Pediatric surgery. Diagnosis and treatment of hernias of the diaphragm itself (the most important)

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Pediatric surgery. Diagnosis and treatment of hernias of the diaphragm itself (the most important)

Lecture notes, cheat sheets

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25. Diagnosis and treatment of diaphragmatic hernias

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".

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 appears 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.

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.

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.

Authors: Drozdov A.A., Drozdova M.V.

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