This document discusses the anatomy of the hiatus and diaphragm. It describes the divisions of the diaphragm including the sternal, costal, and lumbar portions. It details the medial and lateral ligaments that arise from the lumbar portion and form the median arcuate ligament. The document notes the openings in the diaphragm including the esophageal hiatus through which the esophagus passes and the vena cava hiatus through which the inferior vena cava passes. It briefly mentions conditions like hiatal hernia and GERD that can affect the esophageal hiatus.

1. Hiatal Anatomy
Dr.T.Varun Raju
Senior Laparoscopic,GI,General and Bariatric Surgeon
TVR LAPAROSCOPY CENTER
Hyderabad.

2. Why It’s Essential To Know ?
• Dissection at Surgery
• Types of the Hernias
• Eventration
• Median Arcuate ligament Syndrome
• Reconstruction without or with a mesh
• Know about it’s diseases
Congenital defects
Acquired defects
Muscular Dystrophy
Multiple Sclerosis
Lupus
Trauma
Others

3. Dissection at Surgery
• Hiatus Hernia
• G.E.R.D
• Eventration
• Median arcute syndrome

4. Diaphragm
The diaphragm
Greek: dia = in-between, phragma =
fence
Is a musculoaponeurotic structure - respiratory
muscle - between the abdominal and thoracic
cavities.

5. Anatomy
The diaphragm can be divided in sternal
costal and lumbar portions.
The sternal part arises with two small fiber bundles
from the posterior aspect of the xiphoid process, near to the
apex; the costal (or lateral) portion arises from the
inner and superior aspect of the last six ribs, with
interdigitation with the transverse muscle of the abdomen.
The lumbar portions arises from the medial, intermediate, and lateral ligaments of the diaphragm.
The medial ligaments, before reaching the vertebral bodies, delimitate with their internal muscular
bundles, at the level of D11, the esophageal hiatus for the passage of the esophagus and vagus
nerves. The right medial ligament, thicker and longer than the left one, terminates in a flattened tendon
on the anterior aspect of L2–L3 (sometimes up to L4).

6. Laterally to the right
ligament, there is a
small ligament (called
accessory or
intermediate), whose
tendon is inserted at the
level of L1–L2.
Between this ligament
and the right medial
one, there is a vertical
split crossed by the
Greater splanchnic
nerve and the medial
root of the azygos vein
INTERMEDIATE LIGAMENT

7. • The left medial
ligament
ends with a flattened
tendon between L2
and L3
• An accessory
ligament is present,
forming a split for the
large splanchnic
nerve and the medial
root of
hemiazygos
vein.
MEDIAL LIGAMENT

8. The tendons of these
two ligaments
constitute, at the level of
D12, a tendinous arch
called the median
arcuate
ligament, through
which the aorta
and the thoracic
duct cross the
diaphragm
Median arcuate ligament

9. Lateral Ligaments
• The lateral ligaments arise
in the form of two thick tendons at the level of the
arch of the psoas muscle, constituting the
medial arcuate ligament.
• It passes above the psoas muscle,
joining the vertebral body of L1 and its transverse
apophyses, and more laterally, above the
quadrates lumborum muscle,
joining the transverse process of L1 and the apex of
the 12° rib, forming the lateral arcuate
ligament.

10. Hiatus

11. Vena Caval Hiatus
The inferior vena cava passes through the caval
opening, a quadrilateral opening at the junction
of the right and middle leaflets of
the central tendon, so that its margins
are tendinous. ... Vena Cava – Passes through
the diaphragm at T8.

12. Esophageal Hiatus
It is placed superior, anterior, and
slightly left of the aortic hiatus, and
transmits the esophagus, the
vagus nerve, the left inferior
phrenic vessels, and some small
esophageal arteries from left
gastric vessels.
The right crus of the diaphragm loops around forming a sling around
the esophagus.
Fibers of the right crus cross one another below the hiatus.

20. G.E.R.D

23. Thank you !