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

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

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

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

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

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

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

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

9. The crura develop from the mesentery of esophagus

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

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

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

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

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

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

16. Usually CDH discovered prenataly on routine ultrasound

17. After birth
CXR
BARIUM SWALLOW

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

19. Contained sac in morgagni
Omentum
Colon
Stomach
Liver
Small intestine

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

21. Right side:thoracotomy Left side:laparotomy

22. Mortality 30-50% in 24 hours

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

24. HIATAL HERNIA
Sliding
Paraesophageal
mixed

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

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

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

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