Congenital diaphragmatic hernia. Double recurrent hiatal hernia

Diaphragmatic hernia- movement of the abdominal organs 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 existing embryonic period communications between the thoracic and abdominal cavities. Traumatic acquired false hernias are much more common. They occur with injuries of the diaphragm and internal organs, as well as with isolated ruptures of the diaphragm measuring 2-3 cm or more, both in the tendon and in its muscular parts.

True hernias have a hernial sac covering the prolapsed organs. They occur when there is an increase intra-abdominal pressure and the exit of the abdominal organs through the existing openings: through the sternocostal space (parasternal hernias - Larrey, Morgagni) or directly in the region 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 with acquired and with congenital hernia, can be an omentum, transverse colon, preperitoneal adipose tissue(parasternal lipoma).

True hernias of atypical localization are rare and differ from the relaxation of the diaphragm by the presence of a hernial orifice, and, consequently, the possibility of infringement.

Hernias esophageal opening 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 of them 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, the symptoms can be roughly divided into gastrointestinal, pulmonary, 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 are often noted, increased shortness of breath in horizontal position. After eating there is vomiting of food taken. With a torsion of the stomach, accompanied by an inflection of the esophagus, paradoxical dysphagia develops (solid food passes better than liquid food).

When a diaphragmatic hernia is infringed, 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.

Diaphragmatic hernia can be suspected if there is a history of injury, the complaints listed above, a decrease in chest mobility and smoothing of the intercostal spaces on the side of the lesion. Also characteristic are the retraction of the abdomen with large long-term kah, 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 noises of the intestines or splashing noise in this area are heard with simultaneous total absence breath 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 enlightenment and darkening are determined. Moving the spleen or liver gives a darkening in the corresponding section of the lung field. In some patients, the dome of pragma is clearly visible and abdominal organs located above it.

In 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 picture of compression of the prolapsed organs at the level of the opening in the diaphragm (symptom of the hernial orifice). For some patients, to clarify the diagnosis, it is advisable to perform thoracoscopy or impose pneumoperitoneum. With a false hernia, air can pass into the pleural cavity (X-ray determines the picture of pneumothorax).

Treatment. In connection with the possibility of infringement of the hernia, an operation is indicated. With right-sided localization of the hernia, the operation is performed through transthoracic access in the fourth intercostal space; with parasternal hernias, the best approach is the upper median laparotomy; with left-sided hernias, transthoracic access is shown in the seventh-eighth intercostal space.

After the separation of adhesions, the release of the edges of the defect in the diaphragm, the displaced organs are reduced to abdominal cavity and the hernial orifice (diaphragm defect) is sutured with separate interrupted sutures to form a duplication. At large sizes diaphragm defect, it is covered with a synthetic mesh (lavsan, teflon, etc.).

With 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. Apply and sequentially tie U-shaped sutures on the edges of the diaphragm defect and the posterior leaf of the vagina abdominal muscles, periosteum of the sternum and ribs.

In hernias of the lumbocostal space, the defect of the diaphragm is sutured with separate sutures with the formation of duplication.

With strangulated diaphragmatic hernia, transthoracic access is performed. After dissection of the restraining ring, the contents of the hernial sac are examined. While maintaining the viability of the prolapsed organ, it is inserted into the abdominal cavity, with irreversible changes- resect. The defect in the diaphragm is sutured.

Description:

Diaphragmatic hernia is a surgical pathology, which is the movement of organs from the abdominal cavity into the chest through some parts of the diaphragm.
For any hernia, 2 components are required: a hernial orifice and a hernial sac. In this pathology entrance gate serve as natural holes 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, in the presence of congenital diaphragmatic hernia, the picture is different. The child's condition is severe from 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 diagnostic algorithm includes:

1. Collection of complaints and anamnesis of the disease.

2. Objective examination. Allows you to identify the retraction of the abdomen, intestinal noise above the zone of the lungs, violation of the participation of the chest in the act of breathing, displacement of the borders of the heart in a healthy direction.

3. Instrumental examination. The "gold standard" of diagnostics is chest organs. Painting overview shot will depend on the contents of the hernial sac. A dense liver looks like a darkening of the lung fields, and a hollow stomach or intestines - an enlightenment. In some cases, they resort to the radiopaque method using a barium suspension. This procedure will most accurately determine the location and size of the defect.

Other studies - fibrogastroduodenoscopy, ECG. They are used for differentiation with inflammatory pathologies of the gastrointestinal tract, cardiovascular diseases.

Important! In newborns, diaphragmatic hernia, unlike other birth defects not detected on prenatal ultrasound. This is due to the appearance of a hernial protrusion only at the time of the first breaths.

Treatment:

A patient with diaphragmatic hernia often needs surgery. essence surgical correction- bringing the organ into the abdominal cavity with subsequent suturing of the defect. With large sizes of the hole and its inconsistency, plastic surgery is carried out with a synthetic mesh.

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

conservative drug treatment is symptomatic. Prescribe antacids, antispasmodics. A prerequisite treatment is the normalization of diet. Portions of food should be small, fractional intake, puree-like consistency.

Diaphragmatic hernia with timely and adequate treatment has a favorable prognosis for life and health.

Diaphragmatic hernia(DG) make up 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 Pare (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 mesoesophagus.

Complicated disorders embryonic development, can lead to a newborn partial or complete defect of the diaphragm. 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 speak of eventration). With more later dates development, when the membranous diaphragm has already formed and the development of the muscular part is only delayed, the hernial sac, consisting of two serous films, penetrates through the hernial ring that does not contain the muscle.

The place of penetration of sternocostal hernias (sternocostal) is a muscle-free area of ​​​​connection with the sternum and costal part. This place is called the sternocostal triangle of Larrey, and such hernias are called hernias of the Larrey triangle. In the absence of a serous cover, there is a sternocostal foramen of Morgagni.

Due to the anatomical features of the location of the anterior and back 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 hernia;

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 injuries are mostly false, closed injuries- true and false.

With non-traumatic hernias, the only false one is a congenital hernia - a defect in the diaphragm, due to non-closure between the chest and abdominal cavities.

From the weak areas of the diaphragm - these are hernias of the sternocostal triangle zone (Bogdalek's fissure). 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 ​​the underdeveloped sternal part of the diaphragm is retrosternal hernia.

Rare (extremely) hernias of the fissure of the sympathetic nerve, vena cava, aorta. In terms of frequency, hiatal hernias (HH) are in the first place, they make up 98% of all diaphragmatic hernias of non-traumatic origin.

hiatal hernia

Anatomical features. The esophagus passes from the chest cavity into 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 crura of the diaphragm also form the anterior loop, which in most cases is formed from right leg. Behind the esophagus, the crura 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 region of the esophagus are described. In 50% of cases, the esophageal opening is formed from the right crus of the diaphragm, in 40% there are inclusions of muscle fibers from the left crus. Both diaphragmatic legs start from the lateral surfaces from the I-IV lumbar vertebrae. The esophageal ring contracts somewhat during inhalation, resulting in an increase in the esophageal kink at the esophageal opening. 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 esophageal-gastric 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's valve), play the role of an additional valve. When pressure rises in the stomach, especially in the region of its bottom, left half semicircles of the esophageal-gastric junction shifts to the right, blocking the entrance to the esophagus. The cardial section 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. On the eye you can see the junction of the mucous membrane of the esophagus with the gastric mucosa. The junction of the mucous membranes is located next to the anastomosis, but does not necessarily correspond to it.

There is no anatomically expressed 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 sheets of the transverse fascia of the abdomen and intrathoracic fascia. The diaphragmatic-esophageal ligament is attached around the circumference of the esophagus in its diaphragmatic part. Attachment of the ligament occurs in a fairly wide area - from 3 to 5 cm in length. The superior leaflet of the phrenoesophageal ligament is usually attached 3 cm above the junction squamous epithelium into a cylindrical one. The lower sheet 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 that connect to the muscular membrane of the esophagus. This attachment provides dynamic interaction between the esophagus and the diaphragm during the act of swallowing and during breathing, when the abdominal esophagus lengthens or contracts.

The closing mechanism of the esophagus. There is no anatomically expressed sphincter in the region of the cardiac region. It has been established that the diaphragm and its legs do not take part 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 acid. gastric juice. Normally, pressure seems to predispose to its appearance, 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 esophagus, regardless of the position of the body and respiratory cycle. This department has a pronounced motor function, which is convincingly proved by physiological, pharmacological and radiological studies. This part of the esophagus acts as an esophageal-gastric sphincter; When the peristaltic wave approaches, it completely relaxes.

There are several variants of hernias of the esophageal-gastric opening of the diaphragm. BV 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. Stuffing box

should be distinguished : 1. Congenital "short esophagus" with intrathoracic location of the stomach; 2. Paraesophageal hernia, when part of the stomach is introduced to the side of the normally located esophagus; 3. Sliding GPO, when the esophagus, together with the cardial part of the stomach, is drawn into the chest cavity.

Sliding hernia is so called because the posterior top part the cardial part of the stomach is not covered by the peritoneum and, when the hernia is displaced into the mediastinum, it slips according to the type of exit Bladder or cecum with inguinal hernia. In a paraesophageal hernia, an organ or part of an abdominal organ passes into the esophagus to the left of the esophagus, while the cardia of the stomach remains fixed in place. Paraesophageal hernias, as well as sliding hernias, can be congenital or acquired, but congenital hernias are much less common than acquired ones. Acquired hernias are more common in people over the age of 40. The age-related involution of tissues matters, which leads to the expansion of the esophageal opening of the diaphragm, weakening the connection of the esophagus with 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, constant wear tight belts. Traction factor - hypermotility of the esophagus associated with frequent vomiting, as well as violation nervous regulation motility.

Paraesophageal hernia

The hernial 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 a hernial sac lined with a fibrously altered diaphragmatic peritoneum. The stomach is, as it were, wrapped in a defect in relation to the esophageal-gastric junction fixed in the hole. The degree of twist can be different.

Clinic. Clinical symptoms in paraesophageal hernia are mainly due to the accumulation of food in the stomach, partially located in the chest cavity. sick feel pressing pains behind the sternum, especially intense after eating. At first they avoid eating in 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 hernia.

When a hernia is incarcerated, a progressive stretching of the prolapsed part of the stomach occurs until it ruptures. Rapidly developing mediastinitis with severe pain, signs and accumulation of fluid in the left pleural cavity. A hernia may be the cause of the development peptic ulcer stomach, as the passage of food from the deformed stomach is disturbed. These ulcers are difficult to treat and are often complicated by bleeding or. The diagnosis is made mainly by x-ray if a gas bubble is found in the chest cavity. A barium study confirms the diagnosis.

In order to find out the type of hernia, it is very important to determine the localization of the esophageal-gastric anastomosis. With the help of esophagoscopy, concomitant esophagitis can be diagnosed.

Clinic. Most typical features are: pain after eating in the epigastric region, belching, vomiting. With prolonged stay of the stomach in hernial opening diaphragm, dilatation of the veins of the distal esophagus and cardia may occur, manifested by hematemesis.

Treatment. Conservative therapy consists in a special diet. Food should be taken frequently and in small portions. Diet in in general terms similar to antiulcer. After eating, it is recommended to take walks and in no case lie down. To prevent possible complications- infringement and rupture of the wall shows surgical treatment. Optimal access is transabdominal. With gentle sipping, the stomach is lowered into the abdominal cavity. The hernial orifice is sutured with additional closure of the angle of His or esophagofundoplication. Relapses are rare. After the operation, clinical symptoms decrease, nutrition improves.

sliding hernia

The cause of this hernia is the pathology of the phrenoesophageal ligament, which fixes the esophageal-gastric fistula inside the esophageal opening of the diaphragm. Part of the cardial part of the stomach is displaced upward into the chest cavity. The phrenoesophateal ligament becomes thinner and longer. The esophageal opening in the diaphragm expands. Depending on the position of the body and the filling of the stomach, the esophageal-gastric anastomosis is shifted from the abdominal cavity to the chest and vice versa. When the cardia is shifted upward, the angle of His becomes obtuse, the folds of the mucous membrane are smoothed out. The diaphragmatic peritoneum is displaced 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 constant presence of the esophageal-gastric anastomosis above the diaphragm. In advanced cases, fibrous stenosis occurs. Sliding hernias are never infringed. If compression of the cardia displaced into the chest cavity occurs, then circulatory disturbance does not occur, since the outflow venous blood is carried out through the esophageal veins, the contents can be emptied through the esophagus. Sliding hernia is often associated with reflux esophagitis.

The displacement of the cardiac section upward leads to a smoothing of the His angle, the activity of the sphincter is disrupted, and the possibility of gastroesophageal reflux is created. However, these changes are not regular, and a significant number of patients do not develop reflux esophagitis, because physiological function sphincter is preserved. Therefore, one displacement of the cardia is not enough to develop sphincter insufficiency, in addition, reflux can be observed without sliding hernia. An unfavorable ratio 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 proceeds even more severely than peptic. Esophagitis can become erosive and even ulcerative. Permanent inflammatory edema of the mucous membrane contributes to its easy traumatization with hemorrhages and bleeding, which sometimes manifests itself in the form of anemia. Subsequent scarring leads to the formation of strictures and even complete closure of the lumen. Most often, reflux esophagitis accompanies a cardiac hernia, less often a cardiofundal one.

Clinic. Sliding hernias without complications are not accompanied by clinical symptoms. Symptoms occur when gastroesophageal reflux and reflux esophagitis join. Patients may complain of heartburn, belching, regurgitation. The appearance of these symptoms is usually associated with a change in body position, the pain intensifies after eating. Most common symptom burning behind the sternum is observed in 90% of patients. Pain can be localized in the epigastric region, left hypochondrium, and even in the region of the heart. They do not look like ulcers, because they appear immediately after eating, are associated with the amount of food taken, especially painful after a heavy meal. Relief occurs after taking drugs that reduce acidity in the stomach. Regurgitation occurs in half of the cases, especially after taking a heavy meal, bitterness is often felt in the larynx. Dysphagia is a late symptom and occurs in 10% of cases. It develops due to spasms of the inflamed distal end of the esophagus. Dysphagia periodically occurs, periodically disappears. If inflammatory changes progress, dysphagia occurs more frequently and may become permanent.

From the resulting ulceration of the esophagus, bleeding may occur, which proceed hidden.

Kasten's syndrome- a combination of HPD, chronic cholecystitis and peptic ulcer duodenum.

Diagnostics difficult. Patients are most often interpreted as suffering from peptic ulcer, cholecystitis, angina pectoris or pleurisy. Notable cases erroneous puncture of the pleural cavity and puncture or even drainage of a hollow organ (in their practice, they observed how the drainage tube was installed twice in the fundus of the stomach) due to the suspicion of exudative pleurisy.

Triad Senta: HH, cholelithiasis, diverticulosis of the large intestine.

Diagnosis is difficult. Patients are more often treated as suffering cholelithiasis or chronic colitis. Occurs more often during surgery for acute calculous cholecystitis or acute intestinal obstruction with infringement of the colon in a hernia.

An x-ray may help. But it helped us put correct diagnosis and to choose the optimal tactics in a patient admitted with a clinic of acute destructive cholecystitis. The patient underwent cholecystectomy, elimination of irreducible HH with resection of the transverse colon and descending colon, suturing the hernial orifice with esophagofundoplication according to Nissen.

decisive role plays in the diagnosis X-ray examination. In the diagnosis of HH, the main diagnostic method- X-ray. Quincke position (legs above head). Direct symptoms of HH include swelling of the cardia and fornix of the stomach, increased mobility abdominal esophagus, smoothness, absence of an angle of His, anti-peristaltic 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 worth of information endoscopic methods , which, in combination with x-ray studies allow you to increase the percentage of detection this disease up to 98.5%. Characteristic: 1) a decrease in 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 migration 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 reveals EC in 89% of patients. Manometric method for determining the state of the pumping station. With a paraesophageal type of hernia, a diagnostic is offered.

Laboratory research play a supporting role. A significant number of patients with esophageal hernia and esophagitis also suffer from duodenal ulcer or gastric hypersecretion characteristic of peptic ulcer. 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, a Bernstein test is performed. Introduced 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 introduction of hydrochloric acid causes symptoms of esophagitis in the patient.

Treatment. Conservative treatment for a sliding hernia with esophagitis is usually not very successful. It is necessary to exclude tobacco, coffee, alcohol. Food should be taken in small portions, it should contain minimal amount fat remaining in the stomach for a long time. Raising the head end of the bed reduces the possibility of reflux. Drug antiulcer therapy is reasonable, although its effectiveness is low. Antiseptics are contraindicated because they increase congestion in the stomach. Indications for surgery are: inefficiency conservative therapy and complications (esophagitis, impaired patency of the esophagus, severe deformation of the stomach, etc.).

There are many surgical methods for the treatment of HH. They are mainly subject to two requirements: 1) reposition and retention under the diaphragm of the esophageal-gastric junction; 2) restoration of a permanent acute cardiofundal angle.

An interesting operation is the anterolateral movement of the POD with suturing the hernial orifice tightly.

R. Belsey in 1955 first reported on transthoracic esophagofundoplication followed by fixation to the diaphragm with U-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 operation with "calibration" of the cardia. Some surgeons use esophagofundoraphy (suturing of the fundus of the stomach with the terminal part of the 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 deserves attention also because some patients with eeophagitis have lesions biliary tract that require surgical correction. Approximately 1/3 of patients with esophagitis suffer from duodenal ulcers, so it is advisable to combine hernia repair with vagotomy and pyloroplasty. Common surgical method treatment is the Nissen operation in combination with the closure of the Angle of His. In 1963, Nissen proposed a fundoplication for the treatment esophageal hernia complicated by esophagitis. In this operation, the fundus of the stomach is wrapped around the abdominal esophagus, the edges of the stomach are sutured together with the wall of the esophagus. With a particularly wide esophageal opening, the legs of the diaphragm are sutured. This operation well prevents cardio-esophageal reflux and at the same time does not interfere with the passage of food from the esophagus. The Nissen fundoplication is equally good for treating a hernia and preventing reflux. Relapses of the disease are rare, especially in unopened cases. Restoration of anatomical relationships with a sliding hernia leads to a cure for reflux esophagitis. With hernias, combined with shortening of the esophagus due to esophagitis, top scores gives BV Petrovsky's operation. After the fundoplication, the diaphragm is incised anteriorly, the stomach is sutured to the diaphragm with separate sutures and remains fixed in the mediastinum (mediastinolization of the cardia). After this operation, the reflux disappears due to the presence of the valve and there is no infringement of the stomach, since the opening in the diaphragm becomes sufficiently wide. 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 the use of a transpleural fundoplication in such patients, leaving upper section cardia in the pleural cavity. BV Petrovsky in these cases uses valvular gastroplication, which can be performed transabdominally, which is very important for elderly patients.

Traumatic diaphragmatic hernia . It is especially necessary to distinguish between diaphragmatic-intercostal hernias, when the rupture of the diaphragm occurs at the place 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 displacement of organs that occurs after an 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 DGs). Hernias after injuries are more prone to infringement.

Factors contributing to infringement: small size of the defect, rigidity of the ring, abundant food intake, physical stress. The clinical picture with infringements corresponds to the clinic of intestinal obstruction. If the stomach is infringed, it is not possible to install a gastric tube.

Differential Diagnosis

between DG and diaphragm relaxation. Pneumoperitoneum.

Operational treatment

Transpleural or transabdominal access.

Tasks of a General Practitioner

- if there are complaints characteristic of gastrointestinal manifestations (dysphagia, nausea, vomiting, peristaltic noises in the chest, etc., especially after eating, lifting weights) or cardiorespiratory (cyanosis, shortness of breath, seizures, under the same conditions), the patient should be referred for an examination.

This is an extremely rare type of hernia that occurs in only one in 2000-5000 newborns. Do not confuse it with other, more common, types of hernia.
The diaphragm is a muscular formation that separates the chest cavity from the abdominal cavity and helps to breathe. A diaphragmatic hernia occurs in utero when improper formation a hole is formed in it.
Through this hole, the organs of the abdominal cavity can penetrate into the chest and flatten the lungs of the child, preventing them from developing properly. The hole can form on either side of the baby's diaphragm, but more often it occurs on the left.

How do I know if my child has a diaphragmatic hernia?

Diaphragmatic hernia can be diagnosed using ultrasound echography during, starting from 12 weeks of pregnancy and up to childbirth.

How will this affect my child?

Shortly after birth, the baby may have severe breathing difficulties or other problems related to the heart, kidneys, or spinal cord(neural tube defect) such as spinal hernia.
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 cure 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 equipment called percutaneous fetoscopic correction of fetal tracheal occlusion (FETO).
FETO refers to surgical operations which are passed through a small hole in the tissue. The procedure is carried out between 26 and 28 weeks of pregnancy, when a special balloon is inserted into the child's trachea. It stimulates the development of the baby's lungs. Later, the balloon is removed - during pregnancy, during childbirth or after the birth of the crumbs.
FETO is performed only in specialized surgical centers. Unfortunately, diaphragmatic rupture or rupture may occur during surgery. The procedure is prescribed if, without surgery, the child is unlikely to survive. But even with FETO, the baby's chances of surviving are 50%.
In the case of moderate diaphragmatic hernia, it is better to wait with the operation 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. Shortly thereafter, the baby will need surgery under general anesthesia so that during the procedure he will sleep.
During the operation, surgeons will replace the abdominal organs and sew up the hole in the diaphragm. This can take one to two hours, depending on whether the baby's intestines have been affected. Sometimes a flap of synthetic tissue is needed to repair the diaphragm. In this case, later, when the child is older, he will have another operation to replace the flap.
After the operation, the baby will again need help in breathing, so he will continue to ventilate the lungs. For parents, this is the most exciting time. It's so hard to see your child hooked up to so many medical devices. But intensive care is designed to help the baby. Therefore, during recovery, the child will definitely be carefully monitored.
The duration of ventilation of the lungs depends on how badly these organs were damaged while the hernia was squeezing them. 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 from the stomach back into the esophagus).

What are the chances of my baby surviving?

A diaphragmatic hernia can be life threatening for your baby, especially if it's severe or your baby has other serious complications. To understand what the baby's chances of survival are, the so-called lung-head ratio (LHR) is calculated. They do it in the process ultrasound during pregnancy.
With diaphragmatic hernia, the chances of survival vary 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 what treatment will be most effective for the baby.
You can discuss diaphragmatic hernia with other members of our communities.

Correction diaphragmatic hernia in Israel is successfully carried out in a private clinic "Herzliya Medical Center". The use of innovative methods of laparoscopic surgery allowed the hospital specialists to minimize the risk postoperative complications and duration of inpatient treatment.

What is a diaphragmatic hernia?

The diaphragm is a domed muscular structure that separates the chest cavity from the abdominal cavity. In addition to the barrier function, diaphragm muscles play an important role in breathing. The diaphragm has a number of holes that allow the digestive and circulatory systems pass from the thoracic cavity into the abdominal cavity. Muscle around these openings is a relatively weak link in the organ, which often causes pathological expansion and insufficiency of barrier function, called diaphragmatic hernia or hernia of the esophagus.

Types of diaphragmatic hernias

One of the frequent 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 esophageal-gastric sphincter, being the main cause of reflux (the return of stomach contents into the esophagus). Large hiatal hernias can cause abnormal penetration of abdominal organs into chest with severe functional impairment and severe symptoms.

In clinical practice, the most common types of diaphragmatic hernias are:

• Sliding hiatal hernia. This type of hernia of the esophagus is observed in 70-80% of cases. The weakness of the esophageal ring leads to a free displacement of the posterior-upper part of the stomach, not covered by the peritoneum, into the chest cavity. In the vast majority of cases, the stomach freely returns to the abdominal cavity, which is the reason for the name of this pathology. Sliding diaphragmatic hernias are not infringed, and, as a rule, are accompanied by gastroesophageal reflux, as well as secondary changes in the esophageal mucosa (reflux esophagitis)
• Paraesophageal hernia of the diaphragm characterized by a defect to the left of the esophagus, usually not exceeding 10 centimeters. The resulting hernial sac is covered from the side of the abdominal cavity by the peritoneum, which eventually undergoes pronounced fibrotic changes. Unlike a sliding hernia, the upper part of the stomach remains fixed, while a 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

Reasons for the development of diaphragmatic hernia

Diaphragmatic hernias may develop during prenatal development and be innate. Hernia of the esophagus has a clear hereditary predisposition and is often observed in family members in several generations. Acquired hernias can be the result of injuries, wounds, as well as surgical interventions on the abdominal organs and the diaphragm. Rarely develop due to systemic diseases connective tissue and violations of the innervation of the diaphragm (most likely, there is an increase in the previously existing small hernia, which does not cause clinical manifestations before).

Diaphragmatic hernia symptoms

Clinical manifestations of diaphragmatic hernia depend mainly on the size of the defect. Large congenital hernias can cause the newborn's stomach and part of small intestine located in the chest, causing serious violations respiration and hemodynamics. AT adulthood The main complaints of patients with diaphragmatic hernia are:

• Chest pain that occurs intermittently and is usually associated with eating. Often required differential diagnosis with ischemic heart disease, diseases of the lungs and mediastinum
• Respiratory disorders, as well as signs of chronic oxygen deficiency. Often there is a collapse and atelectasis of one of the lungs, caused by pressure from outside
• Symptoms of heart failure. Violation of the ratio of the mediastinal organs leads to a 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 (pain in the epigastric region, heartburn, burning sensation behind the sternum, bad smell from mouth
• Symptoms of intestinal obstruction in case of infringement

Diagnosis of diaphragmatic hernia

In the private clinic "Herzliya Medical Center" all modern methods diagnostics, allowing to timely determine the presence of a diaphragmatic hernia, including:

• Ultrasound examination, including intrauterine ultrasound of the fetus
• Radiography using contrast medium. This method lets with high precision 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.

Diaphragmatic hernia repair at Herzliya Medical Center clinic

Large congenital diaphragmatic hernias, accompanied by the movement of the abdominal organs into the chest, require emergency surgical intervention in the first days of a child's life. In the course of repairing a diaphragmatic hernia in a newborn, the displaced organs are repositioned, the stomach and intestines return to the abdominal cavity, and the diaphragm defect is sutured. emergency operation due to vital indications and the age of patients, it is carried out by 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 a 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 the leading center for abdominal, endoscopic and minimally invasive surgery in Israel. The doctors of the Herzliya Medical Center Hospital have been trained in the best surgical clinics in the USA, Europe and Canada, specializing in modern laparoscopic procedures, gradually replacing classical methods open surgery. Hospital patients are guaranteed individual approach, highly professional postoperative care, excellent service, as well as the warm and humane attitude of the multidisciplinary team.