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    Diaphragmatic Hernia

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    hayssam rashwan
    1) Diaphragmatic hernia is a birth defect where abdominal organs protrude into the chest cavity due to a hole in the diaphragm. It occurs in 1 in 2,000-5,000 births. 2) Symptoms at birth include respiratory distress. Signs include decreased breath sounds and heart sounds on the affected side. 3) Treatment involves stabilizing the infant with ventilation support if needed, then surgically reducing the herniated organs and repairing the diaphragmatic defect. Complications can include recurrence, gastroesophageal reflux, and developmental problems.

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    Diaphragmatic Hernia

    Uploaded by

    hayssam rashwan
    1K views42 pages
    1) Diaphragmatic hernia is a birth defect where abdominal organs protrude into the chest cavity due to a hole in the diaphragm. It occurs in 1 in 2,000-5,000 births. 2) Symptoms at birth include respiratory distress. Signs include decreased breath sounds and heart sounds on the affected side. 3) Treatment involves stabilizing the infant with ventilation support if needed, then surgically reducing the herniated organs and repairing the diaphragmatic defect. Complications can include recurrence, gastroesophageal reflux, and developmental problems.

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    pediatric surgery lectures

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    Diaphragmatic hernia

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    1) Diaphragmatic hernia is a birth defect where abdominal organs protrude into the chest cavity due to a hole in the diaphragm. It occurs in 1 in 2,000-5,000 births. 2) Symptoms at birth include respiratory distress. Signs include decreased breath sounds and heart sounds on the affected side. 3) Treatment involves stabilizing the infant with ventilation support if needed, then surgically reducing the herniated organs and repairing the diaphragmatic defect. Complications can include recurrence, gastroesophageal reflux, and developmental problems.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    1K views42 pages

    Diaphragmatic Hernia

    Uploaded by

    hayssam rashwan
    1) Diaphragmatic hernia is a birth defect where abdominal organs protrude into the chest cavity due to a hole in the diaphragm. It occurs in 1 in 2,000-5,000 births. 2) Symptoms at birth include respiratory distress. Signs include decreased breath sounds and heart sounds on the affected side. 3) Treatment involves stabilizing the infant with ventilation support if needed, then surgically reducing the herniated organs and repairing the diaphragmatic defect. Complications can include recurrence, gastroesophageal reflux, and developmental problems.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 42
    At a glance
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    The key takeaways are that a diaphragmatic hernia is a defect in the diaphragm that allows abdominal organs to migrate into the chest cavity. The main types are Bochdalek, Morgagni, and eventration. Congenital diaphragmatic hernias can cause respiratory distress in infants and require stabilization before surgical repair.

    The different types of diaphragmatic hernias are Bochdalek (most common), Morgagni, and eventration.

    The symptoms and signs of congenital diaphragmatic hernia in infants include respiratory distress, feeding intolerance, scaphoid abdomen, decreased chest movement, decreased breath sounds and bowel sounds heard in the chest.

    Diaphragmatic Hernia

    Definition
    A condition characterized by a defect in the diaphragm, through which the abdominal viscera migrate into the chest during fetal life

    Incidence
    1 in 2,000 5,000 births 80% left side 20% right side Bilaterality is rare Associated anomalies in 40% of cases

    Types
    Bochdalek hernia (most common)

    Hernia of foramen of Morgagni

    Eventration of the diaphragm

    Diaphragm seen from below


    (B) Bochdalek left posterolateral defect (M) Anterior or Morgagni type (H) Hiatus for oesophagus and hiatal hernia (E) Large eventration in the tendinous portion of the right copula (T) A tear causing post-traumatic hernia (A) Abdominal aorta

    Pathophysiology

    Embryology
    Failure of closure of the pleuroperitoneal canal, which occurs during 8th gestational week.

    Consequently, the abdominal viscera herniates into the thorax, which causes pulmonary hypoplasia by compressing the growing lung.

    Congenital diaphragmatic hernia


    Pulmonary hypoplasia Left ventricular hypoplasia Surfactant deficiency

    Hypoxemia Hypercapnea Acidosis Persitent fetal circulation Right to left shunting

    Pulmonary arterial vasoconstriction

    Pulmonary hypertension

    Symptoms

    Most cases are symptomatic at or shortly after birth


    - Respiratory distress including tachypnea, grunting, cyanosis and tachpnea

    - Feeding intolerance

    Signs

    1. Inspection
    - Scaphoid abdomen - Decreased chest movement on the affected side

    2. Auscultation
    - Decreased air entry - Heard bowel sounds are heard in the chest - Heart sounds are distant or displaced on the affected side

    Other presentations
    Asymptomatic Non-specific eg. repeated chest infection Signs of intestinal obstruction or bowel necrosis following volvolus

    Antenatal diagnosis Ultrasonography

    As early as 25th week of gestation 1. Polyhydramnios 2. Bowel loop within the chest 3. Absent or intrathoracic gastric bubble 4. Mediastinal shift 5. Lung to head ratio (LHR): an important indicator of severity

    Laboratory
    - Maternal serum -FP may be decreased
    - Amniocentesis may show decreased Lecithin to Sphingomyelin ratio and associated chromosomal anomalies

    Postnatal diagnosis X-ray


    Bowel loop in the chest Mediastinal shift Small portion of the lung on the ipsilateral side Deficient of the bowel gas in the abdomen

    CT
    distinguish between congenital diaphragmatic hernia and a cystic lung lesion (eg, congenital cystic adenomatoid malformation).

    Differential diagnosis Congenital cystic lung diseases ( eg. Congenital cystic adenomatoid malformation)
    Mediastinal cystic lesions ( eg. Cystic teratoma, Bronchogenic & thymic cysts )

    Other congenital thoracic lesions (eg. Hiatal hernia & primary agenesis of the lung )

    Possible antenatal markers of severity


    Early gestational age at diagnosis on U/S Lung-to-head ratio (LHR) at 24-26 weeks gestation <1.0 Small fetal lung volume on 3D U/S and MRI >50% liver in chest on right side Liver on chest on left side Stomach and spleen on chest in left side No hernial sac (difficult to confirm on scanning)

    Pre-operative preparation
    Immediately following delivery, the infant is intubated (bag and mask ventilation is AVOIDED) to avoid air swallowing and distension of the gut. A nasogastric tube is passed to decompress the stomach and to avoid visceral distention which compresses the lung. Adequate assessment involves continuous cardiac monitoring, arterial blood gas and systernic pressure measurements, urinary catheterization to monitor fluid resuscitation, and both preductal (radial artery) and postductal (umbilicai artery) oximetry.

    Pre-operative preparation (cont.)


    Pressure limited ventilation should be used. Peak inspiratory pressures should be less than 30 cm H2O to avoid barotraumas to the hypoplastic lung.
    Alternative means of support (e.g. inhaled nitric oxide [iNO]) highfrequency oscillatory ventilation [HFOV], ECMO) should be considered for the patient who fails to stabilize on conventional ventilation;

    High-frequency oscillatory ventilation (HFOV): means the use of


    high respiration rate with small tidal volume to improve oxygenation of the fragile hypopiastic lung to maintain preductal oxygenation while avoiding hyperventilation and barotrauma.

    ECMO: means the use of extracorporeal membrane oxygenator

    (artificial lung) in case failure to respond to maximal medical treatment.

    ECMO
    A life support system that employs partial heart-lung bypass providing rest to the lungs for long periods of time during which it is hoped that the lung and, in particular, the lung vasculature will mature.

    Timing of surgery
    It had been gradually shifted from an emergency repair to a policy of stabilization using a variety of ventilatory strategies prior to operation.

    Operation
    Reduction of the content & repair of the diaphragm
    A subcostal incision is made. The abdominal viscera are examined, and the hernia is reduced by gentle traction. A hernia sac is sought and excised if found. Following careful dissection to the posterior leaf of the diaphragm, primary repair of the diaphragm can be accomplished in a single layer using nonabsorbable sutures.

    Operation (cont.)
    Reduction of the content & repair of the diaphragm
    If the diaphragmatic defect is large enough to preclude primary closure, a Gore-Tex patch can be used. If abdominal closure may interfere with chest wall or diaphragmatic compliance or lead to abdominal compartment syndrome, then a temporary silo with delayed primary closure of the fascia or skin can be safely accomplished.

    Use of chest tubes and whether to use suction are controversial. It is preferred to use a chest tube but limit suction to 5 cm H2O.

    Postoperative
    Transfer to ICU Warming IV fluids & antibiotics Ventilatory supports Chest X-ray to detect pneumothorax

    Complications
    1. 2. 3. 4. Recurrence Gastroesophageal reflux Small bowel obstruction may occur secondary to adhesions or intussusception Increased risk of neurodevelopmental problems and growth retardation

    Prognosis
    Poor prognosis in:
    Polyhydramnios Right-sided CDH Intrathoracic stomach and liver LHR < 1.0

    Eventration of the diaphragm


    A developmental anomaly that results in muscular aplasia of the diaphragm.

    associated with congenital myopathies or intrauterine infections

    as a result of phrenic nerve injury during forceps delivery or surgery

    Clinical picture
    Ranges from asymptomatic to severe respiratory distress May present later with repeated attacks of pneumonia, bronchitis or bronchiectasis May present with GIT symptoms of vomiting or epigastric discomfort later in childhood

    Diagnosis
    Chest X-ray:
    Elevated diaphragm with a smooth, unbroken outline

    Treatment
    Asymptomatic patients are treated expectantly Symptomatic patients: Surgery once the condition is stabilized Plication of the diaphragm

    Thank you

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