Congenital diaphragmatic hernia. Twice recurrent hiatal hernia

Diaphragmatic hernia- movement of the abdominal organs into 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-fusion in the diaphragm of existing embryonic period messages between the chest and abdominal cavity. Traumatic acquired false hernias are much more common. They occur when the diaphragm is injured 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 there is an increase intra-abdominal pressure and exit of the abdominal organs 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 in both acquired and congenital hernia can be the omentum, 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.

Hernias hiatus diaphragms are classified as a separate group, as they have a number of features

Clinical picture and diagnostics. The severity of symptoms of diaphragmatic hernia depends on the type and anatomical features of the displaced abdominal organs in pleural cavity, their volume, degree of filling with contents, compression and bending in the area of ​​the hernial orifice, degree lung collapse and displacement of the mediastinum, 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, increased shortness of breath in horizontal position. After eating, vomiting of ingested food occurs. When gastric volvulus is accompanied by kinking of the esophagus, paradoxical dysphagia develops (solid food passes better than liquid food).

When a diaphragmatic hernia is strangulated, sharp paroxysmal pain in the corresponding half of the chest or in 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 established by 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 of the small intestine prolapse against the background of the pulmonary field, separate 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 abdominal organs located above it.

With a contrast study digestive tract determine the nature of the prolapsed organs (hollow or parenchymal), specify the location and size of the hernial orifice 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, the best access is upper median laparotomy; for left-sided hernias, transthoracic access is indicated in the seventh-eighth intercostal spaces.

After separation of the adhesions and release of the edges of the defect in the diaphragm, the displaced organs are relegated to abdominal cavity and the hernial orifice (defect in the diaphragm) is sutured with separate interrupted sutures to form a duplicate. At large sizes If there is a defect in the diaphragm, 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 on the edges of the diaphragm defect and the posterior leaf of the vagina abdominal muscles, 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 remains, it is reset into the abdominal cavity, with irreversible changes- resected. The defect in the diaphragm is sutured.

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 entrance gate serve as natural openings or pathological defects of the diaphragm. When a pressure gradient occurs, the esophagus enters the chest cavity ( abdominal part), stomach, intestinal loops, liver, spleen. They will be the contents of the 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 above the lung zone, disruption of the participation of the chest in the act of breathing, displacement of the boundaries of the heart to the healthy side.

3. Instrumental examination. The “gold standard” for diagnosis is the chest organs. Painting overview photo 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- lowering the organ into the abdominal cavity with subsequent suturing of the defect. If the hole is large and incompetent, plastic surgery is performed using a synthetic mesh.

Important! Strangulated hernia - absolute reading for emergency surgical intervention.

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.

With timely and adequate treatment, a diaphragmatic hernia has a favorable prognosis for life and health.

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).

A diaphragmatic hernia should be understood as the penetration of 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). With more later development, when the 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 the abdominal cavity by 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 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 pressure rises in the stomach, especially in the area of ​​its bottom, left half the semiring 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 superior layer of the phrenoesophageal ligament is usually attached 3 centimeters above the junction squamous epithelium into a cylindrical one. 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, since 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 high blood 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 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 upper 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 violation nervous regulation 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 behind the sternum, especially intense after eating. At first they avoid eating large quantities, then in usual 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 may cause the development peptic ulcer stomach, since the passage of food from the deformed stomach is disrupted. 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 stomach for a long time hernial opening diaphragm, dilatation of the veins of the distal esophagus and cardia may occur, manifested by hematemesis.

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 compression of the cardia displaced into the chest cavity occurs, then circulatory disturbance does not occur, since the outflow venous blood carried out through the esophageal veins, 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 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 cardiofundic 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 a late symptom and is observed in 10% of cases. It develops due to spasms of the inflamed distal end of the 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– combination of hiatal hernia, chronic cholecystitis And peptic ulcer duodenum.

Diagnostics difficult. Patients are most often interpreted as suffering from peptic ulcer, cholecystitis, angina pectoris or pleurisy. Known cases 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 deliver 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 abdominal esophagus, flatness, absence of His angle, antiperistaltic movements of the esophagus (“dance of the pharynx”), 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 duodenal ulcer 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 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 much success. It is necessary to exclude tobacco, coffee, and alcohol. Food should be taken in small portions and should contain minimum quantity fat remaining 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 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 the terminal esophagus) to restore the valvular function of the cardia.

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 that require 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, best results gives 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 in such patients using a transpleural approach, leaving upper section 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 rupture of the diaphragm occurs 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, but 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 strangulation: small size of the defect, rigidity of the ring, heavy food intake, physical stress. The clinical picture of strangulation corresponds to the clinical picture 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

- if there are complaints characteristic of gastrointestinal manifestations (dysphagia, nausea, vomiting, peristaltic sounds in the 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.

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, as a result, incorrect formation a hole is formed in it.
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. Such medical technology 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 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 of synthetic tissue is required to reconstruct the diaphragm. 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 develops severely 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.

Correction diaphragmatic hernia in Israel it is successfully carried out in the private clinic “Herzliya Medical Center”. The use of innovative laparoscopic surgery techniques allowed hospital specialists to minimize the risk postoperative complications, as well as the duration of inpatient treatment.

What is a diaphragmatic hernia?

The diaphragm is a dome-shaped muscular structure that separates the chest cavity from the abdominal cavity. In addition to the barrier function, the diaphragm muscles play an important role in the breathing process. The diaphragm has a series of holes that allow the digestive and circulatory systems penetrate from the chest cavity into the abdominal cavity. Muscle tissue around these openings 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 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 esophageal mucosa (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. Paraesophageal hernia can be complicated by strangulation with the development of acute intestinal obstruction and circulatory disorders 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 violations respiration and hemodynamics. IN mature age The main complaints of patients with diaphragmatic hernia are:

• Chest pain that occurs periodically and is usually associated with eating. Often required differential diagnosis with coronary heart disease, diseases of the lungs and mediastinum
• Breathing disorders, as well as signs of chronic oxygen deficiency. Collapse and atelectasis of one of the lungs, caused by pressure from outside, 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 sensations of peristalsis in the chest
• Symptoms of gastroesophageal reflux (epigastric pain, heartburn, burning sensation in the chest, bad smell from the 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
• Radiography using contrast agent. This method allows with high accuracy determine organ penetration 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 to the vital indications and age of the patients, it is performed using an open method.

Surgical treatment of late manifestations and acquired diaphragmatic hernias is carried out mainly 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. The doctors of the Herzliya Medical Center hospital completed training in the best surgical clinics in the USA, Europe and Canada, specializing in modern laparoscopic procedures, which have gradually replaced classical methods 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.