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Diaphragm disordersDiaphragm disordersBy:Dr seyed Mostafa ShiryazdiBy:Dr seyed Mostafa Shiryazdi
Associate professor of surgeryAssociate professor of surgery
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Clinical AnatomyClinical Anatomy
-musculotendinous membrane-musculotendinous membrane -central:tendinous-central:tendinous -peripheral:muscular-peripheral:muscular
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HIATUSHIATUS
-Aorta:T12 azygus vein-thoracic -Aorta:T12 azygus vein-thoracic ductduct
-Esophagus:T10 vagus nerves-Esophagus:T10 vagus nerves -IVC:T8 -IVC:T8
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BLOOD SUPPLYBLOOD SUPPLY
-abdominal aorta:RPA-LPA-abdominal aorta:RPA-LPA -thoracic aorta:SPA-thoracic aorta:SPA -internal mamary artery-internal mamary artery
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VENOUS DRAINAGEVENOUS DRAINAGE
-left phrenic vein-left phrenic vein -right phrenic vein-right phrenic vein
-Both drain to IVC-Both drain to IVC
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INNERVATIONINNERVATION
-Right phrenic nerve:motor -Right phrenic nerve:motor innervationinnervation
-Left phrenic vein:motor innervation-Left phrenic vein:motor innervation
-Intercostal nerve:sensory -Intercostal nerve:sensory innervationinnervation
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Diaphragm develops between the 4Diaphragm develops between the 4thth and 8and 8thth weeks of gestation weeks of gestation
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Failure closure of the pericardio Failure closure of the pericardio peritoneal canal cause CDH(bochdalek peritoneal canal cause CDH(bochdalek
hernia)hernia)
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The crura develop from The crura develop from the mesentery of the mesentery of
esophagusesophagus
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Higher position of Higher position of diaphragmdiaphragm
LIVER in rightLIVER in right
HEART in leftHEART in left
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Diaphragm developsDiaphragm developsTransverse septumTransverse septum
Pleuroperitoneal membranePleuroperitoneal membraneDorsal and lateral body wallDorsal and lateral body wall
Mesentery of esophagusMesentery of esophagus
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CONGENITAL DIAPHRAGMATIC CONGENITAL DIAPHRAGMATIC HERNIAHERNIA
_BOCHDALEK HERNIA_BOCHDALEK HERNIA -MORGAGNI HERNIA-MORGAGNI HERNIA -ESOPHAGEAL HIATAL HERNIA-ESOPHAGEAL HIATAL HERNIA
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BOCHDALEK HERNIABOCHDALEK HERNIA
Male:female 2/1Male:female 2/1 Left sided 90%Left sided 90% Right sided 10%Right sided 10%
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Clinical FindingClinical Finding
Rsepiratory dystressRsepiratory dystress Absence of breath soundsAbsence of breath sounds Bowel sound in chestBowel sound in chest Scaphoid abdomenScaphoid abdomen
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Bochdalek hernia occurs in Bochdalek hernia occurs in 1:4000-5000 live birth1:4000-5000 live birth
Morgagni hernia occurs <2% of all Morgagni hernia occurs <2% of all diaphragmatic herniadiaphragmatic hernia
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Usually CDH discovered Usually CDH discovered prenataly on routine prenataly on routine
ultrasoundultrasound
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After birthAfter birth
CXRCXR BARIUM SWALLOWBARIUM SWALLOW
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Long term problems in CDHLong term problems in CDH
Gastroesophageal refluxGastroesophageal reflux Chronic lung diseaseChronic lung disease Hearing lossHearing loss Pectus excavatumPectus excavatum seizureseizure
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Contained sac in Contained sac in morgagnimorgagni
OmentumOmentumColonColon
StomachStomachLiverLiver
Small intestineSmall intestine
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treatmenttreatment
Nasogastric tubeNasogastric tube Fluid and electrolyteFluid and electrolyte PEEP or ECMOPEEP or ECMO surgerysurgery
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Right Right side:thoracotomyside:thoracotomy
Left side:laparotomyLeft side:laparotomy
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Mortality 30-50% in Mortality 30-50% in 24 hours24 hours
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MORGAGNI HERNIAMORGAGNI HERNIA
Larrey hernia or retrosternalLarrey hernia or retrosternal Rarely symptomaticRarely symptomatic Symptomatic after 40 yearsSymptomatic after 40 years
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HIATAL HERNIAHIATAL HERNIA
SlidingSliding ParaesophagealParaesophageal mixedmixed
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GERGER
MedicalMedical SurgicalSurgical
FTT-repeated respiratory infection-FTT-repeated respiratory infection-anemia-recurrentanemia-recurrent
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Diaphragm tumorsDiaphragm tumors
Primary(rare):fibrosarcoma-hydatid Primary(rare):fibrosarcoma-hydatid cyst-TBcyst-TB
secondarysecondary
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Eventration of diaphragmEventration of diaphragm
Congenital(non paralysed)Congenital(non paralysed)
Acquired(paralysed)Acquired(paralysed)
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Trauma to diaphragmTrauma to diaphragm
90% left sided90% left sided
Early diagnosis:laparotomyEarly diagnosis:laparotomy
Late diagnosis:thoracotomyLate diagnosis:thoracotomy
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