Surgery : Congenital Diaphragmatic Hernia
Development of diaphragm :
1. Transverse septum
2. Pleuroperitoneal membrane
3. Dorsal mesentery of oesophagus
4. Mesoderm
80% occur on left side
Sites of congenital hernia :
✓ Hernia through foremen of Bochdalek -
⁃ most common
⁃ posterolateral (failure of one or both the pleuroperitoneal membranes
to close the pericardioperitoneal canal)
⁃ Respiratory distress, shift of mediastinum and scaphoid abdomen
✓ Hernia through foramen of Morgagni - anteromedial (parasternal hernia)
-
⁃ present in late childhood or adult life
⁃ c/f of partial (subacute) intestinal obstruction, RUQ pain or chest
tightness
⁃ Majority of them contain transverse colon
✓ Herniation through central tendon -
⁃ can affect R/L apex of cupola or central portion
⁃ Contents may be fundus of stomach (L), portion of liver (R)
✓ Eventration -
⁃ due to paralysis or atrophy of muscle fibres, one or both
hemidiaphragms are weak and are elevated in position
Diagnosis :
• Antenatal diagnosis - polyhydramnios, abdominal absence of stomach
bubble , presence of liver in thoracic cavity
• At birth - pulmonary hypoplasia, reactive pulmonary HTN , scaphoid
abdomen, asymmetrical distended chest
RDS - cyanosis, gasping, sternal retraction, poor respiratory effort
• CXR - gas and fluid levels in chest
• Thin rim of diaphragm is broken or shows a defect
• CT Chest/abdomen - GOLD STANDARD
Treatment :
BAG AND MASK VENTILATION CONTRAINDICATED 🚨
◦ Surgical treatment- wrap head and extremities to prevent hypothermia,
pre warm OT,
◦ reduce hernia and plicate lips of /diaphragmatic defect with non
absorbable sutures
◦ Patch closure with tension free mesh repair
◦ Eventration is treated by plicating redundant diaphragm
◦ In physiologically stable patient - thoracoscopy or laparoscopic
Development of diaphragm :
1. Transverse septum
2. Pleuroperitoneal membrane
3. Dorsal mesentery of oesophagus
4. Mesoderm
80% occur on left side
Sites of congenital hernia :
✓ Hernia through foremen of Bochdalek -
⁃ most common
⁃ posterolateral (failure of one or both the pleuroperitoneal membranes
to close the pericardioperitoneal canal)
⁃ Respiratory distress, shift of mediastinum and scaphoid abdomen
✓ Hernia through foramen of Morgagni - anteromedial (parasternal hernia)
-
⁃ present in late childhood or adult life
⁃ c/f of partial (subacute) intestinal obstruction, RUQ pain or chest
tightness
⁃ Majority of them contain transverse colon
✓ Herniation through central tendon -
⁃ can affect R/L apex of cupola or central portion
⁃ Contents may be fundus of stomach (L), portion of liver (R)
✓ Eventration -
⁃ due to paralysis or atrophy of muscle fibres, one or both
hemidiaphragms are weak and are elevated in position
Diagnosis :
• Antenatal diagnosis - polyhydramnios, abdominal absence of stomach
bubble , presence of liver in thoracic cavity
• At birth - pulmonary hypoplasia, reactive pulmonary HTN , scaphoid
abdomen, asymmetrical distended chest
RDS - cyanosis, gasping, sternal retraction, poor respiratory effort
• CXR - gas and fluid levels in chest
• Thin rim of diaphragm is broken or shows a defect
• CT Chest/abdomen - GOLD STANDARD
Treatment :
BAG AND MASK VENTILATION CONTRAINDICATED 🚨
◦ Surgical treatment- wrap head and extremities to prevent hypothermia,
pre warm OT,
◦ reduce hernia and plicate lips of /diaphragmatic defect with non
absorbable sutures
◦ Patch closure with tension free mesh repair
◦ Eventration is treated by plicating redundant diaphragm
◦ In physiologically stable patient - thoracoscopy or laparoscopic
