Classification of

diaphragmatic hernia


Gabriel
There are two main types
1.congenital diaphragmatic hernias
Eventration
Bochdalek hernia
Morgagni hernia
2.Acquired
Traumatic diaphragmatic rupture
hiatus hernia
iatrogenic
CDHs
Bochdalek hernia: failure of fusion of
pleuroperitoneal canal leaving a direct
communication between pleura and
peritoneum on left side
Makes up about ninety percent of all
cases.
Occurs in one out of every 2,200 to
5,000 live births.

Morgagni hernia makes up 2% of all
cases.
The defect lies between the sternal
and costal attachments of the
diaphragm and is situated in front and
towards right.
Bochdalek hernia - A Bochdalek
hernia involves an opening on the left
side of the diaphragm. The stomach
and intestines usually move up into
the chest cavity.
Morgagni hernia - A Morgagni hernia
involves an opening on the right side
of the diaphragm. The liver and
intestines usually move up into the
chest cavity.
Clinical features
Bochdalek presents with acute
respiratory distress in neonatal period.
In adults most cases are
asymptomatic, few present with
digestive symptoms due to herniation
of stomach or bowels.
Morgagni presents with pain and
tenderness in the right subcostal
region, intermittent obstructive
symptoms.

ADHs
Traumatic diaphragmatic rupture
Blunt or penetrating trauma to the
abdomen and chest.
In most cases the rupture is on the left
side of the diaphragm; tendinonous
portion.
Hiatus hernia
The most common type of DHs.
classification
Type I hiatus hernia It is the cephalad displacement of
the gastrooesophageal junction through the hiatus into the
mediastinum. It is usually small, asymptomatic and
reducible. It is commonest type
Type II hiatus hernia It is superior migration of the
fundus of the stomach along side the GE junction and
oesophagus into the mediastinum with GE junction in
normal intraabdominal location. It is rolling hernia
Type III hiatus hernia It is combination of type I and
type II
Type IV hiatus hernia It is the hernia containing other
abdominal viscera as content like transverse colon and
omentum.
Types
Sliding hernia (85%).
commonly associated with GORD.
Rolling hernia (10-12%).
(paraesophageal)
Combined
Clinical Features
Common in elderly.
Abdominal pain and chest pain.
Hiccough, early satiety.
Regurgitation, post prandial bloating.
Cardiac abnormality (arrhythmia).
Dysphagia dyspnoea.
40% presents as acute features with
perforation/
gangrene/bleeding.
diagnosis
Plain X-ray - lateral and PA erect view
showing retro cardiac air-fluid level.
Barium meal study very useful.
3D CT scan is useful.
Post traumatic hernia; dilated
bowel in left hemithorax.
CT-scan; collasped bowel loops
with omentum within the left
hemithorax
Displacement of the large
intestine into the left hemithorax
Indicationn for surgery
CDH is not an emergency situation.
Gangrene of the stomach
Threatening perforation into the
mediastinum or peritonuem
Perforation
Gastric volvolus
CDH/ADH is often treated with mini
invasive thoracoscopy.
Excision of sac and repair of the defect.
If it is gangrenous, gastrectomy is
required.
Either abdominal or thoracic
laparoscopy
approach can be used in treating rolling
hernia surgically.
Mesh reinforcement to hiatus to close
the defect may be needed.