1. Diaphragm anatomy hernias treatment

2. Anatomy of the diaphragm A dome-shaped anatomical structure consisting of a muscular and tendineous part Diaphragmatic attachments: posterior: the first, second and third lumbar vertebra anterior: the inferior part of the sternum lateral: the costal arch It separates abdominal and thoracic cavities from each other

3. Anatomy of the diaphragm Cartilaginous part of a rib Xyphoid process Central lobe Central tendon Left lobe Esophageal hiatus Aortic hiatus Left crus Right lobe Right crus Foramen of the caval vein Lumbar quadrate muscle XII rib

4. Diaphragmatic hernias Etiology Numerous hiatuses and foramina in the diaphragm Complex embryology Difference of pressure over and beneath the diaphragm

5. Diaphragmatic hernias Classification General classification: congenital acquired posttraumatic Akerlund’s classification: caused by congenital short esophagus paraesophageal sliding

6. Paraesophageal hernia Normal position of gastroesophageal junction. Protrusion of the stomach alongside the esophagus. Phrenoesophageal membrane Bending of the parietal peritoneum Diaphragm Protrusion of the stomach into a hernia sac Part of the stomach localized within the abdominal space Esophagus Cardia

7. Paraesophageal hernia good function of the lower esophageal sphincter asymptomatic clinical course- frequently air eructation postprandial fulness Complications: bleeding incarceration acute dysphagia strangulation Treatment - surgical management

8. Sliding hernia Most common. Gastroesophageal junction above the diapragm. Esophagus Protrusion of the stomach into a hernia sac Phrenoesophageal membrane Cardia Diaphragm Bending of the parietal peritoneum Part of the stomach localized within the abdominal space Phrenoesophageal membrane Bending of the parietal peritoneum Diaphragm

9. Sliding hernia dysfunction of the lower esophageal sphincter heartburn frequently made worse when a patient lies down typical picture on x-ray examination decreased resting pressure of the lower esophageal sphincter Complications esophagitis esophageal strictures

10. Sliding hernia Treatment 1. Medical treatment 2. Surgical Abdominal approach Chest approach Aims of surgical management: Reduction of hernia Closure of a hernial ring Reconstruction of the Hiss’s angle

11. Congenital hernias Morgagni’s and Bochdalek’s hernia frequently asymptomatic diagnosed accidentally paroxysmal or constant epigastric pain respiratory and circulatory disturbances ileus Treatment- surgical management.

12. Congenital hernias Morgagni’s and Bochdalek’s hernia Parasternal diaphragmatic hernia (Morgagni) Posterolateral diaphragmatic hernia (Bochdalek)

13. Posttraumatic diaphragmatic hernia Traumatic rupture of the diaphragm may result from penetrating or blunt traumas Diaphragmatic rupture occurs usually within the central tendon more frequently on its left side Viscera can immediately translocate into the pleural space through the diaphragmatic rupture or their displacement may be gradual and it can last months or even years.

14. Posttraumatic diaphragmatic hernia Clinical presentation of the hernia depends on the part and amount of viscera that displaced into the pleural space. We can observe: bleeding ileus Circulatory and respiratory failure

15. Posttraumatic diaphragmatic hernia Surgical approach through the abdominal cavity is advocated if: recent trauma injuries of viscera are suspected or diagnosed. Surgical approach through the chest is advocated if diagnosis is substantially delayed and intra-abdominal injuries are excluded.