What is diaphragm dome relaxation and what are its consequences? Diaphragm. Diaphragm relaxation

Among the various surgical diseases of the diaphragm, the most common are various hernias and relaxation of the diaphragm. However, practitioners are not sufficiently familiar with these diseases, which often leads to severe diagnostic and treatment errors.

With a diaphragmatic hernia, the abdominal organs move to chest through the resulting defect, a weak area of \u200b\u200bthe diaphragm or through the widened natural opening of the diaphragm. Unlike hernias, when the diaphragm relaxes, there is a sharp thinning of it and the absence of muscles in the whole diaphragm coupon or in any part. This area or the entire dome protrudes high into the chest along with the adjacent organs of the abdominal cavity, while there are no pronounced hernial orifices, therefore, infringement with this disease is impossible.

To date, a large number of different classifications of hernias and relaxation of the diaphragm have been proposed, based on very different principles and subdividing these diseases according to etiological characteristics, nature, localization and size of the hernial orifice, the presence or absence of a hernial sac, and during relaxation - by the reasons for its occurrence and size affected areas. Without going into detail on the numerous classifications of hernias of the diaphragm, which by 1950, according to I. D. Korabelnikov, there were more than 35, we give the classification that is used in our clinic.

So all hernia of the diaphragm can be subdivided according to their origin into traumatic, resulting from a variety of trauma to the diaphragm (open or closed), and non-traumatic, having a different origin.

Depending on the presence or absence of a hernial sac, hernias are respectively divided into true and false. Traumatic hernias are almost always false, being the result of a rupture or injury to the diaphragm, and only extremely rarely are true. The latter are described in the form of casuistic messages and depend on the characteristics of the diaphragm injury.

Among non-traumatic hernias of the diaphragm, it should be noted false congenital hernia, or defects of the diaphragm, which are the result of non-closure of the messages between the thoracic and abdominal cavities, existing in the embryonic period. The rest of the non-traumatic hernias of the diaphragm are true and can be subdivided into hernias of the weak zones of the diaphragm, hernias of atypical localization and hernias of the natural openings of the diaphragm, each of which is subdivided into smaller groups.

So, among congenital hernias, depending on the size of the hernial orifice, there are aplasia the entire diaphragm, a defect usually incompatible with life, or one of its domes, and partial defects diaphragm. The latter in localization can be posterolateral, anterolateral, less often central, phreno-pericardial, and even less often esophageal-aortic.

True hernia of weak areas of the diaphragm arise as a result of certain conditions that contribute to an increase in intra-abdominal pressure, a weakening of the tone of those parts of the diaphragm, which are the area of \u200b\u200bjunction of its various parts. This is the zone of the Larrey gap - the sternocostal triangle, formed at the junction of the sternal and costal sections of the muscular part of the diaphragm, and the Bogdalek gap - the lumbar-costal triangle located between its corresponding sections. In the area of \u200b\u200bthese triangles, there are no muscles in the diaphragm, and it is only a more or less thin connective tissue plate with the pleura and peritoneum adjacent to it. The occurrence of hernias in these areas is all the more likely, the wider the base of the sternocostal triangle and, therefore, the greater the anatomical prerequisites for the development of a hernia.

In addition, hernias often occur in the area of \u200b\u200bthe underdeveloped sternal part of the diaphragm. These hernias, located directly behind the sternum, we call retrosternal, as opposed to hernias of the sternocostal triangle, called retro-costosternal, since they are located somewhat lateral to the sternum and adjacent to the costal cartilage. Both types can be combined under the more general term "parasternal hernia".

True hernias of atypical localization, which are distinguished in their classification by Eppinger (1919) and Landua (1940), are extremely rare and differ from limited relaxation by the presence of pronounced hernial orifices, and therefore, the possibility of infringement.

Among the hernias of natural apertures of the diaphragm, the most common are hiatal hernias, to which, due to their high frequency, as well as anatomical and clinical features and other principles of treatment, we devoted a special lecture. Rare hernias of natural apertures of the diaphragm include hernias of the sympathetic nerve cleft, the opening of the inferior vena cava, and also the aortic cleft. However, they are so rare that their practical value is not great.

Among different types hernias of the diaphragm most often there are traumatic hernias, described for the first time by Ambroise Paré back in 1594. In 1936, Hedblom cited a collection of statistics, numbering 548 cases of traumatic diaphragmatic hernias, I. D. Korabelnikov by 1950 found 268 such observations in the domestic literature, and by 1957 MM Bass gives information about 755 patients, observed by domestic surgeons.

Congenital hernia of the diaphragm is much less common in adults, since most of these patients die soon after birth. According to A.A. Gerke and A.O. Melik-Arutyunov (1956), a congenital diaphragmatic hernia was found at 75,510 autopsies in 59 cases. Butler and Clairaut (1962) indicate that congenital diaphragmatic hernia was the cause of death in 1 in 2200 newborns, and Thomsen (1961) in 1 in 3500 newborns. According to the combined statistics of Schmid (1949), out of 155 children with congenital diaphragmatic hernia, 71 died during the first month, and by the age of 10 another 73 died, which indicates the expediency of an early surgical treatment hernias in newborns and infants. Sick of this age group are treated mainly in special children's surgical clinics, which, of course, is advisable, given the specifics of treatment, as well as pre- and postoperative management of patients in this age group.

Described for the first time in the book of Jean Petit in 1774. At first, relaxation was found only at autopsy. With the introduction of the X-ray method of investigation, the number of such observations began to increase rapidly, and by 1935 Reed and Borden had discovered 173 observations of diaphragm relaxation in the literature. By now, due to the improved recognition of this disease, with which practitioners have become more familiar, relaxation of the diaphragm has been diagnosed quite often.

The relaxation of the diaphragm is congenital and acquired. Evidence for the existence of congenital relaxation can be found in fetuses, newborns and infants in combination with various developmental anomalies: transposition abdominal organs, tetrad of Fallot, patent ductus arteriosus, double ureter, cryptorchidism, microphthalmia and polydactyly, congenital intercostal hernia, bilateral false hernia of the diaphragm.

With congenital relaxation, primary underdevelopment or complete aplasia of the muscles of the abdominal obstruction is observed, which can be caused by a vicious laying of diaphragm myotomes or a violation of the differentiation of muscle elements, as well as intrauterine aplasia or trauma of the abdominal nerve.

Acquired relaxation that occurs in the extrauterine period is much more common. In these cases, in the already formed muscle of the diaphragm, due to various reasons, pronounced dystrophic and atrophic changes occur, up to the complete disappearance of the muscle elements. Quite rarely, acquired relaxation occurs on the basis of direct damage to the diaphragm itself during trauma or inflammatory processes.

The most common cause of acquired relaxation is damage to the phrenic nerve with the development of secondary neurotic muscle atrophy. These injuries can be traumatic (including operating ones), inflammatory and a consequence of the invasion or compression of the nerve by a tumor or scarring.

The development of relaxation during birth trauma of the phrenic nerve, after surgery for diaphragmatic hernia, during which phrenicotomy was performed, after transection of the phrenic nerve during surgery for cancer of the esophagus and cardia, and during surgery for goiter is described. We observed relaxation of the left dome of the diaphragm after pneumonectomy and after transection of the large branches of n. phrenicus in plastic surgery of the esophagus with a diaphragmatic flap for cardiospasm, performed in other medical institutions.

Inflammatory lesions of the phrenic nerve are often observed in pleurisy, when it becomes involved in scars or pleural adhesions, which we observed in 3 patients. In this case, the dome of the thinned, muscle-free diaphragm was located at the level of the III-IV rib, and with histological examination connective tissue was found in the diaphragm, among which individual atrophic muscle fibers with pronounced dystrophic changes... Among the fibrous tissue and the remnants of muscle elements, nerve trunks were visible with the disintegration of the axial cylinders and myelin sheath and the replacement of detritus with adipose tissue, which may serve as confirmation of the importance of damage to the abdominal nerve in the development of relaxation and diaphragm.

In addition, the nerve may be involved in inflammatory infiltration in the area lung root and mediastinum with tuberculous lymphadenitis. The development of relaxation during the invasion of the phrenic nerve by a tumor spreading from the root of the left lung to the mediastinum and pericardium was observed in one patient.

The relaxation of the diaphragm can be complete (total), if the entire dome is thinned and moved into the chest, and partial (limited), if any part of it is displaced.

Clinic. The clinic of hernia of the diaphragm depends on compression and kinks in the hernial orifice of the abdominal organs displaced into the chest, compression of the lung and displacement of the mediastinum by organs that have fallen out through the opening of the diaphragm, and on the dysfunction of the diaphragm itself. Therefore, all symptoms can be divided into gastrointestinaldepending on the disruption of the activity of the displaced organs of the abdominal cavity, and cardiorespiratoryassociated with compression of the lungs and displacement of the mediastinum. During relaxation, the causes of the onset of symptoms are the same, but the absence of a hernial orifice makes it impossible to infringement or even severe compression of the displaced organs. The severity of clinical symptoms depends mainly on the nature, volume and degree of filling of the displaced abdominal organs, and in case of hernias, in addition, on the size, shape and nature of the hernial orifice. So, the movement of the stomach is often accompanied by a picture of acute or chronic volvulus or phenomena associated with its compression, in particular the development of hemorrhagic gastritis or even ulcers.

With kinks of the esophagus, dysphagic symptoms often occur. Moving the liver in some cases is accompanied by jaundice. The greater the volume of the displaced organs, the more pronounced are the symptoms of lung compression and mediastinal displacement. Therefore, all the moments that contribute to an increase in intra-abdominal pressure, such as heavy lifting, pregnancy, constipation, as well as food intake, cause an increase or appearance of symptoms.

Large defects of the diaphragm are often accompanied by the prolapse of a large number of abdominal organs, but with them less often than with narrow hernial orifices, infringement occurs, which sharply changes clinical picture disease and causes a sharp deterioration in the general condition of the patient.

The clinical manifestations of the disease are influenced by the age of the patients. So, in newborns and infants suffering from congenital diaphragmatic hernia, cyanosis, shortness of breath and even asphyxia are usually observed, and in this regard, they are often mistakenly diagnosed with congenital heart disease. A well-known role is played by the localization of the hernial orifice, since, for example, with phreno-pericardial hernias, prolapse of even a relatively small part of the intestine or omentum into the pericardial cavity can cause compression and even cardiac tamponade with the development of corresponding clinical signs.

Most characteristic symptoms diaphragmatic hernia are: the appearance or intensification of pain in the epigastric region corresponding to the half of the chest or hypochondrium, as well as a feeling of heaviness, shortness of breath and palpitations immediately after eating, especially profuse. This forces patients, often feeling practically healthy on an empty stomach, to sharply limit food intake, which in some cases leads to exhaustion. Relatively often, after eating, vomiting occurs (sometimes with an admixture of blood), followed by relief, which is also noted by patients after bowel movement. A very typical symptom is a feeling of "gurgling" and rumbling in the chest on the side of the hernia, as well as a significant increase in shortness of breath when patients move to a horizontal position. The relationship between the severity of the above symptoms and the degree of filling of the gastrointestinal tract has a very significant diagnostic value.

On physical examination, the presence of a scar on the chest or abdominal wall with a hernia of the diaphragm that has arisen after an open injury, a decrease in the mobility of the chest on the side of the lesion with smoothing of the intercostal spaces, and with congenital hernias with a significant displacement of the mediastinum and heart, a heart hump is often observed. With long-term hernias with protruding pleural cavity a significant part of the abdominal organs can be noted the retraction of the abdomen, described for the first time by NI Pirogov.

Percussion above the chest on the side of the lesion, a dull-tympanic sound is noted, auscultation in this zone is a weakening or complete absence of respiratory sounds, instead of which intestinal motility or splashing noise is heard, and a change in auscultatory and percussion data is characteristic, depending on the degree of filling of the stomach and intestines. No less characteristic is the displacement of the dullness of the heart and mediastinum to the healthy side, which is usually expressed the more, the higher the zone of dullness and tympanitis is located. The same complaints and physical data are found during relaxation of the dome of the diaphragm, only with it there are no phenomena associated with compression of organs in the hernial orifice, since they are absent during relaxation.

The above signs usually make it possible to ascertain the movement of the abdominal organs into the chest and suspect a hernia or relaxation of the diaphragm, the exact diagnosis of which is possible only with an X-ray examination, which is carried out in a strictly defined sequence, from simpler to more complex methods, each of which has strictly defined diagnostic possibilities and indications for use.

A characteristic feature of diaphragm hernias is the variability of the X-ray picture depending on the degree of filling of the gastrointestinal tract. It also matters which organs have moved to the chest. So, with a survey fluoroscopy, with a prolapse of the stomach, a large horizontal level with air above it is visible, as in hydropneumothorax, and its height increases after eating or drinking. Simultaneous prolapse of the loops of the small intestine is accompanied by the appearance of diffuse darkening of the pulmonary field with rounded areas of enlightenment, and if the loops of the large intestine fall out, haustration can often be seen against the background of gas. Moving the liver or spleen gives a picture of the darkening of the corresponding section of the pulmonary field.

Often, the dome of the diaphragm is clearly contoured and it can be seen that the abdominal organs are located above it, but in some cases the shadow of the diaphragm is not visible and the level of its location has to be judged on the basis of indirect signs obtained during a contrast study of the gastrointestinal tract. In this case, on the contrasted organs, according to the place of their passage through the diaphragm, retractions or depressions are observed, which are called the "flow symptom" or "hernial orifice symptom". This allows you to determine the localization and size of the defect in the diaphragm, as well as the nature and condition of the missing organs.

With large defects of the diaphragm, the symptoms of the hernial orifice are absent and one arcuate line is expressed at the top, which is called the borderline, which can be formed both by the shadow of the diaphragm during relaxation, and by the wall of the stomach with diaphragmatic hernia. Relaxation in these cases will be indicated by the medial location of the contour of the gastric gas bubble and the lateral location of the splenic angle of the large intestine under the common arch formed by the diaphragm, as well as their formation of the characteristic Duval - Quesu - Fatou triangle. In cases where the nature of the boundary line cannot be established, a diagnostic pneumoperitoneum has to be applied to differentiate the hernia and relax the diaphragm. During relaxation, the shadow of the diaphragm usually moves upward from the contours of the stomach and intestines located under it; with a hernia, air can pass into the pleural cavity and give a picture of pneumothorax or be located in the abdominal cavity and contour the diaphragm to the sides of the hernial orifice. However, it should be emphasized that the indications for the imposition of a diagnostic pneumoperitoneum are very limited, since with a correct assessment of the data of a radiopaque study, in most cases it is possible to make the correct diagnosis.

Treatment. The question of the treatment of various lesions of the diaphragm is solved differently. In patients with a hernia of the diaphragm, the possibility of infringement is a direct indication for surgery. With relaxation of the diaphragm, the operation is indicated only in case of severe health disorders, if the symptoms of the disease are weak, it is advisable to carry out conservative treatment.

Preoperative preparation for hernias and relaxation of the diaphragm consists in prescribing a diet that gives little toxins 2-3 days before the operation, taking laxatives and prescribing on the eve of the operation and early in the morning on the day of the intervention of cleansing enemas (to clean water).

For hernia surgery and diaphragm relaxation, the method of choice for anesthesia is modern endotracheal anesthesia with the use of muscle relaxants and controlled breathing, which can be carried out both manually and with the help of Engstrom or ERO-62 respirators. Such anesthesia makes it possible to perform all manipulations on a relaxed diaphragm, which facilitates suturing of defects and avoids transection of the phrenic nerve.

The choice of access depends on the location and size of the defect, the age and condition of the patient, and the expected nature of the surgery. So, with parasternal hernias, transabdominal access is more convenient, in particular, the upper median laparotomy. In operations on all other parts of the right dome of the diaphragm, a transthoracic approach is used in the seventh or eighth intercostal space, which is also most preferable for manipulations on all parts of the left dome in adult patients. In children with congenital false hernias, when there is usually no fusion of the prolapsed organs with the chest wall, as well as in palliative intra-abdominal operations for relaxation, transabdominal incisions are used.

Let us dwell on some features of the operation for diaphragmatic hernia, the purpose of which is to bring down the displaced organs and suture the defect in the diaphragm. Often, especially with traumatic diaphragmatic hernias, it is necessary to separate numerous adhesions and adhesions between the prolapsed organs and the chest wall, as well as the hernial orifice. This manipulation should be done very carefully, since damage, for example, to a prolapsed spleen, forces it to be removed in order to avoid postoperative bleeding.

After releasing the fallen organs into abdominal cavity it is necessary to close the diaphragm defect. Usually, the edges of the defect are sutured with separate interrupted thick silk sutures, trying, if possible, to create a duplication if the diaphragm tissue is not strong enough. With very large sizes of the edge defect, it is not possible to pull it off and one has to resort to various plastic methods.

Of the various options for organoplasty, only hepatopexy currently retains some importance: the use of other organs was abandoned due to the dangers of creating a fixed diaphragmatic hernia. It is also very traumatic to use various autoplastic methods with cutting out muscle, muscle-pleural and muscle-periosteal flaps. Various variants of thoracoplasty, aimed at bringing the chest wall closer to the edges of the defect, are also undesirable, due to the resulting pronounced deformation of the latter.

Various alloplastic methods of replacing or strengthening diaphragm defects that cannot be eliminated by the patient's own tissues have become more widespread. For this purpose, prostheses made of nylon, nylon, teflon, lavsan or polyvinyl alcohol sponge are used for the first time for plastics of the diaphragm during its relaxation in 1957. Experimental studies carried out by N.O. Nikolaev, an employee of our clinic, and clinical observations have shown the feasibility of isolating the prosthesis from free pleural cavity to reduce the formation of reactive serous effusion. The prosthesis is sutured to the edges of the defect, which is as narrowed as possible, so that it goes 0.5-1 cm under the edge of the diaphragm. This increases the area of \u200b\u200bcontact between the prosthesis and the diaphragm and prevents the development of relapse.

Various methods have been proposed for the surgical treatment of diaphragm relaxation, which can be divided into two main groups:

1. interventions aimed at eliminating individual symptoms - palliative operations on the stomach and large intestine,
2. operations on the diaphragm itself, the purpose of which is to bring the diaphragm and displaced abdominal organs down to their normal position and to strengthen the thinned diaphragm.

Schematically, all of the above methods of operation during relaxation can be represented as follows.

Palliative surgery (symptomatic) on the stomach and large intestine:

1. gastropexy,
2. gastro-gastrostomy,
3. gastroenterostomy,
4. resection of the stomach,
5. colon resection

Diaphragm surgery

A. Plasty of the diaphragm at the expense of its own tissues:

1. resection of a thinned area with stitching of the edges of the diaphragm,
2. dissection of the diaphragm with the formation of duplication,
3. phrenoplication

B. Plastic strengthening of the diaphragm (combined with one of the types of plastic due to the diaphragm's own tissues)

1. Autoplasty:
   • a) a skin flap,
   • b) a muscle flap,
   • c) muscle-periosteal-pleural flap
2. Alloplasty:
   • a) tantalum mesh,
   • b) mesh, plate or fabric made of nylon, nylon,
   • c) a polyvinyl alcohol sponge (ayvalon).

Various operations on the diaphragm in combination with palliative operations on the stomach and large intestine.

It should be noted that the total number of relaxation operations is still relatively small. According to Dejak and Dyuru, by 1942 only about 50 of them had been produced. By 1959 we were able to collect information from the literature on 126 relaxation operations.

In March 1957, we proposed and for the first time performed a diaphragm plasty in a patient with left-sided relaxation using a polyvinyl alcohol sponge (aivalon) prosthesis, which is sutured along the entire line of the diaphragm attachment between the duplication of the thinned, completely muscle-free, abdominal obstruction. The advantage of this type of plastic is the elasticity of the prosthesis, which, due to its porosity, grows connective tissue and firmly grows together with the remains of the diaphragm tissue, reliably strengthening it.

The operation technique is presented in the following diagrams. From the transthoracic approach in the eighth intercostal space on the left, a sharply thinned high-located dome of the diaphragm is exposed, which is dissected in the longitudinal direction so that two flaps of the same size are obtained (Fig. 120, a). Then the plate, sterilized by boiling and soaked in a solution of polyvinyl alcohol (aivalon) antibiotics, is sewn together with the outer flap to the base of the inner flap and to the intercostal tissue along the entire line of the diaphragm attachment (Fig. 120, b). After that, the inner flap is sutured over the prosthesis, also along the entire line of attachment of the diaphragm, which leads to its isolation from the free pleural cavity (Fig. 120, c);

This method was used to operate 11 patients with left-sided relaxation of the diaphragm. There were no deaths and complications directly related to the use of the prosthesis. When studying the condition of patients in terms of 1 to 9 years, no relapses were found. On X-ray examination, an almost normal arrangement of the diaphragm and internal organs is observed.

The complete disappearance or a significant decrease in the symptoms of the disease, noted in the patients we observed, indicates the possibility of providing effective surgical care with this disease.

Literature [show]

1. Doletskiy S. Ya. Diaphragmatic hernias in children. M., I960.
2. Multivolume Guide to Surgery. T. 6, book. 2.M., 1966.
3. Petrovsky B.V., Kanshin N.N., Nikolaev N.O. Diaphragm surgery. L., 1966.

A source: Petrovsky B.V. Selected Lectures on Clinical Surgery. M., Medicine, 1968 (Textbook.Lit. for the student.med.in-tov)

The relaxation of the diaphragm is understood as a one-sided high standing of the dome of the diaphragm, extremely thinned, but maintaining continuity.

The term "relaxation" is currently accepted by the majority to denote this suffering. However, in the literature there are other names such as: eventration of the diaphragm (the name is unfortunate, it gives rise to a hernia), diaphragm insufficiency, idiopathic high standing, unilateral persistent increase in the diaphragm, megadiaphragm (which is incorrect).

The study shows the absence of muscle elements; there is only fibrous tissue between the serous sheets.

The stomach and large intestine protrude from the abdominal organs, then, less often small intestine... The stomach displaced upward undergoes the same changes in position as with a diaphragmatic hernia: the greater curvature is turned upward, adjacent to the diaphragm. The lung is compressed according to the elevation of the diaphragmatic septum, the heart is displaced to the right with left-sided relaxation.

There is every reason to consider the relaxation of the diaphragm. congenital anomaly, a consequence of insufficient anlage of the muscles, which normally grows into poorly differentiated mesenchymal tissue that separates the body cavities. The relaxation of the diaphragm can be combined with other defects. Sometimes it is found in childhood... The fact that the disease is more often established at the age of 30-40 years is explained by the gradual stretching and increase in the level of the diaphragmatic septum as a result of the pressure of the abdominal organs due to the tension of the abdominal muscles.

Some admit not only congenital, but also acquired origin of relaxation of the diaphragm, not only agenesis, but also atrophy of muscle elements. Trauma rarely precedes relaxation of the diaphragm, and if such a relationship in time appears to exist, there is no evidence of a lack of relaxation prior to injury. Vast experience says that transection of the phrenic nerve leads to relaxation of the diaphragmatic septum, but not to its total degeneration. At the same time, one should take into account Kigyo's studies on monkeys, which showed that the combination of transection of the phrenic nerve with the intersection of sympathetic innervation gives an identical disease.

Diaphragm relaxation symptoms

The severity of clinical manifestations of diaphragm relaxation is different - from complete absence of symptoms to significant disorders. There are changes in the position of the abdominal organs, especially the stomach, large intestine, as well as compression of the lung, displacement of the heart, very similar to what is observed with a diaphragmatic hernia. This explains why the clinical symptomatology of both diseases is largely the same. The most significant difference is that there is no strangulation during relaxation.

The manifestations of the disease are combined into the following clinical syndromes:

• digestive, in the form of dysphagia, including paradoxical, vomiting, pain in the stomach, a feeling of heaviness, constipation;
• respiratory, manifested by shortness of breath after physical exertion, after eating;
• cardiac - in the form of palpitation of the heart, tachycardia, anginal phenomena.

Objective research conventional clinical methods can detect the same changes that are found in a diaphragmatic hernia, and the same variability in research results due to different body position or the degree of filling of the stomach.

The only method to distinguish between relaxation of the diaphragm and a hernia is X-ray examination. It makes it possible to establish whether the displaced organs are located under or over the diaphragmatic septum. The borderline abdominal line can be formed by both the diaphragmatic septum and the greater curvature of the stomach, facing cranially. The diagnosis of diaphragm relaxation is undeniable if the contours of the diaphragmatic septum and the contours of the stomach are clearly separable. If the upper contours of the stomach and colon are located on different levels and a diaphragm band is not traced between them, the diagnosis of a hernia is more likely, especially when the height of the location of the organs varies differently when the body is positioned head down. With relaxation, the relationship is more constant. If one contour is visible, then, by reducing the amount of air in the stomach, you can either separate its wall from the diaphragm, or establish that the broken boundary line is formed by the stomach. Repeated X-ray examinations show a relative constancy of the picture with relaxation and greater variability with a hernia.

For the purpose of differential diagnosis, it is recommended to use a gaeumoperitoneum. The air introduced into the abdominal cavity with the intact diaphragm will separate it from the shadow of the stomach and intestines. With a hole in the diaphragm, air enters the pleural cavity. However, during adhesions in the hernial orifice, air will remain in the abdominal cavity.

Diaphragm relaxation treatment

The relaxation of the diaphragm can only be eliminated by surgery. Indications for diaphragm relaxation are decided individually, taking into account the magnitude of the abdominal organs lifting and the severity of clinical symptoms. The task of the operation is the reconstruction of the diaphragm, as a result of which the abdominal and breast organs should take a normal position.

You can excise a portion of the diaphragm and sew the edges of the incision with a frock-coat seam. If lowering the diaphragm is insufficient, it is recommended to apply a second and third row of stitches. To strengthen a very thin diaphragmatic septum, after excision of a part of it, the psoas muscle, intercostal muscles, skin, fascia lata of the thigh were used. The method of doubling the diaphragm is close to the indicated one. These operations are best performed using a thoracic approach.

Diaphragmatic overgrowth can be reduced by creasing. The diaphragm duplication flap is fixed with sutures either to the posterior wall of the chest and abdomen, or to the anterior abdominal wall.

To flatten the diaphragm, it is also proposed to apply corrugating sutures (back to front or front to back) using both thoracic and abdominal access.

The above methods of surgery are used less and less, and the use of alloplastic materials to strengthen the diaphragm comes to the fore. Nylon, nylon, polyvinyl alcohol were used. It is recommended to place an alloplastic material between the sheets of the dissected diaphragmatic septum. For these operations, thoracic access is advisable. The method, developed in detail by Petrovsky, consists in the fact that after dissecting the diaphragm, a plate of polyvinyl alcohol with a size of 30 X 25 X 0.7 cm is placed on the outer half of the diaphragm and sutured with silk to the prevertebral fascia and muscles of the chest wall, then to the remains of the diaphragm at the pericardium and to the anterior wall of the chest along the projection of the medial boundaries of the left dome of the diaphragm. The medial sheet of the diaphragm is placed on the graft.

RELAXATION OF THE IRIS

For the first time, the relaxation of the diaphragm was described by Jean Petit in 1774, implying by this concept the complete relaxation of the domes and its high standing. In clinical practice, terms such as "diaphragm eventration", "primary diaphragm", "megaphenia" are also used, and the terms "limited diaphragm relaxation", "partial eventration", "soft" diaphragm, " diaphragm diverticulum ”, etc. The term“ diaphragm relaxation ”received the greatest clinical recognition.

This disease is based on the inferiority of the muscular elements of the diaphragm. Relaxation can be of a congenital or acquired character. Neuman (1919) considered aplasia or intrauterine trauma of the phrenic nerve to be the cause of congenital underdevelopment of the diaphragm.

According to researchers, congenital relaxation is due to constitutional inferiority of the muscles of the diaphragm, which subsequently leads to its secondary upward displacement. PA Kupriyanov (1960) considers the cause of relaxation to be a developmental defect consisting in the absence of muscle and tendon tissue in the dome of the diaphragm.

The relaxation of the acquired character is a consequence of the inferiority of the muscle tissue of the diaphragm, which occurs in connection with atrophic and dystrophic changes in the muscles, during the transition to it of inflammatory changes from the serous integument or as a result of independent inflammatory processes in the diaphragm, an important point is the injury to the diaphragm. As a result of phrenic nerve injury, of any origin (surgery, inflammatory or tumor process), secondary neurotic muscle dystrophy, thinning, impaired mobility and subsequent high standing of the dome of the diaphragm develops.

For a long time, relaxation of the diaphragm was considered as a malosymptomatic or even asymptomatic disease, and, in contrast to a diaphragmatic hernia, does not pose a threat to the patient's life. However, along with the asymptomatic course, there are forms that are clinically manifested by a disorder in the digestive, respiratory, cardiovascular and a number of other systems.

Relaxation symptoms depend on the displacement of the diaphragm and adjacent organs. In each individual case, a certain group of symptoms from those organs whose function is most impaired comes to the fore. Depending on this, three groups of disorders are distinguished: respiratory, cardiovascular and gastrointestinal.

In the anamnesis of persons suffering from this pathology, there is a long course of concomitant disease, an indication of past trauma to the abdomen or chest, pleurisy, tuberculosis. It should be emphasized that pleurisy can simulate the very relaxation of the diaphragm.

B.V. Petrovsky and co-authors (1965) distinguish 4 forms clinical course relaxation of the diaphragm: asymptomatic, with blurred clinical manifestations, with severe clinical symptoms and complicated (gastric volvulus, stomach ulcer, bleeding, etc.). Children have a special form with pronounced cardiorespiratory disorders. Clinical symptoms depend on the location and degree of relaxation. It is known that left-sided relaxation is accompanied by more severe disorders.

General complaints are characterized by an indication of attacks of pain, weight loss, sometimes attacks of weakness, up to fainting, palpitations, shortness of breath, cough. They are caused by the displacement and rotation of the heart, as well as the shutdown of half of the diaphragm from breathing.

From the gastrointestinal tract, the leading clinical symptoms are a feeling of heaviness after eating, frequent belching, hiccups, heartburn, rumbling in the abdomen, nausea, vomiting, flatulence and constipation, dysphagia and recurrent gastrointestinal bleeding. The reason for these complaints is the prolapse of the dynamic function of the diaphragm, the bend of the abdominal esophagus, volvulus of the stomach with stretching and circulatory disorders, the presence of ulcers, erosive gastritis or venous stasis and gastric bleeding. Even cases of gastric gangrene have been described.

On an objective examination, Hoover's symptoms are determined - a stronger deviation when inhaling the left costal arch up and out. Percussion marks an increase and an upward shift of the Traube space. The lower border of the lungs in front is raised up to the II-IV ribs, the border of cardiac dullness is displaced to the right. Auscultation reveals muffled heart sounds, weakened breathing, intestinal noises and rumbling or splashing noise over the chest.

Instrumental studies make it possible to identify violations of external respiration, especially VC. The electrocardiogram of such patients is characterized by a slowdown in intraventricular conduction, impaired coronary circulation and the appearance of extrasystoles.

X-ray examination is decisive in the diagnosis of relaxation, and the following symptoms are important: 1) a persistent increase in the level of the location of the corresponding dome of the diaphragm to 2-3 ribs; 2) in a horizontal position, the diaphragm and adjacent organs move upward; 3) the contours of the diaphragm represent a smooth, continuous arcuate line. Compression of the lung and displacement of the heart to the right are often detected.

A characteristic X-ray sign is the symptom of Alyshevsky-Vinbek - paradoxical movements of the diaphragm, that is, lifting with a deep breath and lowering with an exhalation. Paradoxical movements of the diaphragm are better detected during the functional test of Müller - inhalation with a closed glottis, in contrast to the opposite direction of movement of the diaphragm from the diseased side - Velman's symptom. Holding the breath at the height of inspiration causes an upward movement of the modified half of the diaphragm due to retraction force lung tissue - Dillon's symptom.

With a contrast study of the stomach in the Trendelenburg position, Funstein's symptom is determined - contrast agent spreads in the stomach, repeating the contours of the dome of the diaphragm. An important point is also the identification of the movement of the stomach into the chest, the bend of the abdominal, esophagus, displacement of the pylorus and the bend of the stomach "cascading stomach", as well as the movement of the transverse colon, especially its splenic angle.

For differential diagnosis, pneumoperitopeum, pyelography, roentgenoimography and various functional tests... Pneumoperitoneum acquires significant value, allowing a layer of gas to separate the dome of the diaphragm from the adjacent organs.

Local or limited relaxation of the diaphragm is observed predominantly on the right. In this case, the dome of the diaphragm protrudes arcuately towards the lung, and the liver is deformed, repeating the shape of the relaxation area, and wedges into the area raised upward.This circumstance often serves as a reason for diagnostic errors, since the area of \u200b\u200blimited relaxation of the diaphragm is very often mistaken for liver echinococcosis.

According to a number of authors, the following diseases are the cause of limited relaxation: echinococcosis of the liver and spleen, diaphragmatic-mediastinal adhesions, subphrenic abscess, supraphrenic exudate, pericardial cysts, changes in the lungs, limited hypoplasia of the diaphragm and other diseases.

Relaxation of the diaphragm is a pathology characterized by a sharp thinning or complete absence of the muscular layer of the organ. This occurs due to abnormalities in the development of the fetus or due to a pathological process that led to the protrusion of the organ into the chest cavity.

In fact, this term in medicine means two pathologies at once, which, however, have similar clinical symptoms and both are caused by the progressive protrusion of one of the domes of the organ.

Congenital developmental anomaly is characterized by the fact that one of the domes is devoid of muscle fibers. It is thin, transparent, and consists mainly of the pleura and peritoneum.

In the case of acquired relaxation, we are talking about muscle paralysis and their subsequent atrophy. In this case, two variants of the development of the disease are possible: the first is a lesion with a complete loss of tone, when the diaphragm looks like a tendon sac, and muscle atrophy is quite pronounced; second - violations motor function while maintaining tone. The appearance of the acquired form is facilitated by damage to the nerves of the right or left dome.

Causes of pathology

• An innate form of relaxation can provoke abnormal laying of myotomes of the diaphragm, as well as impaired muscle differentiation, and intrauterine trauma / aplasia of the phrenic nerve.
• Acquired form (secondary muscle atrophy) can be caused by inflammatory and traumatic organ damage.

Also acquired ailment occurs against the background of damage to the phrenic nerve:

1. traumatic;
2. operating rooms;
3. inflammatory;
4. scar damage with lymphadenitis;
5. tumor.

Congenital form leads to the fact that after the birth of a child, the organ cannot bear the load imposed on it. It gradually stretches, resulting in relaxation. Stretching can occur at different rates, that is, it can manifest itself both in early childhood and in the elderly.

It should be noted that the congenital form of pathology is often accompanied by other anomalies of intrauterine development, for example, cryptorchidism, heart defects, etc.

Acquired form differs from congenital not in absence, but in paresis / paralysis of muscles and their subsequent atrophy. In this case, complete paralysis does not occur, therefore the symptoms are less pronounced than in the congenital form.

Acquired relaxation of the diaphragm can occur after secondary diaphragmitis, for example, with pleurisy or subphrenic abscess, as well as after organ injury.

Distension of the stomach with pyloric stenosis can provoke the disease:

constant trauma from the stomach provokes degenerative changes muscles and their relaxation.

Symptoms

• The manifestations of the disease may differ from case to case. For example, they very pronounced in congenital pathology, and with acquired, especially partial, segmental, they may be completely absent. This is due to the fact that the acquired one is characterized by a lesser degree of tissue stretching, a lower standing of the organ.
• Besides, segmental localization of pathology on the right is more favorable, since the nearby liver, as it were, tampons the damaged area. Limited relaxation on the left can also be covered by the spleen.
• When relaxing the diaphragm, symptoms rarely occur in childhood... The disease often manifests itself in people 25-30 years old, especially in those who are engaged in heavy physical labor.
• The main reason for complaints is displacement of the peritoneal organs into the chest... For example, a part of the stomach rising, provokes a bend of the esophagus and its own, as a result of which the motility of the organs is impaired, respectively, there are pain... Kinked veins can lead to internal bleeding... These signs of the disease intensify after a meal and physical activity. In this situation, the pain syndrome provokes the bending of the vessels supplying the spleen, kidney and pancreas. Pain attacks can be intense.
• Usually, pain syndrome is acute... Its duration varies from a few minutes to several hours. At the same time, it ends as quickly as it begins. Often the attack is preceded by nausea. It is noted that pathology can be accompanied by difficulty in passing food through the esophagus, as well as bloating. These two phenomena quite often occupy a leading place in the clinic of pathology.
• Most patients complain about attacks of pain in the region of the heart... These can be caused by both vagal reflux and direct pressure on the organ by the stomach.

Diagnostic methods

The main method for detecting relaxation is x-ray examination... Sometimes during relaxation there is a suspicion of the presence of a hernia, however, carry out differential diagnosis without holding x-ray examination almost impossible. Only sometimes the features of the course of the disease and the nature of its development make it possible to accurately determine the pathology.

Doctor conducting physical examination, detects the following phenomena:

1. the lower border of the left lung is shifted upward;
2. the zone of subphrenic tympanitis extends upward;
3. intestinal peristalsis is heard in the pathology zone.

Treatment

In this situation, only one way to eliminate the disease is possible - surgical.

However, operations are not done for all patients. To carry out such, testimony is needed.

• Surgical intervention is carried out only in cases where a person has pronounced anatomical changes, clinical symptoms incapacitate, cause severe discomfort.
• Also, indications for surgery are complications that pose a threat to life, for example, ruptured diaphragm, gastric bleeding or acute volvulus.

Deciding on a relaxation treatment surgically, doctors also take into account the presence of contraindications to such, as well as general state the patient.

Relaxation of the diaphragm is a pathology characterized by a sharp thinning or complete absence of the muscular layer of the organ. This appears due to anomalies in the development of the fetus or as a result of a pathological process, the one that led to the protrusion of the organ into the chest cavity.

In fact, this term in medicine means two pathologies at once, which, however, have similar clinical symptoms and both are caused by the developing protrusion of one of the domes of the organ.

Congenital malformation is characterized by the fact that one of the domes is devoid of muscle fibers. It is thin, transparent, and consists mainly of the pleura and peritoneum.

In the case of acquired relaxation, we are talking about muscle paralysis and their further atrophy. In this case, there are two possible options for the development of the disease: the first is a lesion with a complete loss of tone, when the diaphragm looks like a tendon sac, and muscle atrophy is quite pronounced; the second - impaired motor function while maintaining tone. The origin of the acquired form is facilitated by damage to the nerves of the right or left dome.

Causes of pathology

The congenital form of relaxation can be provoked by an abnormal initiation of the diaphragm myotomes, as well as impaired muscle differentiation, and intrauterine trauma / phrenic nerve aplasia.

The acquired form (secondary muscle atrophy) can be caused by inflammatory and traumatic organ damage.

Also, the acquired ailment appears against the background of damage to the phrenic nerve: traumatic, operating, inflammatory, scar damage with lymphadenitis, tumor.

The congenital form leads to the fact that after the birth of the child, the organ cannot bear the load placed on it. It stretches slowly, which leads to relaxation. Stretching can occur at different rates, that is, it can manifest itself both in early childhood and in the elderly.

It is worth noting that the innate form of pathology is often accompanied by other anomalies of intrauterine formation, for example, cryptorchidism, heart defects, etc.

The acquired form differs from the congenital one not by the absence, but by paresis / paralysis of the muscles and their further atrophy. In this case, complete paralysis does not occur, therefore the symptomatology is less pronounced than in the congenital form.

Acquired relaxation of the diaphragm may appear later than secondary diaphragmitis, for example, with pleurisy or subphrenic abscess, as well as later than organ injury.

Distension of the stomach with pyloric stenosis can provoke the disease: continuous trauma from the stomach provokes degenerative muscle metamorphosis and relaxation.

Symptoms

The manifestations of the disease may differ from case to case. For example, they are hefty expressed in congenital pathology, and when acquired, exclusively partial, segmental, they may be completely absent. This is due to the fact that the acquired one is characterized by a lower degree of tissue stretching, more by a low standing of the organ.

In addition, the segmental localization of the pathology on the right is more favorable, because the nearby liver, as it were, tampons the damaged area. Limited relaxation on the left can also be covered by the spleen.

When the diaphragm relaxes, symptoms rarely appear in childhood. The disease often manifests itself in people 25-30 years old, exclusively in those who are engaged in hard physical labor.

The main reason for the claims is the displacement of the peritoneal organs into the chest. For example, a part of the stomach, rising, provokes a bend of the esophagus and a personal one, as a result of which the motility of the organs is disturbed, respectively, painful sensations appear. Kinked veins can lead to internal bleeding. These signs of the disease intensify after a meal and physical activity. In this situation, the pain syndrome provokes the bending of the vessels supplying the spleen, kidney and pancreas. Pain attacks can be of high intensity.

As a rule, pain syndrome manifests itself acutely. Its duration varies from a few minutes to several hours. At the same time, it ends as quickly as it begins. Often the attack is preceded by nausea. It is noted that pathology can be accompanied by difficulty in passing food through the esophagus, as well as bloating. These two phenomena quite often occupy a leading place in the hospital of pathology.

Most patients sting of pain attacks in the region of the heart. These can be caused by both vagal reflux and direct pressure on the organ by the stomach.

Diagnostic methods

The main method for detecting relaxation is X-ray examination. Occasionally, during relaxation, there is a doubt about the presence of a hernia, however, it is practically unthinkable to carry out differential diagnostics without conducting an X-ray examination. Only occasionally, the features of the course of the disease and the nature of its formation make it possible to correctly determine the pathology.

The doctor, conducting a physical examination, discovers the following phenomena: the lower border of the left lung is shifted upward; the zone of subphrenic tympanitis extends upward; in the pathology zone, intestinal peristalsis is heard.

treatment

In this situation, only one way to eliminate the disease is permissible - surgical.

However, operations are performed far away not for every patient. To carry out such, testimony is required.

Surgical intervention is carried out only in cases where a person has pronounced anatomical metamorphoses, clinical signs disabling, causing severe discomfort.

Also, indications for surgery are complications that pose a threat to life, for example, a break in the diaphragm, gastric bleeding, or its acute volvulus.

When deciding on the surgical treatment of relaxation, doctors also consider the presence of contraindications to such, as well as the general condition of the patient.

With mild symptoms or asymptomatic course, there is no need for surgery. You just need to shy away from the powerful physical activity, stress, overeating, and also monitor the regularity of bowel movements. In this case, the patient can, without any danger to health, be under the supervision of doctors for years, which is impossible to say about people with traumatic and congenital hernias of the diaphragm. If the tier of the organ's standing increases much, and the symptoms manifest themselves more strongly, an operation is recommended.