2. Diaphragm disorders By:Dr seyed Mostafa Shiryazdi Associate professor of surgery

3. Clinical Anatomy -musculotendinous membrane -musculotendinous membrane -central:tendinous -central:tendinous -peripheral:muscular -peripheral:muscular

4. HIATUS -Aorta:T12 azygus vein-thoracic duct -Aorta:T12 azygus vein-thoracic duct -Esophagus:T10 vagus nerves -Esophagus:T10 vagus nerves -IVC:T8 -IVC:T8

5. BLOOD SUPPLY -abdominal aorta:RPA-LPA -abdominal aorta:RPA-LPA -thoracic aorta:SPA -thoracic aorta:SPA -internal mamary artery -internal mamary artery

6. VENOUS DRAINAGE -left phrenic vein -left phrenic vein -right phrenic vein -right phrenic vein -Both drain to IVC -Both drain to IVC

7. INNERVATION -Right phrenic nerve:motor innervation -Right phrenic nerve:motor innervation -Left phrenic vein:motor innervation -Left phrenic vein:motor innervation -Intercostal nerve:sensory innervation -Intercostal nerve:sensory innervation

8. Diaphragm develops between the 4 th and 8 th weeks of gestation

9. Failure closure of the pericardio peritoneal canal cause CDH(bochdalek hernia)

10. The crura develop from the mesentery of esophagus

11. Higher position of diaphragm LIVER in right HEART in left

12. Diaphragm develops Transverse septum Pleuroperitoneal membrane Dorsal and lateral body wall Mesentery of esophagus

13. CONGENITAL DIAPHRAGMATIC HERNIA _BOCHDALEK HERNIA _BOCHDALEK HERNIA -MORGAGNI HERNIA -MORGAGNI HERNIA -ESOPHAGEAL HIATAL HERNIA -ESOPHAGEAL HIATAL HERNIA

14. BOCHDALEK HERNIA Male:female 2/1 Male:female 2/1 Left sided 90% Left sided 90% Right sided 10% Right sided 10%

15. Clinical Finding Rsepiratory dystress Rsepiratory dystress Absence of breath sounds Absence of breath sounds Bowel sound in chest Bowel sound in chest Scaphoid abdomen Scaphoid abdomen

16. Bochdalek hernia occurs in 1:4000- 5000 live birth Morgagni hernia occurs <2% of all diaphragmatic hernia Morgagni hernia occurs <2% of all diaphragmatic hernia

17. Usually CDH discovered prenataly on routine ultrasound

18. After birth CXR CXR BARIUM SWALLOW BARIUM SWALLOW

19. 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

20. Contained sac in morgagni OmentumColonStomachLiver Small intestine

21. treatment Nasogastric tube Nasogastric tube Fluid and electrolyte Fluid and electrolyte PEEP or ECMO PEEP or ECMO surgery surgery

22. Right side:thoracotomy Left side:laparotomy

23. Mortality 30-50% in 24 hours

24. MORGAGNI HERNIA Larrey hernia or retrosternal Larrey hernia or retrosternal Rarely symptomatic Rarely symptomatic Symptomatic after 40 years Symptomatic after 40 years

25. HIATAL HERNIA Sliding Sliding Paraesophageal Paraesophageal mixed mixed

26. GER Medical Medical Surgical Surgical FTT-repeated respiratory infection- anemia-recurrent FTT-repeated respiratory infection- anemia-recurrent

27. Diaphragm tumors Primary(rare):fibrosarcoma-hydatid cyst- TB Primary(rare):fibrosarcoma-hydatid cyst- TB secondary secondary

28. Eventration of diaphragm Congenital(non paralysed) Congenital(non paralysed) Acquired(paralysed) Acquired(paralysed)

29. Trauma to diaphragm 90% left sided 90% left sided Early diagnosis:laparotomy Early diagnosis:laparotomy Late diagnosis:thoracotomy Late diagnosis:thoracotomy