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CONGENITAL DIAPHRAGMATIC  HERNIA (CDH)
CONGENITAL DIAPHRAGMATIC  HERNIA (CDH)
THE THORACIC DIAPHRAGM
CONGENITAL DIAPHRAGMATIC  HERNIA (CDH)
EMBRYOLOGY
■ Simply, it is formed by the fusion of tissues from 4 DIFFERENT SOURCES:
I. Septum transversum (central tendon)
II. Pleuroperitoneal membranes
III. Dorsal mesentery of the esophagus
IV. The body-wall (muscular components from somites (C3-5)
CONGENITAL DIAPHRAGMATIC  HERNIA (CDH)
CONGENITAL DIAPHRAGMATIC  HERNIA (CDH)
CONGENITAL DIAPHRAGMATIC  HERNIA (CDH)
PATHOPHYSIOLOGY
■ Most frequently caused by failure of one or both of the
pleuroperitoneal membranes to close the pericardioperitoneal
canals
■ Thus, the peritoneal and pleural cavities are continuous with
one another along the posterior body wall
■ This allows abdominal viscera to enter the pleural cavity,
pushing the lungs and heart
■ In 85% to 90% of cases, the hernia is on the left side
CONGENITAL DIAPHRAGMATIC  HERNIA (CDH)
TYPES
■ The Bochdalek:
– Most common
– Defect in the posterolateral part of the diaphragm.
– This causes lung hypoplasia.
■ The Morgagni (retrosternal):
– Rare
– Results from a defect in the anterior midline,
■ Hiatal hernias:
– portion of the stomach prolapses through the diaphragmatic esophageal hiatus
– The defect thought to be a result of a congenital shorter esophagus.
[B] Bochdalek left posterolateral defect.
[M] Morgagni or anterior.
[H] Hiatus hernia.
[E] large Eventration in the tendinous portion.
[T] a Tear which causes a post-traumatic hernia.
[A] Aorta.
CONGENITAL DIAPHRAGMATIC  HERNIA (CDH)
CONGENITAL DIAPHRAGMATIC  HERNIA (CDH)
CASE SCENARIO
■ Within minutes of birth, a full-term infant boy
develops increasing respiratory distress and
becomes cyanosed. He fails to improve with
upper airway suctioning. The pregnancy was
uneventful. He looks barrel-chested and his
abdomen is scaphoid.
Case Scenario
■ Within minutes of birth, a full-term infant boy develops
increasing respiratory distress and becomes cyanosed.
He fails to improve with upper airway suctioning.The
pregnancy was uneventful. He looks barrel-chested and
his abdomen is scaphoid.
CONGENITAL DIAPHRAGMATIC  HERNIA (CDH)
CLINICAL
PRESENTATION
Clinical Presentation
■ The development of symptoms with CDH
correlates with the degree of pulmonary
hypoplasia and pulmonary hypertension. (1)
■ Infants most commonly present with respiratory
distress and cyanosis in the first minutes or
hours of life.(1)
(1)CURRENT Diagnosis &Treatment:Surgery,Chapter 43:
PediatricSurgery
Clinical Presentation
(1)CURRENT Diagnosis &Treatment:Surgery,Chapter 43:
PediatricSurgery
The majority of neonates born with a Bochdalek diaphragmatic hernia become symptomatic
at, or shortly after, birth.(2)
 Tachypnoea
 Increased respiratory effort
 Hyperinflated Chest
 Scaphoid abdomen
 Heart sounds are on the right side
 The chest on the side of the hernia may be dull
to percussion (1)
 bowel sounds are not usually appreciated.(1)
Where pulmonary hypoplasia is severe, the neonate becomes cyanosed with severe
respiratory distress within minutes of birth. (2)
(2)Jones Clinical PediatricSurgery 7th Edition
Clinical Presentation
■ honeymoon period can happen:(3)
– Which is a period (first 24 to 48 hours after
birth ) of relative stability with high levels of
PaO2 and relatively good perfusion which
followed by progressive cardiorespiratory
deterioration. (3)
(3) Schwartz's Principles of SurgeryChapter 39: PediatricSurgery
Clinical Presentation
(2)Jones Clinical PediatricSurgery 7th Edition
Postero-lateral hernia involve: (2)
The left Hemidiaphragm (85%)
Right-sided (13%)
Bilateral (2%)
Associated anomalies occur in up to 40% of patients
Most are minor and do not affect survival.
The most common serious abnormalities are heart defects, which
affect 20–25% of patients.
Clinical Presentation
(2)Jones Clinical PediatricSurgery 7th Edition
Retrosternal hernia:(2)
Usually asymptomatic unless strangulation occurs.
 Usually Protrudes into the inferior mediastinum
May protrude into the pericardial cavity and cause
cardiac tamponade (Very rare) Presents as
Cardiorespiratory distress in the neonatal period
DIAGNOSIS
PRENATAL DIAGNOSIS
Most congenital diaphragmatic hernias are diagnosed
well before birth, on antenatal ultrasonography. (2)
(2)Jones Clinical PediatricSurgery 7th Edition
Prenatal Diagnosis
■ Diagnosis of congenital diaphragmatic hernia (CDH)
can be achieved as early as 15 weeks’ gestation. (3)
■ US findings:
– herniated abdominal viscera in the chest
– changes in liver position
– mediastinal shift away from the herniated viscera
(3) Schwartz's Principles of SurgeryChapter 39: Pediatric
Surgery
Prenatal Diagnosis
Arrows point to the location of the diaphragm. Arrow head points to the stomach, which is
in the thoracic cavity. (3) Schwartz's Principles of SurgeryChapter 39: Pediatric
Surgery
Prenatal Diagnosis
What is the benefit of Prenatal Diagnosis?(3)
– optimizes prenatal and postnatal care of both the mother and fetus
– allows the mother-to-be to be transferred to a tertiary paediatric surgical centre
before birth.
(3) Schwartz's Principles of SurgeryChapter 39: Pediatric
Surgery
Prenatal Diagnosis
■ Case 1:
– Fetal diagnosed with CDH in week 15 of gestation.
■ Case 2:
– Fetal diagnosed with CDH in week 23 of gestation.
■ Which case have better prognosis ?Why? (3)
– Case 2, early antenatal diagnosis is associated with worse outcomes
(3) Schwartz's Principles of SurgeryChapter 39: Pediatric
Surgery
Prenatal Diagnosis
(2)Jones Clinical PediatricSurgery 7th Edition
Postnatal Diagnosis
diaphragmatic eventration : Elevated thinned out diaphragm, Bowel loops in chest
and Mediastinal shift
Postnatal Diagnosis
(2)Jones Clinical PediatricSurgery 7th Edition
congenital diaphragmatic hernia (Bochdalek type). Multiple bowel loops fill the left pleural
cavity, and the heart is displaced to the right.
Postnatal Diagnosis
■ the diagnosis of CDH is made by chest x-ray
■ In left-sided defects: (2)
– Loops of bowel may be seen in the left chest.
– The heart is deviated to the right.
– The hypoplastic left lung appears small and is further compressed by the mass effect of the
herniating liver, gut and spleen.
■ Sometimes the appearance may be difficult to distinguish from basal lung cysts, in which case
a repeat chest x-ray is performed after a nasogastric tube has been inserted, the tip of which
may be seen in the chest (2)
(2)Jones Clinical PediatricSurgery 7th Edition
Postnatal Diagnosis
■ a barium study will show bowel within the thoracic cavity when there is a diaphragmatic
hernia.(2)
■ Right-sided hernias can be difficult to distinguish from a diaphragmatic eventration. (1)
– This can be differentiated by an MRI scan
(2)Jones Clinical PediatricSurgery 7th Edition
(1)CURRENT Diagnosis &Treatment:Surgery,Chapter 43:
PediatricSurgery
Postnatal Diagnosis
■ Once the diagnosis of a CDH is confirmed, additional radiographic and US
examinations should be carried out to search for associated anomalies.
MANAGEMENT
Management
■ in utero correction of diaphragmatic hernia and fetoscopic tracheal occlusion
has been achieved in a research setting.
■ However, the techniques are complex and the indications are still being
refined.
■ No improvement survival, nor reduced morbidity, compared with current
postnatal techniques.
(2)Jones Clinical PediatricSurgery 7th Edition
Management
■ Initial treatment :
• involves intensive cardiorespiratory support and insertion of a nasogastric
tube to prevent bowel dilatation within the chest.
• Care must be taken to avoid hyperinflation and barotrauma of the small
hypoplastic lungs.
• High-frequency oscillatory ventilation (HFOV) in combination with nitric
oxide has improved survival rates.
(2)Jones Clinical PediatricSurgery 7th Edition
Management
■ Ventilation with a facemask should be avoided as this may force air into the stomach,
increasing its volume at the expense of the already compromised lungs.
■ Vigorous endotracheal ventilation should also be avoided because of the risk of causing
barotrauma or tension pneumothorax.
(2)Jones Clinical PediatricSurgery 7th Edition
Management
■ Sudden deterioration of the neonate’s condition during initial resuscitation
suggests a developing tension pneumothorax.
– may necessitate prompt release by needle aspiration or insertion of an
intercostal drain.
■ How to avoid this complication ?
– strict avoidance of hyperventilation and limited inflation pressures
(2)Jones Clinical PediatricSurgery 7th Edition
Management
■ The key to success is careful gentle ventilation that minimizes injury to the
hypoplastic lungs.
(2)Jones Clinical PediatricSurgery 7th Edition
Management
(2)Jones Clinical PediatricSurgery 7th Edition
• The primary focus of management is achieving adequate ventilation with control of
pulmonary hypertension.
• Surgery to return the herniated contents to the abdominal cavity and to repair the defect in
the diaphragm is only performed once the neonate’s condition has stabilized.
Management
■ Surgery generally involves repair through a transverse or subcostal abdominal
incision on the same side as the defect.
■ Thoracoscopic surgery has a role in selected cases, usually with smaller
diaphragmatic defects.
(2)Jones Clinical PediatricSurgery 7th Edition
Management
■ the hernia can be repaired in one of three ways:
– Primary Repair: If the opening in the diaphragm is small and the amount of diaphragmatic
muscle is adequate, is adequate muscle for closure, a single layer of nonabsorbable
horizontal mattress sutures can be used (3)
– Patch Repair: If the opening in the diaphragm is large or a significant portion of the diaphragm
is absent, the surgeon will require additional tissue or material to close the defect. Often, a
synthetic biocompatible material will be used to patch the opening(4)
– Muscle-Flap Repair: In some patients, the surgeon will close the hole in the diaphragm with a
flap of muscle-the internal oblique or latissimus dorsi from the infant's abdomen/back (4)
(4)University of California, San Francisco (UCSF)(3) Schwartz's Principles of SurgeryChapter 39: Pediatric
Surgery
Management
■ Survival rates post-surgery of more than 80%
■ The major cause of death remains pulmonary hypoplasia and pulmonary
hypertension
– due to the small pulmonary vascular bed and to the changing resistance of
the pulmonary arterioles
(2)Jones Clinical PediatricSurgery 7th Edition
Management
■ Anterior diaphragmatic hernia :
■ Repair is still advisable because of the risk of strangulation of the bowel that
protrudes through the defect.
■ Commonly performed as a laparoscopic procedure
(2)Jones Clinical PediatricSurgery 7th Edition
Management
■ Recurrence: (1)
– occurs in 10%-20% of infants
– is most common when a prosthetic patch is used for the repair
– It should be considered in any child with a history of CDH who presents with
new GI or pulmonary symptoms.
(1)CURRENT Diagnosis &Treatment:Surgery,Chapter 43:
PediatricSurgery
1 2 3
4 - University of California, San Francisco (UCSF)
http://www.pedsurg.ucsf.edu/conditions--procedures/congenital-diaphragmatic-hernia.aspx
THANKYOU

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CONGENITAL DIAPHRAGMATIC HERNIA (CDH)

  • 5. EMBRYOLOGY ■ Simply, it is formed by the fusion of tissues from 4 DIFFERENT SOURCES: I. Septum transversum (central tendon) II. Pleuroperitoneal membranes III. Dorsal mesentery of the esophagus IV. The body-wall (muscular components from somites (C3-5)
  • 9. PATHOPHYSIOLOGY ■ Most frequently caused by failure of one or both of the pleuroperitoneal membranes to close the pericardioperitoneal canals ■ Thus, the peritoneal and pleural cavities are continuous with one another along the posterior body wall ■ This allows abdominal viscera to enter the pleural cavity, pushing the lungs and heart ■ In 85% to 90% of cases, the hernia is on the left side
  • 11. TYPES ■ The Bochdalek: – Most common – Defect in the posterolateral part of the diaphragm. – This causes lung hypoplasia. ■ The Morgagni (retrosternal): – Rare – Results from a defect in the anterior midline, ■ Hiatal hernias: – portion of the stomach prolapses through the diaphragmatic esophageal hiatus – The defect thought to be a result of a congenital shorter esophagus.
  • 12. [B] Bochdalek left posterolateral defect. [M] Morgagni or anterior. [H] Hiatus hernia. [E] large Eventration in the tendinous portion. [T] a Tear which causes a post-traumatic hernia. [A] Aorta.
  • 15. CASE SCENARIO ■ Within minutes of birth, a full-term infant boy develops increasing respiratory distress and becomes cyanosed. He fails to improve with upper airway suctioning. The pregnancy was uneventful. He looks barrel-chested and his abdomen is scaphoid.
  • 16. Case Scenario ■ Within minutes of birth, a full-term infant boy develops increasing respiratory distress and becomes cyanosed. He fails to improve with upper airway suctioning.The pregnancy was uneventful. He looks barrel-chested and his abdomen is scaphoid.
  • 19. Clinical Presentation ■ The development of symptoms with CDH correlates with the degree of pulmonary hypoplasia and pulmonary hypertension. (1) ■ Infants most commonly present with respiratory distress and cyanosis in the first minutes or hours of life.(1) (1)CURRENT Diagnosis &Treatment:Surgery,Chapter 43: PediatricSurgery
  • 20. Clinical Presentation (1)CURRENT Diagnosis &Treatment:Surgery,Chapter 43: PediatricSurgery The majority of neonates born with a Bochdalek diaphragmatic hernia become symptomatic at, or shortly after, birth.(2)  Tachypnoea  Increased respiratory effort  Hyperinflated Chest  Scaphoid abdomen  Heart sounds are on the right side  The chest on the side of the hernia may be dull to percussion (1)  bowel sounds are not usually appreciated.(1) Where pulmonary hypoplasia is severe, the neonate becomes cyanosed with severe respiratory distress within minutes of birth. (2) (2)Jones Clinical PediatricSurgery 7th Edition
  • 21. Clinical Presentation ■ honeymoon period can happen:(3) – Which is a period (first 24 to 48 hours after birth ) of relative stability with high levels of PaO2 and relatively good perfusion which followed by progressive cardiorespiratory deterioration. (3) (3) Schwartz's Principles of SurgeryChapter 39: PediatricSurgery
  • 22. Clinical Presentation (2)Jones Clinical PediatricSurgery 7th Edition Postero-lateral hernia involve: (2) The left Hemidiaphragm (85%) Right-sided (13%) Bilateral (2%) Associated anomalies occur in up to 40% of patients Most are minor and do not affect survival. The most common serious abnormalities are heart defects, which affect 20–25% of patients.
  • 23. Clinical Presentation (2)Jones Clinical PediatricSurgery 7th Edition Retrosternal hernia:(2) Usually asymptomatic unless strangulation occurs.  Usually Protrudes into the inferior mediastinum May protrude into the pericardial cavity and cause cardiac tamponade (Very rare) Presents as Cardiorespiratory distress in the neonatal period
  • 25. PRENATAL DIAGNOSIS Most congenital diaphragmatic hernias are diagnosed well before birth, on antenatal ultrasonography. (2) (2)Jones Clinical PediatricSurgery 7th Edition
  • 26. Prenatal Diagnosis ■ Diagnosis of congenital diaphragmatic hernia (CDH) can be achieved as early as 15 weeks’ gestation. (3) ■ US findings: – herniated abdominal viscera in the chest – changes in liver position – mediastinal shift away from the herniated viscera (3) Schwartz's Principles of SurgeryChapter 39: Pediatric Surgery
  • 27. Prenatal Diagnosis Arrows point to the location of the diaphragm. Arrow head points to the stomach, which is in the thoracic cavity. (3) Schwartz's Principles of SurgeryChapter 39: Pediatric Surgery
  • 28. Prenatal Diagnosis What is the benefit of Prenatal Diagnosis?(3) – optimizes prenatal and postnatal care of both the mother and fetus – allows the mother-to-be to be transferred to a tertiary paediatric surgical centre before birth. (3) Schwartz's Principles of SurgeryChapter 39: Pediatric Surgery
  • 29. Prenatal Diagnosis ■ Case 1: – Fetal diagnosed with CDH in week 15 of gestation. ■ Case 2: – Fetal diagnosed with CDH in week 23 of gestation. ■ Which case have better prognosis ?Why? (3) – Case 2, early antenatal diagnosis is associated with worse outcomes (3) Schwartz's Principles of SurgeryChapter 39: Pediatric Surgery
  • 30. Prenatal Diagnosis (2)Jones Clinical PediatricSurgery 7th Edition
  • 31. Postnatal Diagnosis diaphragmatic eventration : Elevated thinned out diaphragm, Bowel loops in chest and Mediastinal shift
  • 32. Postnatal Diagnosis (2)Jones Clinical PediatricSurgery 7th Edition congenital diaphragmatic hernia (Bochdalek type). Multiple bowel loops fill the left pleural cavity, and the heart is displaced to the right.
  • 33. Postnatal Diagnosis ■ the diagnosis of CDH is made by chest x-ray ■ In left-sided defects: (2) – Loops of bowel may be seen in the left chest. – The heart is deviated to the right. – The hypoplastic left lung appears small and is further compressed by the mass effect of the herniating liver, gut and spleen. ■ Sometimes the appearance may be difficult to distinguish from basal lung cysts, in which case a repeat chest x-ray is performed after a nasogastric tube has been inserted, the tip of which may be seen in the chest (2) (2)Jones Clinical PediatricSurgery 7th Edition
  • 34. Postnatal Diagnosis ■ a barium study will show bowel within the thoracic cavity when there is a diaphragmatic hernia.(2) ■ Right-sided hernias can be difficult to distinguish from a diaphragmatic eventration. (1) – This can be differentiated by an MRI scan (2)Jones Clinical PediatricSurgery 7th Edition (1)CURRENT Diagnosis &Treatment:Surgery,Chapter 43: PediatricSurgery
  • 35. Postnatal Diagnosis ■ Once the diagnosis of a CDH is confirmed, additional radiographic and US examinations should be carried out to search for associated anomalies.
  • 37. Management ■ in utero correction of diaphragmatic hernia and fetoscopic tracheal occlusion has been achieved in a research setting. ■ However, the techniques are complex and the indications are still being refined. ■ No improvement survival, nor reduced morbidity, compared with current postnatal techniques. (2)Jones Clinical PediatricSurgery 7th Edition
  • 38. Management ■ Initial treatment : • involves intensive cardiorespiratory support and insertion of a nasogastric tube to prevent bowel dilatation within the chest. • Care must be taken to avoid hyperinflation and barotrauma of the small hypoplastic lungs. • High-frequency oscillatory ventilation (HFOV) in combination with nitric oxide has improved survival rates. (2)Jones Clinical PediatricSurgery 7th Edition
  • 39. Management ■ Ventilation with a facemask should be avoided as this may force air into the stomach, increasing its volume at the expense of the already compromised lungs. ■ Vigorous endotracheal ventilation should also be avoided because of the risk of causing barotrauma or tension pneumothorax. (2)Jones Clinical PediatricSurgery 7th Edition
  • 40. Management ■ Sudden deterioration of the neonate’s condition during initial resuscitation suggests a developing tension pneumothorax. – may necessitate prompt release by needle aspiration or insertion of an intercostal drain. ■ How to avoid this complication ? – strict avoidance of hyperventilation and limited inflation pressures (2)Jones Clinical PediatricSurgery 7th Edition
  • 41. Management ■ The key to success is careful gentle ventilation that minimizes injury to the hypoplastic lungs. (2)Jones Clinical PediatricSurgery 7th Edition
  • 42. Management (2)Jones Clinical PediatricSurgery 7th Edition • The primary focus of management is achieving adequate ventilation with control of pulmonary hypertension. • Surgery to return the herniated contents to the abdominal cavity and to repair the defect in the diaphragm is only performed once the neonate’s condition has stabilized.
  • 43. Management ■ Surgery generally involves repair through a transverse or subcostal abdominal incision on the same side as the defect. ■ Thoracoscopic surgery has a role in selected cases, usually with smaller diaphragmatic defects. (2)Jones Clinical PediatricSurgery 7th Edition
  • 44. Management ■ the hernia can be repaired in one of three ways: – Primary Repair: If the opening in the diaphragm is small and the amount of diaphragmatic muscle is adequate, is adequate muscle for closure, a single layer of nonabsorbable horizontal mattress sutures can be used (3) – Patch Repair: If the opening in the diaphragm is large or a significant portion of the diaphragm is absent, the surgeon will require additional tissue or material to close the defect. Often, a synthetic biocompatible material will be used to patch the opening(4) – Muscle-Flap Repair: In some patients, the surgeon will close the hole in the diaphragm with a flap of muscle-the internal oblique or latissimus dorsi from the infant's abdomen/back (4) (4)University of California, San Francisco (UCSF)(3) Schwartz's Principles of SurgeryChapter 39: Pediatric Surgery
  • 45. Management ■ Survival rates post-surgery of more than 80% ■ The major cause of death remains pulmonary hypoplasia and pulmonary hypertension – due to the small pulmonary vascular bed and to the changing resistance of the pulmonary arterioles (2)Jones Clinical PediatricSurgery 7th Edition
  • 46. Management ■ Anterior diaphragmatic hernia : ■ Repair is still advisable because of the risk of strangulation of the bowel that protrudes through the defect. ■ Commonly performed as a laparoscopic procedure (2)Jones Clinical PediatricSurgery 7th Edition
  • 47. Management ■ Recurrence: (1) – occurs in 10%-20% of infants – is most common when a prosthetic patch is used for the repair – It should be considered in any child with a history of CDH who presents with new GI or pulmonary symptoms. (1)CURRENT Diagnosis &Treatment:Surgery,Chapter 43: PediatricSurgery
  • 48. 1 2 3 4 - University of California, San Francisco (UCSF) http://www.pedsurg.ucsf.edu/conditions--procedures/congenital-diaphragmatic-hernia.aspx

Editor's Notes

  1. Congenital Diaphragmatic Hernia (CDH) Right Side: https://www.youtube.com/watch?v=skVoKShLOXg A diaphragmatic hernia is defined as a communication between the abdominal and thoracic cavities with or without abdominal contents in the thorax. The etiology may be congenital or traumatic. The symptoms and prognosis depend on the location of the defect and associated anomalies. The defect may be at the esophageal hiatus (hiatal), paraesophageal (adjacent to the hiatus), retrosternal (Morgagni), or at the posterolateral (Bochdalek) portion of the diaphragm. The term congenital diaphragmatic hernia typically refers to the Bochdalek form. These lesions may cause significant respiratory distress at birth, can be associated with other congenital anomalies, and have significant mortality and long-term morbidity. The overall survival from the CDH Study Group is 67%. The Bochdalek hernia accounts for up to 90% of the hernias seen in the newborn period, with 80-90% occurring on the left side. The Morgagni hernia accounts for 2-6% of congenital diaphragmatic defects. The size of the defect is highly variable, ranging from a small hole to complete agenesis of this area of the diaphragm.
  2. In summary: The diaphragm is simply a partition (skeletal muscle), and it separates the pleural and pericardial cavities from the peritoneal cavity. It is C-SHAPED, with two domes that curve upwards. Has a central tendon and peripheral muscular and tendinous processes. Also has right and left crura (elongated anatomical structure of any type), that are tendinous in nature. They attach to the vertebral column. It also aids in the process of inspiration by increasing the volume of the pleural cavities when it contracts, thus it will decrease the intrathoracic pressure, and vice versa in expiration (elastic recoil of respiratory tissues allows them to compress and return to their size). The diaphragm is also involved in non-respiratory functions, helping to expel vomit, feces, and urine from the body by increasing intra-abdominal pressure, aiding in childbirth, and preventing acid reflux by exerting pressure on the esophagus as it passes through the esophageal hiatus. The openings of the diaphragm are mainly 3. To remember them easily, read this: Vena Cava (8 letters) – Passes through the diaphragm at the caval opening at T8. Esophagus (10 letters) – Passes through the diaphragm at T10. Aortic Hiatus (12 letters) – Passes through the diaphragm (does not pierce it) between the right and left crura just behind the diaphragm at T12. Mainly innervated by the phrenic nerve (C3, C4, C5), but for the central portion, afferent signals are sent by the phrenic nerve. The peripheral portion in innervated by the intercostal (T5-T11) and the subcostal (T12), which send sensory afferent.
  3. https://en.wikipedia.org/wiki/Thoracic_diaphragm
  4. Formation - Body Cavities & Diaphragm: https://www.youtube.com/watch?v=FknttVgoqEo Because the septum transversum is located initially opposite cervical segments three to five and because muscle cells for the diaphragm origínate from somites at these segments, the phrenic nerve also arises from these segments of the spinal cord (C3, C4, and C5 keep the diaphragm alive!).
  5. Medical Embryology - Development of Body cavities, Intraembryonic coelom, and diaphragm: https://www.youtube.com/watch?v=_sS9JesO_ZA
  6. A: 5th Week B: 7th Week C: 4th Month
  7. Although CDH is characterized by a structural diaphragmatic defect, a major limiting factor for survival is the associated pulmonary hypoplasia. Lung hypoplasia was initially thought to be due solely to the compression of the lung from the herniated abdominal contents, which impaired lung growth. However, emerging evidence indicates that pulmonary hypoplasia, at least in some cases, may precede the development of the diaphragmatic defect. Pulmonary hypoplasia is characterized by a reduction in pulmonary mass and the number of bronchial divisions, respiratory bronchioles, and alveoli. The pathology of pulmonary hypoplasia and CDH includes abnormal septa in the terminal saccules, thickened alveoli, and thickened pulmonary arterioles. Biochemical abnormalities include relative surfactant deficiencies, increased glycogen in the alveoli, and decreased levels of phosphatidylcholine, total DNA, and total lung protein, all of which contribute to limited gas exchange. ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- The vast majority of infants with CDH develop immediate respiratory distress, which is due to the combined effects of three factors: First, the air-filled bowel in the chest compresses the mobile mediastinum, which shifts to the opposite side of the chest, compromising air exchange in the contralateral lung. Second, pulmonary hypertension develops. This phenomenon results in persistent fetal circulation, with resultant decreased pulmonary perfusion and impaired gas exchange. Finally, the lung on the affected side is often hypoplastic, such that it is essentially nonfunctional. Varying degrees of pulmonary hypoplasia on the opposite side may compound these effects. The second and third factors are thought to be the most important. Neonates with CDH are usually in respiratory distress requiring ventilation and intensive care, and the overall mortality in most series is around 50%. ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- The posterolateral location of this hernia is known as Bochdalek’s hernia; it is distinguished from a CDH of the anteromedial location known as Morgagni’s hernia. As a result of the defect, abdominal contents herniate through the resultant defect in the posterolateral aspect and compress the ipsilateral developing lung. These lungs have smaller bronchi, with less bronchial branching and less alveolar surface area than lungs in normal infants. The ipsilateral lung is affected more severely; however, lungs from both sides are affected by pulmonary hypoplasia. In addition to the abnormal airway development, the pulmonary vasculature is also significantly affected by increased thickness of arteriolar smooth muscle. Also, arteriolar vasculature is extremely sensitive to the multiple local and systemic vasoactive factors. Hence, the severity of pulmonary hypoplasia and pulmonary hypertension significantly affect the overall morbidity and mortality in CDH infants.
  8. Nelson Textbook of Pediatrics, 19th Edition. Fig. 95-10 A (p. 594) Color Atlas of Anatomical Pathology by Cooke, Stewart, 3rd Edition. Fig. 4.31 Left-sided congenital diaphragmatic hernia. (p. 70-71) M/neonate. Abdominal contents are present in the thorax. There is hypoplasia of the left lung and the mediastinum is pushed to the right. Death occurred shortly after delivery.
  9. allows the mother-to-be to be transferred to a tertiary paediatric surgical centre before birth.
  10. herniated abdominal viscera in the chest which may also look like a mass or lung anomaly
  11. Diaphragmatic eventration refers to an abnormal contour of the diaphragmatic dome. It typically affects only a segment of the hemidiaphragm, compared to paralysis/weakness where the entire hemidiaphragm is typically affected.
  12. The horizontal mattress suture is an everting suture technique that spreads tension along a wound edge. This technique is commonly used for pulling wound edges together over a distance, or as the initial suture to anchor two wound edges (holding sutures)