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Diaphragmatic Hernia E Postgrad Med J: first published as 10.1136/pgmj.37.426.191 on 1 April 1961. Downloaded from POSTGRAQ. MED. J. (I96I), 37, 191 DIAPHRAGMATIC HERNIA E. HOFFMAN, M.D., F.R.C.S. Thoracic Surgeon to the Newcastle upon Tyne Regional Chest Surgery Service, Poole Hospital, Middlesbrough DIAPHRAGMATIC HERNLZE are being recognized cervical region, and in the course of its caudal with increasing frequency. Herniation of ab- migration it receives its innervation from branches dominal contents into the thoracic cavity may of the 3rd, 4th and sth cervical nerve roots (the occur through sites of embryological fusion, phrenic nerve) which accompanies it in its through the cesophageal hiatus, or following descent. In the 17 mm. embryo, the septum traumatic rupture of the diaphragm. transversum has reached its permanent position. The posterior part of the diaphragm is formed Congenital Hernia by the fusion of the pleuro-peritoneal membrane The development of the diaphragm is compli- and the dorsal mesentery. The pleuro-peritoneal cated (Fig. i). The anterior portion is formed membrane is the last structure to complete the from the septum transversum. The septum trans- formation of the diaphragm. This takes place versum originally arises in the upper part of the earlier on the right side, at about the 17 to i8 mm. by copyright. FIG. I.-Embryological formation of http://pmj.bmj.com/ the diaphragm (Modification from Harrison's 'A Textbook of Human Embryology '). i and 2 -Left and right pleuro-peri- toneal membranes. ia and 2a- Contributions from body wall. 3-Septum transversum. ... on September 30, 2021 by guest. Protected .... o... 0-R6IW1 cl Postgrad Med J: first published as 10.1136/pgmj.37.426.191 on 1 April 1961. Downloaded from I92 POSTGRADUATE MEDICAL JOURNAL .Appril I96I embryonic stage, and later on the left side at about increasing dyspnea for 2 years. X-ray of his chest (Fig. 5) showed a rounded cystic opacity in the right the 19 to 20 mm. stage. Before the formation of cardiophrenic angle. A lateral film showed that the air- the pleuro-peritoneal membrane, there is a free containing opacity was situated retrosternally. Barium communication between the pleural and peritoneal meal showed the stomach and small intestine to be cavities, the ' hiatus pleuro-peritonealis '. In normal. Barium enema (Fig. 6) demonstrated part of the large bowel to be herniated into his chest. Further about the ioth week of fuetal life, the herniated questioning elicited the information that he had suffered intestines return from the umbilical cord to the from flatulence for the past io years. A right thora- abdominal cavity, and if the pleuro-peritoneal cotomy was carried out, the hernia reduced, and the canal is still open, loops of bowel will herniate into hernial orifice repaired. His post-operative con- the pleural cavity (Bochdalek hernia). Embryo- valescence was uneventful, and an X-ray of his chest was logical sites of fusion of the diaphragm are sites of satisfactory. potential weakness and it is at these points that This type of congenital hernia is due to the congenital hernia occur. abnormal development of that portion of the The following cases are examples of these types diaphragm which is formed from the fusion of the of hernia. embryonal septum transversum, and the body wall components. This hernia is probably not as rare Case No. I. Congenital Diaphragmatic Hernia in as previously thought, since symptoms are present the Newborn (Bochdalek Hernia) in only a small proportion of patients. If the This baby was found to be dyspnreic and cyanosed at contents of the hernial sac are extraperitoneal fat birth. X-ray of the chest (Fig. 2) showed the right chest or omentum, not adherent to the sac, symptoms to be filled with intestines, which were displacing the structures ad- mediastinum to the left. At thoracotomy his chest was are unlikely. If these become found to be filled with loops of small and large intestine. herent, symptoms, particularly pain, may occur These were reduced, and the hernial orifice, which was due to traction. Transverse colon in the sac located in the postero-lateral part of the diaphragm, produces symptoms which are predominantly was sutured. He made an uneventful recovery, and an abdominal. The patients usually complain of X-ray showed satisfactory expansion of his lungs. intermittent attacks of colic, bouts of abdominal Herniae of the postero-lateral part of the dia- distension, and sometimes vomiting. If the con- by copyright. phragm (through the foramen of Bochdalek) are tents of the hernia are extraperitoneal fat or the most common type of congenital diaphragmatic omentum, then the shadow seen radiologically is hernia in the newborn. Surgical repair should be opaque; if bowel is present, then the typical air- carried out preferably within the first 48 hours of containing space is seen (Figs. 5 and 6). life. The operative mortality, unfortunately, is The majority of cases do not require surgery, as high, this being partly due to the frequent presence they have no symptoms. When colon is present, of a hypoplastic lung, which does not inflate after however, operation should be carried out whether reduction of the contents of the hernia. This are or because of the type of hernia contains no sac, and is therefore a symptoms present not, http://pmj.bmj.com/ ' danger of strangulation. ' false hernia. The following two cases demonstrate congenital Case No. 2. Congenital Diaphragmatic Hernia malformations of the diaphragm which may be (Bochdalek Hernia) in a Boy aged 2 mistaken for congenital diaphragmatic herniae. This boy was referred for further investigation be- cause of failure to thrive, and attacks of abdominal colic. Case No. 4. Eventration ofthe Diaphragm His chest X-ray (Fig. 3) showed gas-containing shadows This man of 49 years of age was admitted with a suggestive of intestines at the left base. However, it was io-year history of dyspepsia, which did not fit any typical on September 30, 2021 by guest. Protected not possible to assess whether these were above or below pattern, and was not related to meals. His X-rays the diaphragm. Barium enema (Fig. 4) demonstrated (Figs. 7 and 8) showed an elevated left diaphragm, which colon in the chest. A thoracotomy was carried out and moved sluggishly on screening. Barium meal (Fig. 9) herniated loops of small and large intestines were found showed no evidence of hiatus hernia, but the stomach in the chest; there was no hernial sac present. These was inverted, giving the characteristic ' fish-hook ' were reduced, and the hemial orifice, which was found appearance, recognized as being typical of an eventration. to be at the site of the foramen of Bochdalek, was re- At thoracotomy the diaphragm was found to be thin, paired. His post-operative X-ray was satisfactory. lax, and lying in folds; it was incised, overlapped and The great majority of infants born with these sutured. He made a good recovery, and was relieved of congenital defects, if untreated, die in the first few his symptoms. hours or days. A few, however, may survive to Eventration is included here because it is easily adult life, and the hernia be discovered incidentally confused with diaphragmatic hernia, as the symp- at routine X-ray examination. toms and radiological appearances are similar. In its literal meaning, eventration should signify Case No. 3. Congenital Retrosternal (Parasternal) actual herniation, but the accepted meaning of the Diaphragmatic Hernia (Morgagni Hernia) term is used to describe a condition of an abnormal This 72-year-old man had had a productive cough with elevation of the intact diaphragm. True eventra- Postgrad Med J: first published as 10.1136/pgmj.37.426.191 on 1 April 1961. Downloaded from "April I96 I HOFFMAN: Diaphragmatic Hernia FIG. 2. FIG. 3. by copyright. http://pmj.bmj.com/ ,F.6.k.'.& on September 30, 2021 by guest. Protected FIG. 5. FIG. 4. Postgrad Med J: first published as 10.1136/pgmj.37.426.191 on 1 April 1961. Downloaded from I94 POSTGRADUATE MEDICAL JOURNAL April I96I FIC. 7. FIG. 6. by copyright. http://pmj.bmj.com/ on September 30, 2021 by guest. Protected FIG. 9. FIG. 8. Postgrad Med J: first published as 10.1136/pgmj.37.426.191 on 1 April 1961. Downloaded from April I96I HOFFMAN: Diaphragmatic Hernia FIG. I0. by copyright. FIG. II. I http://pmj.bmj.com/ on September 30, 2021 by guest. Protected :..,-.... aK, :..-3 .s ..: ;;.-.. *- '- FIG. I2. *. ... FIG. 13. Postgrad Med J: first published as 10.1136/pgmj.37.426.191 on 1 April 1961. Downloaded from I96 POSTGRADUATE MEDICAL JOURNAL April I961 i i 4FIG.Tl-- 15. FIG. 14. by copyright. http://pmj.bmj.com/ on September 30, 2021 by guest. Protected FIG. i6. FIr.. 17. Postgrad Med J: first published as 10.1136/pgmj.37.426.191 on 1 April 1961. Downloaded from Aphril I96I HOFFMAN: Diaphragmatic Hernia 197 tion is of congenital origin. The term eventration Case No. 6. Traumatic Rupture of the Diaphragm should not be used in conditions where there is an due to a Car Accident elevated diaphragm due to phrenic nerve paralysis. This 48-year-old man was admitted to a general Eventration results when there is failure of muscle surgical ward following a road accident. In the crash he was thrown forward injuring the left side of his development; whereas in phrenic nerve paralysis, chest and abdomen on the steering wheel. On ad- the diaphragm shows a normally developed muscle mission he was slightly shocked and complained of which is atrophic. In eventration movements of severe pain in the left chest and abdomen. His abdomen the affected leaf of the diaphragm may be greatly was tender with rigidity below the left costal margin.
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