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

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

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

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

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

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

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

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

The crura develop from the mesentery of esophagus

Higher position of diaphragm LIVER in right HEART in left

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

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

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

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

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

Usually CDH discovered prenataly on routine ultrasound

After birth CXR BARIUM SWALLOW

Long term problems in CDH Gastroesophageal reflux Chronic lung disease Hearing loss Pectus excavatum seizure

Contained sac in morgagni Omentum Colon Stomach Liver Small intestine

treatment Nasogastric tube Fluid and electrolyte PEEP or ECMO surgery

Right side:thoracotomy Left side:laparotomy

Mortality 30-50% in 24 hours

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

HIATAL HERNIA Sliding Paraesophageal mixed

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

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

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

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