DIAPHRAGM

From Big Medical Encyclopedia

DIAPHRAGM (grech, diaphragma partition; synonym grudobryushny barrier) — the muscular and tendinous partition separating a chest cavity from belly, performing function of the main respiratory muscle.

The EMBRYOLOGY

the Bookmark D. is carried out at a three-week embryo at the level of IV — the V cervical segment, from it to the 4th week the cross partition of Gis (septum transversum) develops, edges are divided by primary whole (see) on belly and plevroperikardialny cavities. Then from the outside crescent folds located along side departments of a trunk pleuroperitoneal membranes (membranae pleuroperitoneales) intended for formation of the most part of domes begin to form, and lumbar part D is formed of back crescent folds. These departments grow to a cross partition forward, connect to it, but leave the pleuroperitoneal channel (ductus pleuroperitonealis) reporting pleural and belly cavities from each party. To the 8th week there occurs accretion of all bookmarks D., edges at this I stage represents the connective tissue plate which is completely isolating a chest cavity from belly. The derivative of a wall of a trunk — a secondary costal part (pars costalis) takes part in formation of a narrow rim along edge of a diaphragm. In the II stage there is a transformation of a connective tissue plate into sukhozhilnomyshechny education at the expense of a differentiation on site of muscles from the myoblasts located in the corresponding bookmarks D. and coming from III—V or IV—V myotomes. To the 24th week of D. differs from D. of the newborn only in the smaller thickness of muscle fibers.

Arising at the level of cervical segments, D. gradually moves away from the place of an initial bookmark in process of development of heart and the lungs which are pushing aside it from top to bottom and by the end of the 3rd month is located at the level of the usual attachment.

Disturbance of bookmarks D. or their accretion leads to malformations of D., such as inborn absence of D. or its inborn defects. Disturbance of development of muscles conducts to the fact that D. remains at a connective tissue stage of development owing to what the inborn relaxation of D.

== ANATOMY == forms

D. represents a flat thin muscle (m. phrenicus), cover fibers, beginning on a circle of the lower aperture of a thorax, go up and, converging radially, pass into tendinous stretching, forming dome-shaped cambers with impression in the center for heart (planum cardiacum) on the right and at the left. According to it in D. allocate the central tendinous part (pars tendinea), or the tendinous center (centrum tendineum), and more extensive regional muscular part (pars muscularis), in a cut allocate three parts: sternal, costal and lumbar.

Sternal part (pars sternalis) is poorly expressed, consists of several short muscle bundles departing from an inner surface of a xiphoidal shoot of a breast. A sternal part is separated from costal by the narrow triangular crack filled with cellulose — sternocostal space (spatium sternocostale) — Larrey's triangle.

Costal part (pars costalis) begins the separate bunches going up and passing into the tendinous center from an inner surface of cartilages of the VII—XII edges. The triangular crack, Bokhdalek's (trigonum lumbocostale) triangle separates costal part D. from lumbar.

Fig. 1. Diaphragm (from below): 1 and 18 — a big lumbar muscle; 2 — an unpaired vein; 3, 4 and 5 — the right leg of a diaphragm; 6 — a big splanchnic nerve; 7 — the right lower phrenic artery; 8 — the right lower phrenic veins; 9 — the lower vena cava; 10 — the lower left phrenic veins; 11 — the tendinous center; 12 — a gullet; 13 — the left lower phrenic artery; 14 — the left adrenal gland; 15 — a ventral aorta; 16 — a left kidney; 17 — a semi-unpaired vein; 19 — a chest channel.

Lumbar part (pars lumbalis) consists from each party of three legs (tsvetn. fig. 1): outside, intermediate and internal. The outside leg (crus laterale) begins from an outside lumbocostal arch (areus lumbocostalis med.), located between the XII edge and a cross shoot of L 1-2 , and internal lumbocostal arch (areus lumbocostalis med.), going from a body of one of these vertebrae and attached to its cross shoot. The intermediate leg (crus intermedium) begins from a front surface of bodies of L 2-3 , goes up and knaruzh, connecting to fibers of an outside leg, and passes into the tendinous center. Between intermediate and outside legs there passes the sympathetic trunk (truncus sympathicus), and between intermediate and internal — on the right celiac nerves and an unpaired vein, at the left — a semi-unpaired vein.

The internal leg (crus mediale) begins from bodies of L 3-4 and front longitudinal ligament of a backbone. Internal legs, connecting, at first form an arch (lig. arcuatum) limiting an opening for an aorta (hiatus aorticus) through a cut also there passes the chest channel. Behind the aortal opening is limited to a backbone.

The esophageal opening of D. (hiatus esophageus) is formed at the expense of the right leg; the left leg takes part in its education only in 10% of cases.

In the right leg allocate three muscle bundles from which right does not take part in formation of an esophageal opening, and a part of fibers of the average bunch and a bunch which is coming over to the left side form a muscular loop around a gullet.

The esophageal opening represents the channel from 1,9 to 3,0 cm wide both from 3,5 to 6 cm of Distance long between esophageal and aortal openings apprx. 3 cm, very seldom there is the general esophageal and aortal opening.

Through an esophageal opening of D. there pass also vagus nerves (nn. vagi).

In the tendinous center D. there are three departments: two side and front (average), in Krom there is a foramen of the inferior vena cava (foramen venae cavae s. quadrilaterum).

From above D. is covered with an intrathoracic fascia, a pericardium in the zone planum cardiacum, and also a pleura in the place of contact with lungs and in a zone of sine — phrenic and mediastinal and diafragmalnoreberny. The last is deepest and reaches 9 cm, but never reaches the level of an attachment of D. to edges thanks to what the narrow prephrenic space of 3 — 4 cm in depth (spatium praediaphragmaticum) limited to a verkhnenaruzhny surface of D., an inner surface of edges, a pleura and filled with friable cellulose is formed.

From below D. is covered with an intra belly fascia, on a big extent the peritoneum which is absent only between a leaf of a coronal ligament of liver around openings of a gullet, the lower vena cava and on all lumbar and the last tooth of costal part D. To this retroperitoneal part D. prilezhat the pancreas and a duodenum and also surrounded with an adipose capsule of a kidney and adrenal glands. The liver prilezhit to the most part of the right dome and to internal department of the left dome, about the Crimea the greater cul-de-sac and a spleen also adjoin. These bodies connect to D. by means of the corresponding sheaves. At hernias of an esophageal opening of D. the phrenic and esophageal sheaf is of great importance (lig. phrenicoesophageum) covering a front surface of a gullet. The lower bound of D. is stable and corresponds to the place of its attachment whereas the provision of domes is very variable and depends on the constitution, age, various patol, processes. Usually the top of the right dome is at the level of IV, and left — the V intercostal space. At a breath of a kupola of D. fall by 2 — 3 cm and are flattened.

Fig. 2. Diaphragm (from above): 1 — an aorta; 2 and 15 — the right and left perikardodiafragmalny arteries; 3 and 13 — the right and left phrenic nerves; 4 and 14 — the right and left perikardodiafragmalny veins; 5 — a phrenic part of a pericardium; 6 and 12 — right and left myshechno - phrenic veins; 7 and 11 — right and left myshechnodiafragmalny arteries; 8 — a gullet; 9 - breast; 10 — the lower vena cava; 16 — an esophageal texture; 17 — a chest channel.

Blood supply it is carried out by a pair muscular and phrenic artery (a. musculophrenica) from internal chest arteries, an upper phrenic artery (a. phrenica sup.) and lower phrenic (. phrenica inf.) from an aorta and six lower intercostal arteries (aa. intercostales). Outflow of a venous blood happens on the pair veins going parallel to arteries, and, besides, on an unpaired vein on the right and semi-unpaired — at the left, and also on veins of a gullet (tsvetn. fig. 2).

Limf, vessels Form, according to various authors, from two (D. A. Zhdanov, 1952) to three (I. N. Matochkin, 1949) and even five networks: pleural, subpleural, intrapleural, subperitoneal, peritoneal (G. M. Iosifov, 1930; M. S. Ignashkina, 1961). Limf.sosuda D. play a role in distribution of inflammatory processes of an abdominal cavity in pleural and vice versa, thanks to system limf, the vessels pro-butting. They are located preferential along a gullet, aortas, the lower vena cava and other vessels and nerves passing through.

Outflow of a lymph from D. is carried out from above through prelateroretroperikardialny and back mediastinal nodes, from below — through subphrenic: paraortalny and periesophagal.

Innervation. Each half of D. is innervated by a phrenic nerve (n. phrenicus), branches of six lower (VII—XII) intercostal nerves and fibers of a phrenic texture (plexus diaphragmaticus) and abdominal brain.

The only motor nerve of the corresponding half of D. is the phrenic nerve which is formed generally of C3-4 of roots of spinal nerves. It incorporates motive and sensitive fibers that matters in emergence frenikus-symptom (see). Branches of the lower intercostal nerves are only sensory and vasomotor nerves narrow (to 1 — 2 cm) a peripheral zone of a diaphragm.

The PHYSIOLOGY

D. performs two functions: static and dynamic. Static (basic) function consists in maintenance of normal relationship between bodies of chest and belly cavities, it depends on a muscle tone of. Disturbance of this function leads to moving of belly bodies to a thorax.

Dynamic (motive) function is connected with impact by alternately reduced and relaxing D. on lungs, heart and abdominal organs.

As a result of the movements D. the bulk of ventilation of the lower shares of lungs and 40 — 50% of ventilation — upper shares is carried out, edges it is provided with generally costosternal mechanism.

At a breath reduces intrapleural pressure, promoting filling with a venous blood of the right departments of heart, and pressing on a liver, a spleen and belly bodies, promotes outflow from them a venous blood, working as the pump.

D.'s impact on digestive organs consists c the massing action on a stomach and intestines, at the lowered D.'s tone the amount of air in a stomach and intestines increases.

METHODS of the RESEARCH

At percussion it is possible to find change of level of standing of D. or to suspect movement of abdominal organs in chest on the basis of emergence of zones of obtusion over it and a tympanites in combination with listening of this zone of a vermicular movement of intestines and the weakened respiratory noise.

Change of situation and function D. often is followed by reduction of respiratory lung volume (see. Vital capacity of lungs ) and change of functional respiratory trials, and at changes of position of heart — changes of an ECG.

Datas of laboratory in diagnosis of diseases of D. of independent value have no.

X-ray inspection — the main objective diagnostic method of damages and D. V diseases of a direct projection of D. represents two continuously convex arches: the top of right is at the level of V edge in front, left — is one edge lower. At a profile research the forefront of D. is located above, and then it goes kzad slantwise down. At quet breathing of a kupola of D. fall by 1 — 2 cm (on one edge), during the forcing of a breath and exhalation D.'s excursion reaches 6 cm. High standing of both domes of D. takes place at pregnancy, ascites, and in combination with disturbances of mobility — at paralytic intestinal impassability, diffusion peritonitis. High standing of one of domes is noted at paralyzes and paresis, D.'s relaxation, big tumors and cysts, abscesses of a liver, subphrenic abscesses.

Low standing of domes D. (phrenoptosia) is noted at the asthenic constitution, a visceroptosis, defects of a front abdominal wall and emphysema of lungs, and at the last also restriction of their mobility is observed.

At paralyzes and D.'s relaxation paradoxic movement of a dome when at a breath it rises can be observed, and at an exhalation — falls. The nature of the movements D. and its functional state investigate by means of special rentgenol, methods. At polygraphy make usually two pictures (diplogramm) on one film with exposure of 75% from usual, at first in situation D. on the maximum exhalation, and then on a breath (see. Polygraphy ).

Rentgenokimografiya is one-slot-hole, two-slot-hole or multislot-hole using a special lattice allows to study the direction, amplitude and a form of respiratory teeth of D. (see. Rentgenokimografiya ), and a rentgenoelektrokimografiya (see. Elektrokimografiya ) — to receive record of details of the movement of a contour of any site D. Registration of the movements D. is possible also at X-ray cinematographies (see). For aim studying of details of certain sites D., especially at cysts and tumors, it can be applied tomography (see). About situation and D.'s condition it is possible to judge by a contrast research of adjacent bodies (a gullet, a stomach, intestines) indirectly.

Help to isolate D.'s image from adjacent bodies in the absence of unions diagnostic pneumoperitoneum (see), pheumothorax (see. Pheumothorax artificial ) and a pneumomediastinum (see. Pnevmomediastinografiya ).

PATHOLOGY

Malformations

the Most often found malformations of D. — not fusion of the pleuroperitoneal channel or disturbance of accretion of separate bookmarks D. seldom meets formation of inborn false hernias (defects) by D. Ochen total absence of a dome or is even more rare — all D., usually incompatible with life. Along with it the inborn underdevelopment of muscular tissue in both either one dome or its some department meets development of an inborn full or partial relaxation of D. K to malformations also extremely exceptional cases of so-called not omission of D. when the place of its attachment is located to a chest wall and a backbone above usual belong.

Damages

They can be divided on open (fire, chipped and cut) and closed (traumatic); the last are subdivided on direct, indirect and spontaneous. All thoracoabdominal wounds with an internal injury are followed by D.'s damages (see. Torakoabdominalnye damages ). Occasionally the isolated its wounds without damage of bodies, adjacent to it, meet. The closed D.'s damages meet at transport injuries and falling from height. D.'s rupture is most often caused by sudden increase in intra belly pressure, much less often the similar mechanism can be noted at injuries of a thorax, In 90 — 95% of cases at the closed D.'s injury its left half is surprised; the rupture of both domes is very seldom observed. As a rule, there is a rupture of a tendinous part of a dome or its lead over muscular department. The rupture of a lumbar part with damage of an esophageal opening or D.'s separation from the place of its attachment is less often observed. Also the direct closed D.'s damages at its gap meet by the broken rib. The isolated closed D.'s damages are also observed seldom, usually they are combined with damage of pelvic bones and belly bodies.

Through D.'s rupture both at open, and at the closed damages in a pleural cavity abdominal organs — more often a stomach, an epiploon, loops of thick and thin guts can drop out. Occasionally at big gaps on the right in defect the liver, and at the left a spleen can drop out. Loss can arise as directly after an injury, and later this or that time term.

Clinical picture usually masks displays of the accompanying injury (plevropulmonalny shock, respiratory and cardiovascular insufficiency, a hemopneumothorax, peritonitis, bleeding, fractures of bones). Independent diagnostic value only signs of a prelum of a lung and shift of heart the belly bodies moved to a thorax and especially have symptoms of their prelum or infringement. It is difficult to distinguish D.'s damages. The direction of the wound channel is an auxiliary sign of thoracoabdominal wound at open damages. The authentic diagnosis can be made at open damages on the basis of loss in a wound of a thorax of belly bodies or the expiration from it a calla and urine, and also detection in a thorax of hollow abdominal organs at obligatory in similar cases as well as at the closed damages, rentgenol, a research.

Existence haemo - or pheumothorax at injury of a stomach causes suspicion against possible damage of.

At a laparotomy concerning an injury of a stomach or a torapotomiya at damages of bodies of a chest cavity it is necessary to inspect surely D. for an exception of its gap.

Fig. 1. Diagrammatic representation of sewing up of a rupture of a diaphragm (transthoracic way): 1 — lungs; 2 — a pericardium; 3 — an aorta.

Treatment. At the diagnosed D.'s rupture its simple sewing up (fig. 1) by separate seams from not resolving suture material after bringing down of belly bodies and excision of impractical fabrics of a diaphragm through the same access is shown, the Crimea used for audit (torako-or a laparotomy). For strengthening of seams formation of a duplikatura of is possible. Need for plastic strengthening of D., as a rule, does not arise as the extensive damages giving big defect usually are followed by an injury of adjacent bodies, not compatible to life.

Phrenic hernias

Phrenic hernias represent moving of belly bodies to a chest cavity through defect or a weak zone D. Existence of hernial gate, a hernial bag and hernial contents is characteristic of them. In the absence of a hernial bag hernia is called false (hernia diaphragmatica spuria) and if it is available — true (hernia diaphragmatica vera); in these cases the hernial bag is surely covered from below with a parietal peritoneum, and from above — a parietal pleura.

All hernias of D. divide, according to B. V. Petrovsky's classification, H. N. Kanshina, N. O. of Nikolaev (1966), on traumatic and not traumatic.

Not traumatic hernias, in turn, hernias of natural foramens of D. — an esophageal opening, rare hernias of natural foramens of are divided into false inborn hernias (defects) of D., true hernias of weak zones D., true hernias of atypical localizations.

From not traumatic hernias also inborn hernias (defects) of D. which quite often incorrectly call eventrations are false, they can be observed as well at adults.

Fig. 2. Diagrammatic representation of an arrangement of parasternal phrenic hernias: 1 — a diaphragm; 2 — retrokostosternalny hernia; 3 — retrosternal hernia.

Parasternal hernias (fig. 2) for which designation also use the terms «front phrenic hernia», «retroksifoidalny», «substernal», «subkostosternalny», «subkostalny», «hernia of Morganyi», «Larrey's hernia» belong to true hernias of weak zones. Parasternal hernia can be retrokostosternalny, leaving through a sternocostal triangle of Larrey, it can be called Larrey's hernia, and the retrosternal, connected with an underdevelopment sternal part D. Usually contents of a hernial bag at parasternal hernias are the epiploon and a cross colon, but also parasternal lipomas at which through hernial gate in D. as at the sliding hernia, the preperitoneal fatty tissue is stuck out often meet. True hernias of a lumbocostal triangle meet very seldom. The casuistic rarity is represented by true hernias of atypical localization, at them quite often there are no expressed hernial gate. Occur among hernias of natural foramens of D. of hernia of an esophageal opening very often and in connection with features of an anatomic structure, clinics and treatments represent special group of phrenic hernias. Separate cases of rare hernias of other natural foramens of D. are described: cracks of a sympathetic nerve, opening of the lower vena cava.

Traumatic hernias arise owing to thoracoabdominal wounds and D.'s ruptures and behind very rare exception are false. Hernial gate can be localized in any department of D., most often in the left dome. Seldom traumatic frenoperikardialny hernia, usually meets loss of an epiploon in a cavity of a pericardium, and the intercostal phrenic hernia arising at simultaneous damage of D. in the field of a phrenic and costal sine and a chest wall when belly bodies through a mezhreberye or area of the injured edge are stuck out outside.

Symptomatology. In some cases (at wide hernial gate, gradual and insignificant loss of belly bodies) phrenic hernias can not give symptoms for a long time.

Emergence them depends on a prelum of a lung and shift of heart the belly bodies which dropped out in a thorax, and also on a prelum and excesses of the dropped-out bodies, in these cases symptoms are more expressed at narrow hernial gate. According to it are usually noted cardiopulmonary, went. - kish. and general symptoms. Complaints to pains in an anticardium, a thorax, hypochondrium, an asthma, heartbeat, vomiting, feeling of weight in an anticardium after food are most characteristic. Gurgle and rumbling in the corresponding half of a thorax is quite often noted.

At the torsion of a stomach which is often observed at big phrenic hernias followed by an excess of a gullet the paradoxical dysphagy when the swallowed liquid is late is observed, and firm food passes well. Expressed a wedge, the picture is observed at the restrained phrenic hernias. There is an attack of the sharpest pain and feeling of a prelum in the corresponding half of a thorax or an upper part of a stomach, is frequent with irradiation in a back, a shovel. There is pernicious vomiting, in the beginning reflex, and then (at infringement of intestines) connected with intestinal impassability. Often the depressed case develops. At infringement of intestines intoxication develops. Infringement of a hollow abdominal organ can be followed by its necrosis and perforation with development pyopneumothorax (see).

Diagnosis. The presumable diagnosis of phrenic hernia is established on the basis of the instructions on an injury of a stomach and thorax (at traumatic hernias) stated above complaints, definition of obtusion or the tympanites over the corresponding half of a thorax changing intensity depending on filling of a stomach and intestines, listening of intestinal noise in this zone. The diagnosis is finalized at rentgenol, a research.

Fig. 3. The survey roentgenogram of a thorax of the patient with left-side traumatic phrenic hernia: lack of an accurate contour of a diaphragm at the left, a horizontal fluid level in the stomach (is specified by an arrow) moved to a chest cavity is characteristic. Two shooters specified the right dome of a diaphragm.
Fig. 4. The roentgenogram of a thorax in a side projection of the patient with left-side phrenic hernia: a prelum of a loop of a large intestine (1) at the level of hernial gate in a diaphragm (2).

Rentgenol, a picture depends on character and volume of the moved bodies. At loss of a stomach the big horizontal level (fig. 3) in the left half of a thorax with the level of air over it can be observed; at loss of intestines — certain sites of an enlightenment and blackout. D.'s contours can accurately not be defined. The contrast research of a stomach and intestines allows to define character (hollow or parenchymatous) the dropped-out bodies, to specify localization of hernial gate (fig. 4) on the basis of a prelum of the moved bodies at the level of an opening in D. (a symptom of hernial gate).

It is the most difficult to differentiate hernia and D. Odnako's relaxation there is a row rentgenol, the signs allowing to make it.

Treatment. The established diagnosis of phrenic hernia in connection with a possibility of infringement is the indication to operation, except for the sliding hernias of an esophageal opening of D. at which infringement does not happen.

Anesthesia — an endotracheal anesthesia using muscle relaxants (see). The choice of access depends on the party of defeat, localization of hernial gate and the nature of hernia. At rare right-hand localization operation is possible only through transthoracic access to the IV mezhreberye. At parasternal hernias both on the right, and at the left the best access — upper median laparotomy . (see). At left-side hernias, in connection with a possibility of unions with a lung which are difficult for dividing at a laparotomy transthoracic access to the VII—VIII mezhreberye with crossing of a costal arch is shown. However in cases of inborn posterolateral defects of D. with success access below and parallel to a costal arch can be applied. Operation consists in division of unions of the dropped-out belly bodies with a lung and in the field of hernial gate. Extra care should be observed at loss of a spleen, damage usually forces to make a cut splenectomy (see).

Fig. 5. The diagrammatic representation of sewing up of defect in a diaphragm over a patch from synthetic fabric (transthoracic access): 1 — a pericardium; 2,3 — a diaphragm.
Fig. 6. The diagrammatic representation of substitution of defect of a diaphragm by means of synthetic fabric (transthoracic access): 1 — a pericardium; 2 — a diaphragm; 3 — synthetic fabric.
Fig. 7. The diagrammatic representation of sewing up of defect in a diaphragm at parasternal hernia after bringing down of the dropped-out bodies and excision of a hernial bag (transabdominal access). At the left above — a type of hernia before operation.

After division of unions and liberation of edges of defect reduce the dropped-out bodies in an abdominal cavity and take in defect. It is in the majority accidental it it is possible by imposing of separate seams with formation of a duplikatura. Quite often at traumatic hernias of edge of D. are sprained and grow together with a chest wall that makes an impression of total absence of. Allocation of edges of defect allows to straighten them and to sew. If it does not work well, it is necessary to resort to a number of receptions, napr, D.'s mobilization, in particular at the expense of a section of a phrenic and costal sine. It is possible to use alloplastichesky strengthening of D. fabric from polymers, to-ruyu hem to D. as a patch from within and over it sew edges of defect (fig. 5). If it is impossible, the patch is sewn over a gap. At side defects owing to D.'s separation its edge is fixed to fabric of a mezhreberye; at big defects resort to alloplastichesky strengthening (fig. 6), and sew the crane of fabric so that it came on 1,5 cm for the region of.

At parasternal hernias after bringing down of the moved interiors the hernial bag is turned out and cut at a neck. Then on D.'s edges and a back leaf of a vagina of belly muscles, and also a periosteum of a breast and edges put stitches (fig. 7), usually P-shaped which consistently tie.

Posterolateral defects take in transabdominalno separate seams with formation of a duplikatura and leaving in a pleural cavity of the drainage entered through.

Operations for the restrained phrenic hernias have the features. Access at the restrained phrenic hernias established before operation shall be transthoracic. Therefore and when the restrained phrenic hernia is found during a laparotomy concerning an acute abdomen, later considerable term after infringement, reasonablly to pass on thoracotomy (see) to avoid threat of a rupture of the restrained body and not to infect an abdominal cavity. In the absence of the expressed necrotic changes at first cut the restraining ring on a fluted probe and investigate a condition of the restrained department of body. At confidence in its viability the dropped-out body is immersed in an abdominal cavity and take in defect in D. that usually does not cause difficulties in connection with narrow hernial gate. At irreversible changes the struck department is resected, and then take in D., leaving a drainage in a pleural cavity.

Fig. 8. Scheme of different types of hernias of an esophageal opening of a diaphragm: 1 — the ratio of a gullet, a diaphragm and a stomach is normal (for comparison); 2 — esophageal; 3 — cardial; 4 and 5 — fundal; 6 — antral; 7 — intestinal; 8 — stuffing; 9 — the acquired short gullet; 10 — an inborn short gullet; 11 — subtotal gastric hernia; 12 — total gastric hernia.

Hernias of an esophageal opening of a diaphragm can be sliding (axial) and paraezofagealny (fig. 8). The sliding hernias polumit the name because during the movement of the cardia on an axis of a gullet above D. the cardial department of a stomach owing to mesoperitoneal situation takes part in formation of a wall of a hernial bag. The sliding hernias (fig. 8, 2, 3, 9—12) of an esophageal opening of D. subdivide on esophageal, cardial, cardiofundal and huge (subtotal and total gastric hernias at which there is torsion of a stomach in a thorax). The sliding hernia can be fixed and unstable, inborn and acquired. Besides, in connection with features of anatomy, clinic and treatment, allocate the acquired short gullet of I and II degrees and an inborn short gullet the { a chest stomach) tied with its prevention in an abdominal cavity in the embryonal period. Blood supply of a chest stomach in these • cases is carried out from branches of intercostal arteries.

At paraezofagealny hernias there is a shift of a stomach or intestines through an esophageal opening of D. near a gullet while the cardia remains on site.

It, unlike the sliding hernias, causes a possibility of infringement. Paraezofagealny hernias on the nature of the dropped-out bodies divide into fundal, antral, intestinal, gastrointestinal, omental (fig. 8, 4—8).

In development of the acquired sliding hernia of an esophageal opening of D. major importance has reduction of longitudinal muscles of a gullet as a result of his irritation, a reflex from a stomach and adjacent bodies at cholelithiasis, an ulcer and so forth. Development of traumatic hernia of an esophageal opening after operation on D. and a stomach is possible.

At hernias of an esophageal opening there is a straightening of a corner of Gis who is formed between a gullet and a greater cul-de-sac, smoothing of the valve of Gubarev (a labelloid fold of a mucous membrane in the place of transition of a gullet to a stomach) and there is an incompetence of cardia with gastroesophagal reflux (see).

Symptomatology. The most frequent symptom — burning or dull ache in an anticardium, behind a breast and in left or is more rare in right hypochondrium with irradiation to the area of heart, a shovel, the left shoulder. Pain amplifies after food and in horizontal position of the patient, is followed by an eructation, vomiting, heartburn. The dysphagy is quite often noted, especially at a complication by a stricture of a gullet, and anemia owing to hron, bleedings. Often happens reflex stenocardia (see).

Fig. 9. Roentgenogram of cardial hernia of an esophageal opening of a diaphragm: over a diaphragm the contrasted department of a stomach (1) which got into a chest cavity through an expanded esophageal opening is visible. The shadow of a stomach (2) under a diaphragm is visible (3).

Diagnosis. The specified complaints and a wedge, symptoms allow to suspect hernia of an esophageal opening of. The final diagnosis is established at rentgenol, a research, at Krom note continuation of folds of cardial department of a stomach above a diaphragm (fig. 9) with shortening of a gullet (or without it), the developed Gis's corner and a reflux of a contrast agent from a stomach in a gullet. The reflux needs to be checked in horizontal position of the patient during the pressing for a stomach.

At accompanying a reflux esophagitis (see. Esophagitis ) the gullet can be expanded and shortened. On the roentgenogram existence of the «notches» separating cardias) from a gastroesophagal threshold is characteristic.

For diagnosis use and ezofagoskopiya (see), allowing to investigate a condition of a mucous membrane of a gullet and to state existence ref a luxury esophagitis.

Treatment. At uncomplicated forms of hernia of an esophageal opening of D. conservative treatment — same is shown, as well as at peptic ulcer (see). In the absence of an akhiliya food should be eaten in the small portions of 5 — 6 times a day. After food of the patient shall not lay down, the last meal shall be not less than in 3 hours prior to a dream. It is not necessary to drink plentifully since it promotes regurgitations (see). It is necessary to avoid the expressed inclinations of a trunk and to sleep with the raised upper body. Medicinal therapy is directed to decrease in secretion (as at a peptic ulcer), on elimination of locks, includes reception of antiacid drugs and sedatives.

As the indication to surgical treatment serves unsuccessfulness of prolonged repeated conservative treatment at patients with expressed a wedge, displays of hernia, and also at a complication of hernia a peptic stricture of a gullet and bleeding. Use a trance - abdominal access, except for cases of extended peptic strictures of the lower third of a gullet when transthoracic access is necessary.

Fig. 10. The diagrammatic representation of fundoplication across Nissen (a podshivaniye of a greater cul-de-sac): 1 — a diaphragm; 2 — a gullet; 3 — a fundoplikatsionny cuff; 4 — a stomach.

A large number of various operational methods from which the greatest distribution was gained by the fundoplication across Nissen (fig. 10) directed to recovery of valve function of the cardia is offered.

After mobilization of abdominal department of a gullet the back wall of fundal department of a stomach is carried out behind a gullet and sewed with its front wall the two-row seam taking a wall of a gullet. The cuff surrounding a gullet is formed thanks to what the acute angle of Gis is recovered. Isolated gastropexy (see), an ezofagofundorafiya shall be left as insufficiently effective. Sewing up of an esophageal opening as at the same time valve function of the cardia is not recovered is also inefficient, and at a short gullet this method is not applicable at all.

During the shortening of a gullet for elimination of a reflux valve gastroplication can be used (on H. To N. Kanshin). In this case fundoplication is carried out not around a gullet, and around the mobilized cardial department of a stomach. A number of surgeons uses at the same time Kollis's operation consisting in a section of the stomach moved up from top to down along a gullet parallel to small curvature on 12 — 15 cm with its lengthening at the expense of the formed gastric tube.

At treatment of peptic strictures of a gullet in case of failure of repeated dilatation special buzha showed a resection of the narrowed site with a valve ezofagogastroanastomoz.

Paraezofagealny hernias give more expressed symptomatology connected with a prelum of hernial contents, and the possibility of infringement does operation shown at once after establishment of the diagnosis. Operation consists in bringing down of belly bodies and sewing up of an opening in.

At the restrained hernias operate the same as at other phrenic hernias.

Fig. 11. The survey roentgenogram of a thorax of the patient with a full relaxation (thinning) of the left dome of a diaphragm: 1 — a dextrocardia; 2 — the left dome of a diaphragm; 3 — a gas bubble of a stomach; 4 — a gas bubble of a large intestine.

Phrenasthenia — sharp thinning by D. deprived of muscles with shift it together with abdominal organs, adjacent to it, in chest. The line of an attachment of D. remains on the usual place. As a rule, there is a prelum of a lung on the party of defeat and the shift of heart to the opposite side (fig. 11), there is cross and longitudinal torsion of a stomach so the cardia and antral department appear at one level.

The relaxation happens inborn (because of an aplasia the muscle is absent) and acquired (most often in connection with injury of a phrenic nerve; in this case at gistol, a research D. the remains of atrophic muscle fibers can be found).

The relaxation happens full (the whole dome is struck, left is more often) and limited (any department of D. is struck, is more often to the pereena medial on the right).

Clinical picture. The limited right-hand anteromedial relaxation usually proceeds asymptomatically, represents accidental rentgenol, a find. At a left-side relaxation the same symptoms, as at phrenic hernia, but, unlike

the Last, due to the lack of gryzhrvy orphans infringement is impossible. At the gradual shift of bodies the disease can proceed asymptomatically.

The diagnosis is made on the basis of signs of shift of abdominal organs in the relevant side of a chest cavity and confirmed at rentgenol, a research. Unlike hernia, over the moved belly bodies the shadow of highly located D. usually clearly is defined, under a cut the stomach and a large intestine give a symptom of open corners. The limited right-hand anteromedial relaxation should be differentiated. with tumors and cysts of a liver, a pericardium and a lung.

Fig. 12. The diagrammatic representation of plastics of the left dome of a diaphragm by means of a prosthesis from a polyvinylalcoholic sponge (transthoracic access): and — sewing together of an outside rag of a diaphragm (1) with a sponge (2) and the basis of an internal rag (3), the ends of edges are visible (4); — a podshivaniye of an internal rag of a diaphragm (3) over a sponge to fabric of a mezhreberye.

Treatment. Operation is shown only in the presence of expressed a wedge, symptoms and consists or in formation of a duplikatura of the thinned D., or in its plastic strengthening with use of alloplastichesky materials. For this purpose it is suitable ayvalon (a sponge from polyvinylalcohol) which in the form of a special patch is sewed between leaves of a duplikatura of D. along the line of its attachment (fig. 12).

Fig. 13. The diagrammatic representation of inborn phrenic hernias at children (projections are presented in each drawing a straight line, side on the right at the left): 1 — 3 — true (having a hernial bag): 1 — limited protrusion of a dome, 2 — considerable protrusion of a dome, 3 — full protrusion of a dome; 4 — 6 — false (defects of a diaphragm): 4 — slit-like back defect, 5 — a major defect of the right dome, 6 — a total defect of the left dome; 7 and 8 — hernias of an esophageal opening of a diaphragm: 7 — with the raised gullet (it is specified by an arrow), 8 — paraezofagealny (the gullet is specified by an arrow), 9 — hernia of front department of a diaphragm (through Larrey's crack); 10 — frenoperikardialny hernia.

Phrenic hernias at children result more often from a malformation of D., is more rare — owing to an injury, pyoinflammatory or infectious process therefore they can be divided on inborn and acquired. Inborn hernias subdivide into true (fig. 13, 1—3), the having hernial bags, and false (fig. 13, 4—6) at which abdominal organs through through defect of D. directly adjoin to a lung and heart. Frequency of inborn hernias of D. makes 1 on 1700 newborns (S. Ya. Doletsky, 1976). The combination of hernia of D. to other malformations (congenital dislocation of a hip, a wryneck, a pylorostenosis, an omphalocele, heart disease, narrowing of a pulmonary artery and so forth) is observed in 6 — 8% of cases.

The acquired D.'s hernias divide on traumatic and not traumatic. Can be the reasons of traumatic hernias: D.'s ruptures (acute and chronic) and D.'s relaxation (owing to an injury of a phrenic nerve). Not traumatic hernias can arise at through defects of D. (as a result of the abscess which is located under or over D.) and at D.'s relaxation (after poliomyelitis or tuberculosis).

Hernias of an esophageal opening of D. (fig. 13, 7 and 8) at children develop in connection with delay of rate of lowering of a stomach from a chest cavity in belly and lack of an obliteration of air and intestinal pockets what emergence of hernial bags is result of. Inborn hernias of D., including at its slit-like defects, and also frenoperikardialny hernias (fig. 13, 9 and 10) arise in anatomically «weak» departments of D. — a sternocostal interval, a lumbar triangle, etc. Formation of the thinned zones or through defects of D. happens at early stages of development of an embryo and a fruit. Disturbance of trophic processes in a muscular bookmark D. results in slow rate of development of D., the intra belly pressure increased in comparison with intrapleural — to implementation of abdominal organs in chest that occurs in recent weeks an antenatal life. Post-natal development of D. is followed by its relative atrophy in connection with the increasing value of function of intercostal muscles. Progressively sternocostal and lumbocostal triangles decrease, the area of the tendinous center at the expense of muscular departments increases. D.'s weight concerning the weight of all body decreases.

The acquired D.'s hernias result from the opened or closed injury. Quite often D.'s rupture happens to the subsequent development of traumatic phrenic hernia at a change of a basin owing to sharp increase in intra belly pressure. Tubercular bronkhadenit and nonspecific inflammatory process in a mediastinum can be complicated by damage of a phrenic nerve with an atrophy of a part or all dome of D. and development of its relaxation. At subphrenic abscess or decubitus, as a result of long drainage of a pleural cavity, formation of defect in D. with the subsequent movement of abdominal organs in chest is possible.

Clinical picture. At newborns with slit-like defect in back department of D. (Bokhdalek's triangle) cyanosis, vomiting, shift of heart, the scaphoid sunk-down abdomen («asphyxial infringement») are observed. During the moving of considerable volume of abdominal organs to chest lag in development of the child, an asthma is observed at run, deformation of a thorax. At hernia of an esophageal opening anemia, vomiting with impurity of blood, pain, the phenomenon of an erosive esophagitis is noted. In some cases phrenic hernias can proceed asymptomatically (or with an unusual combination of usual symptoms). They come to light at rentgenol, the research of a thorax conducted in other occasion.

Infringement of phrenic hernia is characterized by a combination of signs of intestinal impassability and respiratory insufficiency (see).

Diagnosis. Establishment of the diagnosis of traumatic phrenic hernia is promoted by existence of an injury in the anamnesis or hems on skin of a breast. Physical symptoms in zones of a projection of hernia (shortening of a percussion sound or a tympanites, intestinal noise, splash and so forth) give the grounds to suspect phrenic hernia and to make rentgenol. a research for establishment of the final diagnosis. Rentgenol, disappearance of a contour of D. («ambit»), its characteristic deformation, separate blackouts and enlightenments of the pulmonary field, levels in cavities, «a symptom of variability» — an essential sign rentgenol are signs of phrenic hernia. pictures at repeated researches. In doubtful cases make a contrast research went. - kish. path.

At newborns the differential diagnosis is carried out with D.'s paresis in connection with a birth trauma. At paresis D.'s dome in 1 — 2 month holds the correct position. In some cases in connection with the shift of heart to the right and cyanosis make the wrong diagnosis of a dextrocardia or heart disease. Crucial importance in diagnosis has rentgenol. research of a thorax.

Treatment operational. Exception limited relaxations and a full relaxation of D. at an arrangement of its dome make not higher than IV edges and small hernias of a nishchevodny opening provided that in all cases there are no complaints, patol, deviations, lag of the child in development. In the presence of pains, vomiting, recurrent intestinal impassability, went. - kish. bleedings operation in establishment where children have an experience in interventions of this sort is shown. The immediate surgery is carried out at asphyxial infringement at the newborn, at D.'s rupture and the restrained D.'s hernia of any localization.

Operation is made more often transabdominal access under an intubation anesthesia (see. Inhalation anesthesia ). At true hernias of D. the hernial bag is taken in sboryashchy seams or with creation of a duplikatura. Excision of a hernial bag is not obligatory. At slit-like and major defects of D. bringing down of bodies is promoted by administration of air in a pleural cavity through hernial gate by means of a metal catheter.

D.'s defects take in one number of the noose not resolving sutures. At frenoperikardialny hernias and considerable hernial gate apply substitution of defect alloplastichesky material (ayvalon, teflon, nylon), at an obligatory otgranicheniye of the last from a pleural or pericardiac cavity a leaf of a peritoneum on a leg, a fascia or an epiploon. Excision of a hernial bag at front and paraezofagealny hernias is not obligatory; the peritoneum is cut on perimeter of hernial gate to sew deserozirovanny fabrics. Success of operation is connected with movement of a gullet in perednebokovy department of an esophageal opening, sewing up of legs of D. behind a gullet, ahead of an aorta, creation of an acute esophageal and gastric angle by fixing of an abdominal piece of a gullet to a stomach and fixing of a greater cul-de-sac to a diaphragm in the field of their natural contact. Operation is completed a pyloroplasty in order to avoid the persistent vomiting caused pylorospasm (see) in connection with an injury of vagus nerves. At newborns at the small volume of the abdominal cavity which is not containing the bodies reduced from a pleural cavity the first stage create artificial (artificial) ventral hernia, to-ruyu eliminate in terms from 6 days up to 12 months after the first operation. Drainage of a pleural cavity at newborns is made across Byulau (see. Byulau drainage ), avoiding the forced raspravleniye of a lung and developing of acute emphysematous pneumonia. The drainage can be carried out below the XI—XII edge transabdominalno to avoid its excess at a raspravleniya of a lung.

Postoperative complications are observed more than at 50% of the operated children. Distinguish the general complications (a hyperthermia, oppression of a respiratory center, disturbance of a water salt metabolism), pulmonary (an atelectasis, hypostasis, pneumonia, pleurisy), abdominal (dynamic and mechanical intestinal impassability), and also excessive increase intra belly pressure (see), D. which is followed by restriction of excursions and a syndrome of a prelum of the lower vena cava (see. Venas cava ). A recurrence is most often observed at paraezofagealny hernias.

The lethality after operation for phrenic hernias at children makes 5 — 8% (at newborns — to 10 — 12%).

Diseases

Symptoms of diseases of D. are connected with change of its situation (high standing, a relaxation, tumors) or moving of abdominal organs to a thorax at phrenic hernias.

Depending on dominance a wedge, manifestations these symptoms can be divided into three basic groups: the general, cardiopulmonary, went. - kish. These symptoms are not specific, they can be observed also at some other diseases and gain diagnostic value only at certain objective data.

An inflammation of a diaphragm — diaphragmatites (or diafragmita) are subdivided on acute and chronic, specific and nonspecific. In most cases they are secondary. Hron, diaphragmatites usually specific — tubercular, syphilitic or fungal (actinomycosis) and independent a wedge, do not matter as well as hron, the nonspecific diaphragmatitis connected with hron, inflammatory processes of adjacent bodies.

The acute nonspecific diaphragmatitis almost always happens secondary and only occasionally depends on hematogenous spread of an infection from the remote suppurative focuses. In most cases it takes place at acute pleurisy and nizhnedolevy abscesses of a lung or at subphrenic abscesses.

A wedge, manifestations of an acute diaphragmatitis keep within the diafragmatichesky symptom complex described by M. M. Vikker: sharp pains in the lower parts of a thorax corresponding to the place of an attachment of D., morbidity in this zone at a palpation, local muscle tension of a stomach. Characteristic sign of an acute diaphragmatitis of V. I. Sobolev (1950) considers high standing of the struck D.'s dome with restriction of its mobility and flattening, shortening of sine, a thickening of contours of D. in the presence of changes from an adjacent lung or subphrenic space. As such diaphragmatites are secondary, treatment is directed to elimination of basic process. Existence of acute primary diaphragmatites in literature is disputed, a wedge, they do not matter.

Cysts and tumors. Most often secondary cysts and D.'s tumors connected with germination in it high-quality (including parasitic) or malignant cysts and tumors of belly and chest cavities meet (an echinococcus and tumors of a liver, lung, gullet, stomach, etc.).

Primary cysts of D. represent a considerable rarity. By 1966 only 38 cases of not parasitic cysts of are described. They can be true (having an epithelial vystilka) — dermoid, echinococcal, vascular and coelomic; false — the pseudocysts which are formed as a result of limited subpleural or subperitoneal accumulations of serous liquid; tubercular.

Also primary tumors of are also rare. According to B. V. Petrovsky, H. N. Kanshina and N. O. of Nikolaev (1966), in the world literature 68 primary tumors of D. are described: 37 high-quality (lipomas, fibrolipomas, fibromas, leiomyomas, neurofibromas, lymphangiomas) and 31 malignant (from them 24 sarcomas, and the others — gemangio-and fibroangioendotelioma, gemangioperitsitoma, mesotheliomas, synoviomas). In the next years only single observations are described.

Symptoms to a certain extent depend on the sizes and localization of a cyst or a tumor.

At small tumors and D.'s cysts symptoms are practically absent. At the big sizes of a tumor signs of a prelum of a lung and shift of bodies of a mediastinum with development of the phenomena hron can take place, hypoxias (see), a symptom of «drum sticks» (see. Drum fingers ), and at big right-hand cysts and tumors there are symptoms from bodies of a thorax, and at left-side — they are generally caused by a prelum of belly bodies or a gullet. At the secondary cysts and tumors burgeoning in D. from adjacent bodies and at metastatic defeats, there are pains and symptoms which are defined by the basic patol, process.

Diagnosis of primary tumors and D.'s cysts of hl. obr. radiological is also based on detection at benign tumors of the roundish shadow merging with a shadow of. Benign tumors and cysts of the left dome are well visible against the background of a lung, the deformed gas bubble of a stomach or a splenic corner of a large intestine, and at right-hand localization they merge with a shadow of a liver that forces to differentiate them with a right-hand limited relaxation of D., tumors and cysts of a liver or similar educations in the lower lung lobe.

In these cases the diagnostic pneumoperitoneum or pheumothorax can be used.

At malignant tumors, infiltriruyushchy D., there is no accurate ocherchennost of education, there is only a thickening and deformation of a dome which in some cases mask a pleural exudate.

Treatment. The established diagnosis of primary cyst or D.'s tumor is the indication to the operative measure which is carried out, as a rule, transtorakalno. Operation consists in enucleating of a benign cyst or D.'s tumor or in its excision within healthy fabrics (at suspicion on malignant character) with the subsequent sewing up of defect of D. separate silk seams. At the big extent of the defect formed after an oncotomy these or those plastic methods can be applied to its closing.

Removal of secondary tumors and D.'s cysts is made when it is possible, by the same principles along with removal of the main center.

Aggregated data about damages and basic diseases of D. are provided in the table.


Table. Classification and clinicodiagnostic characteristic of some damages and diseases of a diaphragm

Bibliography: Bairov G. A. Urgent surgery of children, L., 1973; Doletsky S. Ya. Phrenic hernias at children, M., 1960, bibliogr.; Nesterenko Yu. A., Klim and certain I. V. and Lelekhova N. I. Ruptures of the right dome of a diaphragm, Surgery, No. 4, page 106, 1975; Petrovsky B. V., Kan tires of H. N and Nikolaev N. O. Hirurgiya of a diaphragm, L., 1966, bibliogr.; Utkinv.V. iapsitis B. K. Hernias of an esophageal opening of a diaphragm, Riga, 1976; Fekete F., C 1 about t P. etLortat-Jacob J. L. Ruptures du diaphragme, Ann. Chir., t. 27, p. 935, 1973; H e i m i n g E., E b e 1 K. D. u. G h a r i b M. Komplikationen bei Zwerchfellanomalien, Z. Kinderchir., Bd 15, S. 147, 1974; Koss P. u. R e i t t e r H. Erkrankungen des Zwerchfells, Handb. d. Thoraxchir., hrsg. v. E. Derra, Bd 2, T. 1, S. 191, B. u. a., 1959; Olafsson G., Rausing A. H o 1 e n O. Primary tumors of the diaphragm, Chest, v. 59, p. 568, 1971; Strug B., Noon G. P. a. B e an of 1 1 A. Page of Traumatic diaphragmatic hernia, Ann. thorac. Surg., v. 17, \e. 444, 1974.

B. V. Petrovsky; S. Ya. Doletsky (ped.), author of tab. H. N. Kanshin.

Яндекс.Метрика