الفهرس 
Surgical Anatomy and Embryology of The DiaphragmOnly 14 pages are availabe for public view
 |  | from | 138 |  |  |
| | | from | 138 | | |
Abstract
The diaphragm is a domed fibromuscular sheet that separates the abdominal and thoracic cavities. The major role of the diaphragm is inspiratory, but it is used also in abdominal straining.
During inspiration contraction of the diaphragm pulls the lower surface of the lungs downward then during expiration the diaphragm simply relaxes and the elastic recoil of the lungs, chest wall and abdominal structures compresses the lungs.
Diaphragmatic hernia is the main surgical condition of the diaphragm. This condition can be classified into congenital (Bochdalack, Morgagni and eventration of diaphragm), traumatic and hiatus hernia (Sliding, paraesophegeal).
The incidence of congenital diaphragmatic hernia (CDH) has been reported as 1 in 3000–5000 live births, however, in population studies -including cases resulting in premature terminations, still births and neonatal deaths prior to transfer to tertiary centers -the incidence approaches 1 in 2000.
Congenital diaphragmatic hernia (CDH) still remains a challenging problem for both surgeons and neonatologists. Improved known pathophysiology mechanisms explaining the respiratory failure has led to changes in the management of newborn infants with congenital diaphragmatic hernia.
Congenital diaphragmatic hernia is defined as a protrusion of abdominal viscera into the thorax through an abnormal opening or defect that is present at birth.
In some cases, this protrusion is covered by a membranous sac. In contrast, diaphragmatic eventrations are extreme elevations, rather than protrusions, of part of the diaphragm that is often atrophic and abnormally thin.
Infants with congenital diaphragmatic hernia may be quite ill at birth, often suffering from acute respiratory distress and hemodynamic instability.
The prognosis of congenital diaphragmatic hernia has improved dramatically in the last decade, and for those infants diagnosed inutero, the survival rate is now as high as 80% with antenatal diagnosis and optimal care.
Recent technique of ventilation, the use of inhaled Nitric oxide, surfactant installation, and ECMO all have been contributing to the improved survival rate in equipped medical centers all over the world.
Today, traumatic diaphragmatic hernia has become a lesion of increasing incidence and importance. The early detection of diaphragmatic injury is very important as this will prevent its harmful effects as respiratory distress, herniation of abdominal viscera and also its delayed effects which include the technical problems of repair due to atrophy of remnants of diaphragm and possibility of strangulation.
Penetrating trauma most commonly occurs from gunshot or knife injuries to the chest or abdomen. Presently, 80-90% of blunt diaphragmatic ruptures result from motor vehicle crashes (MVCs). Falls and other traumatic events rarely are implicated.
Today, traumatic diaphragmatic hernia has become a lesion of increasing incidence and importance. The early detection of diaphragmatic injury is very important as this will prevent its harmful effects as respiratory distress, herniation of abdominal viscera and also its delayed effects which include the technical problems of repair due to atrophy of remnants of diaphragm and possibility of strangulation.
Injury to (or rupture of) the diaphragm as a result of blunt truncal trauma is seen with increasing frequency. The prevalence of diaphragmatic rupture among blunt trauma victims ranges from 0.8% to 8%.
Diaphragmatic injuries can be classified according to the mechanism of injury, side involved, unilateral or bilateral location, clinical sequelae after the onset of injury, and severity of the anatomical disruption. Because the diaphragm is buffered by the liver on the right side, 95% of injuries occur on the left side, bilateral injuries occur in less than 3% of all cases.
Diaphragmatic injuries can be classified according to the mechanism of injury, side involved, unilateral or bilateral location, clinical sequelae after the onset of injury, and severity of the anatomical disruption
As with any trauma, the patient’s condition must be stabilized, and must be resuscitated as much as possible before the operation.
People with traumatic hernias frequently have concomitant injuries and require emergency exploration. When diagnosed, surgery must be performed as soon as possible, as any delay might cause a herniation of any abdominal organ. The choice of surgical approach can be thoracotomy, laparotomy or both if necessary.
The classical symptoms of hiatal hernia are heartburn, regurgitation, odynophagia (painful swallowing), globus and occasionally waterbrush.
The use of minimally invasive surgery for repair of DH is controversial. Thoracoscopic and laparoscopic approaches have been described.
Laparoscopy is a superior early diagnostic tool compared with thoracoscopy, because survey of the entire abdomen can be performed and subsequent repairs made, especially in the acute trauma setting.
Laparoscopy provides better orientation and surgical exposure of both the abdominal and thoracic cavity (through the defect), permitting survey for other injuries.
Consequently, early detection, proper preparation and appropriate management are essential to achieve a good outcome.
Laparoscopic technique has been found to be associated with low morbidity and mortality rates, short hospital stay, decreased postoperative pain, and early return to full activity.
The treatment of a foramen of Morgagni hernia is surgical. All symptomatic adults should undergo repair. Most recent reports recommend repair in most asymptomatic adults because hernias may enlarge over time and there is a low but definite risk of progression to incarceration and strangulation.
Three major types of surgical procedures correct gastroesophageal reflux and repair the hernia in the process including: Nissen fundoplication, Belsy Mark IV fundoplication, Hill repair. They can be performed by open laparotomy or laparoscopic approaches, which currently are being employed more frequently.