Diaphragmatic hernia
Synonyms in the broadest sense
Medical: Hiatal hernia
English: hiatal hernia, hiatus hernia
Definition of the diaphragmatic hernia
At a Double skin break (Hiatal hernia) is it a Disease of the diaphragm, where the opening in diaphragm (Esophageal hiatus), through which the esophagus passes, widens. This means that there is a risk that parts of the M.agent from the abdominal cavity through into the Chest cavity relocate and cause health problems.
Please also read our article on this Diseases of the diaphragm.
Anatomy of the diaphragm
The Abdominal cavity and the Chest cavity are through that diaphragm separated from each other. The esophagus runs from the throat through the chest cavity and enters the abdominal cavity through a slit-like opening in the diaphragm (hiatus esophageus), only to open into the stomach shortly afterwards. This is where the so-called lower esophageal sphincter (muscle fibers of the esophagus arranged in a ring) is located, which prevents acidic stomach contents from flowing back into the esophagus.
Through the slit-like opening of the diaphragm, parts of the stomach can be pressed from the abdominal cavity into the chest cavity above the diaphragm, which is called "Diaphragmatic hernia“Or Hiatal hernia referred to as.
Figure diaphragm
- Diaphragm (red) -
Diaphragm - Chest cavity -
Cavitas thoracis - Abdominal cavity -
Cavitas abdominis - Tendon center of
Diaphragm -
Centrum tendineum - Rib part of the diaphragm -
Pars costalis diaphragmatis - Esophageal slit -
Aortic hiatus - Vena cava hole -
Foramen venae cavae - Aorta in the aortic slot -
Aorta in the aortic hiatus - Loin part of the diaphragm -
Pars lumbalis diaphragmatis - Lungs - Pulmo
The diaphragm separates
the thoracic and abdominal cavities
You can find an overview of all Dr-Gumpert images at: medical illustrations
Cause of a diaphragmatic hernia
It can be assumed that several factors contribute to the development of a Diaphragmatic hernia (hiatal hernia) contribute.
Factors like:
- Obesity (obesity)
- a pregnancy
- Constipation (constipation)
- heavy lifting
- to cough
or - Vomit
increase the pressure in the abdominal cavity. With age, the elasticity of the connective tissue anchoring of the esophagus in the place where it passes through the diaphragm decreases (Esophageal hiatus), so that if the pressure in the abdominal cavity increases due to the factors described above, it may no longer be possible to prevent parts of the stomach from penetrating the chest cavity.
Forms of two-skin hernia
There are different types of diaphragmatic hernia
- Cardiofundal malposition
- Axial diaphragmatic fracture = sliding hernia / sliding fracture (approx. 90%)
- Paraesophageal hernia of the diaphragm (hiatal hernia)
- Mixed hernias (mixed fracture)
Cardiofundal malposition
In the kardiofundal failure the esophagus opens into the esophagus at a more obtuse angle (His angle, esophagogastral angle) stomachbecause of the stomach on diaphragm fastening ligament is loosened.
Since this form is rarely associated with clinical complaints, the cardiofundal malposition is more of an incidental finding during gastroscopy (Gastroscopy) represent.
Axial diaphragmatic hernia (hiatal hernia)
The sliding hernia (axial diaphragmatic hernia) is the most common form of double-skin hernia with around 90% of cases.
In this form, the stomach entry area (cardia) enters the chest cavity through the diaphragmatic opening of the esophagus (hiatus esophageus).
The function of the lower esophageal sphincter (esophageal sphincter) is no longer guaranteed and acidic stomach contents can flow back (reflux). The typical symptom is heartburn.
Sliding hernia is more common with age, so that 50% of people over 50 years of age have a sliding hiatus hernia.
Paraesophageal hernia
The paraesophageal hiatal hernia (diaphragmatic hernia) is characterized in that the entrance area of the stomach (cardia) is in its anatomically correct position, i.e. located below the diaphragm within the abdominal cavity.
Also the lower one Esophageal sphincter (esophageal sphincter) is intact. Another part of the stomach, however, turns inside out next to the esophagus into the chest cavity.
This can clinically lead to a Feeling of pressure in the heart area (esp. after eating), difficulty swallowing, belching of undigested chunks of food and Shortness of breath by displacing the lung come.
As complication it can be caused by constriction of the supplying blood vessels Stomach ulcer up to tissue destruction and potentially life-threatening bleeding.
Mixed fractions
Mixed hernias (mixed fractures) are combinations of the axial and paraesophageal Diaphragmatic hernia and occur more frequently than pure paraesophageal hiatal hernia.
A rare one Extreme variant is the thoracic or also Upside-down stomach. The entire stomach is located in the chest cavity.
Symptoms
A diaphragmatic hernia often goes unnoticed for a long time and does not cause any symptoms. Mostly there are very small fractures that do not affect any other organs and therefore go unnoticed. The first symptoms are mostly heartburn and acid regurgitation, this comes about because the opening of the diaphragm cannot properly seal the stomach entrance. As a result, gastric juice runs back into the esophagus.
If the hernial opening widens over time, parts of the stomach and esophagus may slip through the opening of the diaphragm and be relocated to the upper abdomen. If this is the case, a Redistribution of the internal abdominal organs. The changed pressure conditions can impair the organs above the stomach and the diaphragm. That can too Pain in the diaphragm to lead. The lungs can be restricted in their expansion, which is a shortness of breath can trigger in the patient. These serious complaints suggest surgical treatment.
Furthermore, the changed pressure conditions in the upper abdomen can also lead to irritation of the nerves that supply the heart, which can lead to or even to a heart stumble Racing heart can lead. As a rule, these complaints are extremely annoying but not life-threatening. Nevertheless, in such a case, an operation should urgently be considered.
Numerous nerves run in the abdomen that transmit stimuli to the brain. With a diaphragmatic hernia, which is actually painless, the stomach and esophagus can penetrate. This can cause irritation to nerves that are present in this area of the abdomen. This nerve stimulation can be passed on to parts of the body that are far away from the actual place of origin. With a large diaphragmatic hernia with associated Organ displacement it can therefore also happen that pain or an uncomfortable feeling is felt in the area of the back. Erroneously, the patient initially thinks the causes are in the back itself and in fact it turns out to be very difficult to infer a diaphragmatic hernia from back pain. Many weeks, months and examinations often pass before the diaphragm is shortlisted as the cause.
Diagnosis of the diaphragmatic hernia
The diagnosis Diaphragmatic hernia can through a Gastroscopy or by a X-ray with porridge (a procedure in which the patient swallows porridge containing contrast medium) in the head-down position and abdominal press.
therapy
The Axial hiatal hernia (axial diaphragmatic hernia) is only used for complaints like Reflux / heartburn medication, usually with Proton pump inhibitors, treated. These reduce acid build-up in the stomach.
The paraesophageal hernia And the mixed form is also an indication for surgery because of the potentially life-threatening risk of complications, even without clinical symptoms.
A so-called transabdominal gastropexy is performed as a surgical procedure, whereby the stomach is completely returned to the abdominal cavity and finally fixed to the abdominal wall.
Surgical techniques
In some cases, the treatment can be conservative, that is, surgery is not required for the time being and people wait and see. This is mainly done when the diaphragmatic hernia does not cause any major discomfort. In the case of health problems, a hernia operation must be performed. There are various surgical techniques that are used today for hernia treatment.
- laparoscopy
As a rule, diaphragmatic surgery is performed laparoscopically today, i.e. a large abdominal incision as it used to be done is now only necessary in exceptional cases, e.g. if the visibility under the keyhole technique is too poor or if the anatomical conditions do not allow laparoscopic surgery. During the laparoscopic operation of a diaphragmatic hernia, 2-3 small incisions are made in the upper abdomen, through which instruments are then inserted into the abdomen. A camera that shows the surgeon the outside view on a monitor is also used.
- Gastropexy
It is also possible to fix the stomach to the anterior abdominal wall. This action is called gastropexy and it prevents the stomach from changing its position. The duration of this operation, which is very often performed in general surgery today, is between 30 minutes and 1.5 hours.
Access, visibility, the selected surgical technique and the patient's condition are decisive for the duration of the operation. For example, an operation on an overweight patient who also has many comorbidities would take longer than on a young athletic person. The keyhole surgery usually takes a little longer than the surgery on the open abdomen, but in any case it has a better cosmetic result in the end. Both surgical procedures have the same success rate. Sometimes it can also happen that the surgeon starts the operation with a minimal surgical technique, but then switches to an open surgical technique for reasons of visibility or complications.
The most common problem with a diaphragmatic hernia is the stomach slipping through the hernia. In a hernia operation, the hernia can be narrowed so that the stomach can no longer slide upwards. However, a kind of cuff made from parts of the esophagus can also be placed around the neck of the stomach. This spreads the upper part of the stomach, which also prevents the stomach from sliding up. This surgical measure is also known as fundoplication and is now the most successful surgical technique for treating reflux disease. Since a diaphragmatic hernia can always go hand in hand with reflux, this surgical technique is often preferred.
The operation of a diaphragmatic hernia is always performed under general anesthesia. After the procedure, the patient is placed on the monitoring station for a short time, after which he comes to the normal ward. Then the patient should be on sick leave for 1-2 weeks. Depending on the professional activity, he must be careful not to lift heavy weights for the next 4-6 weeks. In addition, exercise should be avoided for the next 14 days. The abdominal press should also not be used too heavily during this time.
Exercise with a diaphragmatic hernia
Exercise can trigger a diaphragmatic hernia. Particularly when patients have weak connective tissue, diaphragmatic hernias can increase in certain sports. Quite often, heavy-lift sports cause a hiatal hernia. These include weight lifting, shot put, and bodybuilding. Depending on the constitution and the condition of the connective tissue, it can also be used in other sports, e.g. Ball sports or athletics, to the development of a diaphragmatic hernia.
A conservative treatment of a diaphragmatic hernia usually leads to the fact that the hernial opening soon enlarges and causes discomfort if certain sports are continued. In the presence of a diaphragmatic hernia and no change in sporting lifestyle, symptoms of complaints will inevitably occur. In this case, surgery for the diaphragmatic hernia should definitely be considered. After the operation, the sport that triggered it should not be practiced for at least 6-8 weeks. If weight sports have been carried out, serious consideration should be given to discontinuing them completely, as a new break can occur again even after an operation. If this is the case, another operation is necessary, which is a little more difficult than the first operation. A plastic net would be sewn into the hernial opening as an additional stabilizing component, so that the closure is more stable and no abdominal organs can slip through.
