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Lecture notes, cheat sheets
Pediatric surgery. Diaphragmatic hernia. Phrenico-pericardial hernias (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 7. Diaphragmatic hernia. Frenico-pericardial hernias Congenital diaphragmatic hernias are a kind of malformation of the diaphragm, in which the abdominal organs move into the chest cavity through natural or pathological holes in the diaphragm, as well as by protrusion of its thinned area. Depending on the size of the hernial orifice, their location, the number and size of the displaced organs, a violation of the function of respiration, digestion and cardiovascular activity develops. All this can be compensated and not detected for a long time. Decompensation often occurs soon after birth, or severe complications occur at an older age. Depending on the location of the hernial orifice, congenital diaphragmatic hernias are divided into: 1) hernia of the diaphragm itself (false and true); 2) hiatal hernia (usually true); 3) hernias of the anterior part of the diaphragm - parasternal (true) in the region of the sternocostal triangle (Lorrey's fissure) and phrenic-pericardial, arising in the presence of defects in the diaphragm and pericardium (false). Aplasia (absence) of the dome of the diaphragm can be regarded as an extensive false hernia of the diaphragm itself, and relaxation is referred to as true hernias with protrusion of the entire dome. The so-called true diaphragmatic hernia occurs due to the underdevelopment of the muscular and tendon layer of the diaphragm, which, becoming thinner, protrudes into the chest cavity, forming a hernial sac. The underdevelopment of all layers of the thoracic obstruction is accompanied by the formation of through defects of various shapes and sizes. In such cases, the abdominal organs move freely into the chest cavity, and a false diaphragmatic hernia is formed that does not have a hernial sac. 1. Hernia of the diaphragm itself. Complicated false hernia of the diaphragm proper Among congenital malformations of the diaphragm, false hernias of the diaphragm proper are most common, and true ones are somewhat less common. The clinical course, prognosis and technique of surgical interventions in these groups of congenital diaphragmatic hernias differ quite significantly from each other, although sometimes, when similar complications occur, the symptomatology and surgical tactics are the same. Congenital defects of the diaphragm, through which the organs of the abdominal cavity move into the chest, are usually of three types: a slit-like defect in the lumbar-costal region (Bogdalek's gap), a significant defect in the dome of the diaphragm, and aplasia - the absence of one of the domes of the diaphragm. clinical picture In the presence of a slit-like defect in the region of the lumbocostal region (Bogdalek's fissure), an acute course of a false hernia of the diaphragm proper occurs, usually in the first hours or days after the birth of a child. In most cases, a hernia is manifested by symptoms of increasing asphyxia and cardiovascular insufficiency, which develop as a result of flatulence of the intestinal loops and stomach moved into the chest cavity. In such cases, compression of the lungs and displacement of the mediastinal organs occur - a condition called "asphyxial infringement". In older children, true infringement of the abdominal organs displaced through a defect in the diaphragm is possible. The clinical manifestation of these complications of false hernias of the diaphragm itself has its own characteristics. "Asphyxial infringement" can only conditionally be called a complication of congenital diaphragmatic hernia. This is rather a common clinical manifestation of a false hernia of the diaphragm itself, if the displacement of hollow organs into the pleural cavity occurred before the birth of the child. In the first hours of life, intestinal loops and the stomach are filled with gas, their volume increases sharply and the compression of the organs of the chest cavity increases. With a narrow slit-like defect, the hollow organs are unable to move back into the abdominal cavity on their own. The most constant sign of "asphyxic infringement" is progressively increasing cyanosis. The child becomes lethargic, the cry is weak, vomiting occurs periodically. Breathing is difficult, superficial and relatively rare (20-30 per minute). The participation of auxiliary respiratory muscles is noticeable, the sternum and false ribs sink down. When inhaling, the epigastric region is retracted funnel-shaped (more on the left). The abdomen is small, somewhat asymmetrical due to the protruding liver. During a cry or an attempt to feed a child, cyanosis increases markedly. The phenomena of asphyxia are somewhat reduced when the child is transferred to a vertical position with a slight inclination towards the hernia. It should be remembered that artificial respiration is not indicated if a complication of a diaphragmatic hernia is suspected, since it sharply worsens the child's condition: the suction of the abdominal organs into the chest cavity increases, and hence the displacement of the mediastinal organs and compression of the lungs increase. Physical data greatly help in making a diagnosis. On the side of the hernia (usually on the left), breathing is sharply weakened or not audible. In older children, faint noises of intestinal peristalsis are detected. On the opposite side, breathing is weakened to a lesser extent. Heart sounds are heard clearly, as a rule, dextrocardia is detected. At the birth of a child, heart sounds are heard in the usual place, but relatively quickly (1-2 hours) shift to the right beyond the midline or even the nipple line. Absence of the dome of the diaphragm (aplasia) is extremely rare, and children with this severe defect are born dead or live no more than 1 hour. The clinical picture is not much different from the above with an acute false hernia of the diaphragm. However, the dysfunction of the respiratory and circulatory organs increases so rapidly that it is extremely difficult to make a correct diagnosis, transport to the surgical department and perform an operation in a short period of time. X-ray examination is crucial for clarifying the diagnosis. The main symptoms of a diaphragmatic hernia are a displacement of the boundaries of the heart (usually to the right) and the appearance in the lung field of cellular cavities of uneven size, corresponding to the filling of displaced intestinal loops with gas. When examining a child in the first hours after birth, the cavities are relatively small, their number gradually increases, and they become larger. Sometimes, when the stomach is displaced into the chest cavity, a large air cavity is visible, which has a pear-shaped shape. In the abdominal cavity, the intestinal loops are slightly filled with gas. A contrast study, which is carried out with iodolipol, is indicated only if the diagnosis is in doubt. For these purposes, a newborn is injected through a tube into the stomach with 5-7 ml of iodized oil (iodolipol), which, spreading, well contours the wall of the stomach. A re-examination after 2-3 hours can show the passage of the contrast agent through the small intestine and reveal its displacement into the chest cavity. In some cases, X-ray examination can diagnose such concomitant malformations as congenital intestinal obstruction. At the same time, a sharp swelling of individual intestinal loops moved into the chest cavity with horizontal levels of fluid or flatulence of the adductor intestine is seen. Infringement of false diaphragmatic hernias. Due to the presence of "hard" hernial orifices in false diaphragmatic hernias, infringement of the displaced abdominal organs is possible more often than in other hernias of the abdominal obstruction. Infringement of hollow organs is characterized by a sudden onset. The phenomena of acute obstruction of the gastrointestinal tract in combination with respiratory failure come to the fore. An early sign that allows you to suspect infringement are bouts of cramping pain. Infants suddenly begin to worry, toss about in bed, grab their stomachs with their hands. Older children indicate emerging pain in the chest or upper abdomen. The duration and intensity of attacks can be different, usually contractions are repeated every 10-15 minutes. In between, patients behave relatively calmly. The general condition progressively worsens. Vomiting always accompanies infringement, occurs during an attack of pain, often repeated. Delay of a chair and gases is observed in all cases. Only at the beginning of the disease is sometimes a scanty stool (with infringement of the upper intestines). The chest on the side of the infringement lags behind in movement during breathing; revealed: shortness of breath, cyanosis, increased heart rate. The abdomen is slightly retracted, mildly painful on palpation in the epigastric region. Percussion and auscultation is determined by the displacement of the mediastinal organs in the opposite side of the hernia, the weakening or absence of breathing on the affected side. At the beginning of the disease in the chest cavity, ringing peristalsis noises are often heard. Infringement develops more often in children with subacute hernia. In this regard, the patient may have chronic pulmonary insufficiency, pneumonia. During the examination, the doctor should pay special attention to the condition of the lungs. X-ray examination X-ray examination reveals symptoms typical of a diaphragmatic hernia: mediastinal displacement; the presence of cellular cavities due to intestinal loops moved into the chest cavity. Characteristic of obstruction caused by infringement. is the presence of several large or multiple horizontal levels. Differential diagnosis The differential diagnosis of a false diaphragmatic hernia in a newborn should be carried out with some congenital heart defects and birth trauma of the brain, in which cyanosis and general weakness of the child give reason to suspect "asphyxial infringement". However, the absence of characteristic changes in the respiratory system and X-ray data help to make the correct diagnosis. Attacks of cyanosis are also observed in a newborn with acute lobar emphysema or lung cyst. Clinical symptoms in such cases are of little help in the differential diagnosis. X-ray examination in these diseases, as well as in diaphragmatic hernia, shows a sharp shift in the boundaries of the heart, but in acute emphysema there is no characteristic cellular structure of the pulmonary field on the side of the lesion, corresponding to gas bubbles of intestinal loops. A lung cyst manifests itself as separate large cavities, but unlike a hernia, there is a visible closed diaphragm contour, a normal gastric bladder and the usual number of intestinal loops in the abdominal cavity. A contrast study of the digestive tract helps to make a definitive diagnosis. Differentiation of infringements of false diaphragmatic hernias has to be carried out with pleurisy, which, with staphylococcal pneumonia, begins acutely, has a variable x-ray picture, and in older children it is multi-chamber. To clarify the diagnosis, it is sufficient to conduct a contrast X-ray examination. It is clear that diagnostic puncture in case of suspected strangulated hernia is categorically contraindicated. Treatment Congenital false diaphragmatic hernia of the diaphragm itself with an acute course in newborns ("asphyxic strangulation") and the phenomenon of strangulation in infants and older children are an absolute indication for immediate surgery. Underestimation of the importance of emergency surgical intervention entails the death of the patient with symptoms of asphyxia (in newborns) or acute obstruction of the gastrointestinal tract. Preoperative preparation for emergency operations is short-term. The newborn is placed in an oxygen tent (couveuse), warmed. In some cases, if there is severe hypoxia and the effects of asphyxia increase, the child is immediately intubated and begin to conduct controlled breathing. In newborns and children of the first months of life, in some cases there are difficulties in suturing the wall of the abdominal cavity, the dimensions of which are insufficient, and it does not contain the reduced organs. In such children, a two-stage closure of the abdominal cavity should be resorted to, which reduces the tension of the diaphragm sutures and reduces intraperitoneal pressure. 2. Complicated true hernia of the diaphragm proper The nature of the course of the disease depends mainly on the degree of displacement of the abdominal organs into the chest. In some cases, the hernial gates are small in size, and the hernial sac is stretched to a significant extent and filled with organs moved into the pleural cavity. Compression of the lungs, displacement of the heart and mediastinal vessels with a significant violation of their function. The patency of the gastrointestinal tract may be impaired. clinical picture The acute course of a true congenital hernia of the diaphragm itself occurs in the presence of a total displacement of the abdominal organs into the chest, which is usually observed in newborns and children in the first months of life. In older children, infringement of the displaced abdominal organs may occur in the presence of a relatively small defect in the diaphragm proper and a significant hernial sac. The clinical manifestations of these complications have some differences. The acute course of true hernias and relaxation of the diaphragm usually manifests itself in the first days after birth as a symptom of "asphyxial infringement". The general condition of the child progressively worsens, cyanosis increases, breathing becomes superficial, slow. The abdomen is retracted, while breathing, the epigastric region sinks. There is vomiting. However, the listed symptoms are less pronounced than with false hernias, and are not so constant. Infringement of true hernias of the diaphragm itself is extremely rare. This is mainly due to the absence of clearly defined ("hard") hernial orifices or their significant diameter. With a limited diaphragm defect, infringement manifests itself with a sudden onset. The clinical picture is characterized by sharp pains in the chest and abdomen, respiratory failure and intestinal obstruction. X-ray examination X-ray examination allows you to clarify the diagnosis. The pictures show the movement of intestinal loops into the pleural cavity and a sharp shift of the mediastinum in the opposite direction. A characteristic radiological sign of significant true hernias of the diaphragm itself, as well as its relaxation, is the high standing and paradoxical movement of the abdominal obstruction. With multi-axis transillumination, the diaphragm is visible in the form of a thin regular arcuate line below which gas bubbles of the stomach and intestinal loops are located. Differential diagnosis Differential diagnosis should be carried out, as in the acute course of a false hernia, with some congenital heart defects, birth trauma of the brain and lobar emphysema of the lung. Treatment In case of an acute course or infringement of a true hernia of the diaphragm itself, an urgent operation is indicated. Preoperative preparation is minimal. The young child is warmed after transport, the necessary drugs for anesthesia are administered, and an intravenous fluid infusion machine is applied. The operation is performed under endotracheal anesthesia. The position of the child with transthoracic access is on the side opposite to the hernia, with laparotomy - on the back. With the parietal location of the hernial sac, so-called sliding hernias are usually observed. In such cases, it is more convenient to dissect the thinned zone in an arcuate manner over the displaced organs and move the latter in a blunt way (together with part of the hernial sac) downwards. postoperative treatment. In the postoperative period, newborns are placed in a heating incubator and an elevated position is created (after the child has recovered from anesthesia), humidified oxygen is prescribed. On the first day, every 2 hours, the accumulating contents are sucked out of the stomach with a thin probe. Parenteral nutrition is carried out for 24-48 hours. After 2-3 days, for the purpose of stimulation, blood transfusions are performed in the amount of 20-25 ml. Feeding by mouth usually begins on the 2nd day after surgery: every 2 hours, 10 ml of glucose solution, alternating with breast milk. The fluid deficiency is replenished by intravenous administration of a glucose solution, and after the removal of the drip infusion apparatus, by single-stage transfusions. If there is no vomiting, then from the 3rd day the amount of fluid is increased, gradually bringing it to the age norm. On the 7-8th day, the child is applied to the chest. Older children are also transferred to parenteral nutrition on the first day, then a liquid postoperative table with a sufficient amount of proteins and vitamins is prescribed. The usual diet starts from the 6-7th day. All children after surgery are prescribed broad-spectrum antibiotics to prevent pneumonia and heart medications. Physiotherapy (UHF currents, then KI iontophoresis) is prescribed from the day following the operation. Therapeutic breathing exercises begin from the first days, gradually moving to more active exercises. After the operation, the first x-ray examination is carried out on the operating table, while determining the level of standing of the diaphragm and the degree of expansion of the lung. Re-examination in a satisfactory condition is done in 3-5 days. If prior to this, an effusion in the pleural cavity is clinically detected and the child's condition remains severe, an X-ray examination is performed on the 2nd day after the operation. In some cases, this helps to identify indications for puncture (presence of profuse effusion). 3. Hiatus hernia A hiatal hernia is usually called the displacement of abdominal organs into the posterior mediastinum or pleural cavities through an enlarged esophageal opening. The stomach is displaced, mainly to the right. clinical picture In children with a hernia of the esophageal opening of the diaphragm, as a rule, regurgitation is noted already in infancy, then vomiting, which is permanent. As a result, aspiration pneumonia recurs. A lag in physical development is characteristic, pallor, a decrease in hemoglobin are noted. Relatively often, patients develop hemorrhagic syndrome: vomiting of blood, hidden or visible blood in the stool. Older children complain of rumbling and pain in the chest coughing fits. Infringement of a hernia of the esophageal opening occurs acutely. Strong cramping pains appear in the epigastric region. The child becomes restless, there is vomiting "fountain". In vomit, mucus and food, sometimes stained with blood, bile, as a rule, is not visible. When the esophagus is infringed (kinked), vomiting occurs after each sip of food. The diagnosis is clarified by X-ray examination. X-ray examination A child with a suspected strangulated hernia of the esophagus is given anteroposterior and lateral images, which show a gas bubble of the displaced stomach with a large horizontal level of fluid on one or both sides of the midline. In some cases, the gas bubble is not determined, since the displaced and strangulated stomach is filled with liquid. For better orientation in the pathology, it is necessary to supplement the examination with images with a contrast agent administered through the mouth. The study is carried out in the usual vertical position and lying down with moderate compression of the epigastric region. In hernias with an elevated esophagus, the contrast agent enters the stomach above the site of strangulation. In paraesophageal hernias, the contrast agent stops in the esophagus above the diaphragm. Displacement of intestinal loops into the pleural cavity through the esophageal ring is rarely observed. Treatment With a strangulated hernia of the esophageal opening in children, a radical operation is performed by transthoracic access. 4. Hernias of the anterior part of the diaphragm. Complicated phrenic-pericardial hernias The movement of the abdominal organs through the Lorrey fissure, or Morgagni's hole, into the retrosternal space is commonly called hernia of the anterior diaphragm. There are parasternal and frenic-pericardial hernias. clinical picture The clinical picture of phrenic-pericardial diaphragmatic hernia manifests itself acutely from the first hours or days of a child's life: constant cyanosis, shortness of breath, vomiting, anxiety. In some cases, the displacement of the abdominal organs into the heart sac through a defect in the tendon part of the diaphragm and pericardium disrupts the function of the heart so much that a sharp arrhythmia occurs or it stops. X-ray examination X-ray can make the correct diagnosis. In the study in two projections, there is a layering of the contours of the intestine on the shadow of the heart. Treatment The operation for phrenic-pericardial hernia of the diaphragm is performed after the diagnosis is made. Authors: Drozdov A.A., Drozdova M.V. << Back: Bleeding from dilated veins of the esophagus in portal hypertension >> Forward: Hernia of the umbilical cord
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