
recent trauma
injuries of viscera are suspected or diagnosed.
Surgical approach through the chest is advocated if diagnosis is substantially delayed and intra-abdominal injuries are excluded.