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DIAPHRAGMATIC HERNIA etiopathogenesis.ppt
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- 2. Clinical Anatomy Clinical Anatomy musculotendinous membrane musculotendinous membrane central: central: tendinous tendinous peripheral: peripheral: muscular muscular
- 3. HIATUS HIATUS Aorta: T12azygos vein, thoracic duct Aorta: T12 azygos vein, thoracic duct Esophagus:T10 vagus nerves Esophagus:T10 vagus nerves IVC:T8 IVC:T8
- 4. BLOOD SUPPLY BLOOD SUPPLY abdominal aorta: RPA, LPA abdominal aorta: RPA, LPA thoracic aorta: SPA thoracic aorta: SPA internal mammary artery internal mammary artery
- 5. VENOUS DRAINAGE VENOUS DRAINAGE left phrenic vein left phrenic vein right phrenic vein right phrenic vein Both drain into IVC Both drain into IVC
- 6. INNERVATION INNERVATION Right phrenicnerve: motor innervation Right phrenic nerve: motor innervation Left phrenic nerve: motor innervation Left phrenic nerve: motor innervation Intercostal nerve: sensory innervation Intercostal nerve: sensory innervation
- 7. Diaphragm develops Diaphragm develops Transverseseptum Transverse septum Pleuroperitoneal membrane Pleuroperitoneal membrane Dorsal and lateral body wall Dorsal and lateral body wall Mesentery of esophagus Mesentery of esophagus
- 8. Diaphragm develops betweenthe 4 Diaphragm develops between the 4th th and and 8 8th th weeks of gestation weeks of gestation separates thoracic cavity from abdomen separates thoracic cavity from abdomen The crura develop from the mesentery of The crura develop from the mesentery of esophagus esophagus
- 10. CONGENITAL DIAPHRAGMATIC CONGENITAL DIAPHRAGMATIC HERNIA HERNIA BOCHDALEK HERNIA BOCHDALEK HERNIA MORGAGNI HERNIA MORGAGNI HERNIA ESOPHAGEAL HIATAL HERNIA ESOPHAGEAL HIATAL HERNIA
- 12. BOCHDALEK HERNIA BOCHDALEK HERNIA Failure of closure of the Failure of closure of the pericardio- peritoneal canal cause CDH pericardio- peritoneal canal cause CDH (bochdalek hernia) (bochdalek hernia) Most common type (Bochdalek hernia Most common type (Bochdalek hernia occurs in 1:4000-5000 live birth) occurs in 1:4000-5000 live birth) Posterolateral defect Posterolateral defect Male:female 2/1 Male:female 2/1 Left sided 90%/ Right sided 10% Left sided 90%/ Right sided 10%
- 13. BOCHDALEK HERNIA BOCHDALEK HERNIA - -Geneticmutations have been Genetic mutations have been implicated, Amniocentesis with implicated, Amniocentesis with karyotyping may identify karyotyping may identify chromosomal defects especially chromosomal defects especially trisomy 18 and 21 trisomy 18 and 21 -surfactant deficiency -surfactant deficiency -Associated anomalies are Heart -Associated anomalies are Heart anomalies and abdominal wall defects anomalies and abdominal wall defects
- 14. BOCHDALEK HERNIA BOCHDALEK HERNIA Diaphragmatic defect allows abdominal Diaphragmatic defect allows abdominal viscera to fill thoracic cavity viscera to fill thoracic cavity Abdomen remains small and scaphoid Abdomen remains small and scaphoid Lungs are hypoplastic with decreased Lungs are hypoplastic with decreased bronchial and vascular branching bronchial and vascular branching
- 15. CDH may bediscovered prenataly on CDH may be discovered prenataly on routine ultrasoundas early as 15 routine ultrasoundas early as 15th th week of week of gestation gestation -herniation of abdominal viscera into -herniation of abdominal viscera into chest chest -change in liver position -change in liver position -mediastinal shift -mediastinal shift -Lung to heart ratio may be used to -Lung to heart ratio may be used to predict hiatus hernia predict hiatus hernia
- 16. Clinical Finding inneonates/ Clinical Finding in neonates/ infants infants Respiratory distress (caused by Respiratory distress (caused by hypoplastic ipsilateral lung, pulmonary hypoplastic ipsilateral lung, pulmonary hypertension and mediastinal shift hypertension and mediastinal shift compromising air exchange in opposite compromising air exchange in opposite lung) lung) Absence of breath sounds Absence of breath sounds Bowel sound in chest Bowel sound in chest Scaphoid abdomen Scaphoid abdomen
- 17. After birth After birth CXR CXR BARIUM SWALLOW BARIUM SWALLOW
- 20. TREATMENT TREATMENT Earlier thetreatment of Diaphragmatic Earlier the treatment of Diaphragmatic Hernia was considered a surgical Hernia was considered a surgical emergency emergency It is now accepted that Pulmonary It is now accepted that Pulmonary Hypertension with right to left shunt and Hypertension with right to left shunt and degree of Pulmonary hypoplasia are leading degree of Pulmonary hypoplasia are leading causes of cardiopulmonary insufficiency causes of cardiopulmonary insufficiency The emphasis is on controlled ventilation The emphasis is on controlled ventilation and avoiding over-inflation of un-involved and avoiding over-inflation of un-involved Lung Lung
- 21. Avoiding pulmonaryhypertension via Avoiding pulmonary hypertension via Hypoxia, Nitric oxide may be helpful Hypoxia, Nitric oxide may be helpful Correction of acidosis Correction of acidosis Excess administration of IV fluids Excess administration of IV fluids should be avoided lest it compounds should be avoided lest it compounds cardiac failure cardiac failure Infants who remain severely hypoxic Infants who remain severely hypoxic may need ECMO. Gradually the lung may need ECMO. Gradually the lung function improves over 7-10 days function improves over 7-10 days TREATMENT TREATMENT
- 22. treatment treatment Nasogastric tube Nasogastrictube Fluid and electrolyte Fluid and electrolyte PEEP or ECMO PEEP or ECMO surgery surgery
- 23. OPERATION OPERATION Infants whoare not on ECMO should be Infants who are not on ECMO should be operated as soon as hemodynamic operated as soon as hemodynamic status has been optimized status has been optimized Others have to wait till pulmonary Others have to wait till pulmonary function has improved function has improved Abdominal or thoracic approach may be Abdominal or thoracic approach may be used (Right side:thoracotomy used (Right side:thoracotomy Left side:laparotomy) Left side:laparotomy)
- 24. COMPLICATIONS COMPLICATIONS Bleeding fromliver/spleen while Bleeding from liver/spleen while reducing into abdomen reducing into abdomen Hemothorax Hemothorax Problems due to Hypoplastic lung or Problems due to Hypoplastic lung or pulmonary hypertension pulmonary hypertension
- 25. Mortality 30-50% in24 Mortality 30-50% in 24 hours hours
- 26. Long term problemsin CDH Long term problems in CDH Gastroesophageal reflux Gastroesophageal reflux Chronic lung disease Chronic lung disease Hearing loss Hearing loss Pectus excavatum Pectus excavatum seizure seizure
- 27. MORGAGNI HERNIA MORGAGNI HERNIA Larrey hernia or retrosternal Larrey hernia or retrosternal Much less common Much less common 2% of all diaphragmatic hernia 2% of all diaphragmatic hernia Contained sac may contain Omentum, Contained sac may contain Omentum, Colon, Stomach, Liver or Small intestine Colon, Stomach, Liver or Small intestine Rarely symptomatic Rarely symptomatic May be symptomatic after 40 years May be symptomatic after 40 years
- 28. HIATAL HERNIA HIATAL HERNIA Sliding Sliding Paraesophageal Paraesophageal Mixed Mixed Usually associated with GER Usually associated with GER Treatment Medical/Surgical Treatment Medical/Surgical
- 29. Eventration of diaphragm Eventrationof diaphragm Congenital(non paralysed) Congenital(non paralysed) Acquired(paralysed) Acquired(paralysed)
- 30. Trauma to diaphragm Traumato diaphragm (Acquired Diaphragmatic (Acquired Diaphragmatic Hernia) Hernia) 90% left sided 90% left sided Early diagnosis:laparotomy Early diagnosis:laparotomy Late diagnosis:thoracotomy Late diagnosis:thoracotomy