Main surgical approaches
The choice of surgical approach plays a decisive role in the success of the operation. According to the classification, four basic approaches to the diaphragm are used:
- Transabdominal — the approach is performed through the abdominal cavity.
- Transthoracic — the intervention is performed through the thoracic cage.
- Thoracoabdominal — a combined approach that opens both cavities simultaneously.
- Combined — performed strictly sequentially: first, a laparotomy is performed, followed by a thoracotomy.
Treatment of congenital diaphragmatic hernias
The tactics of surgical treatment for congenital pathologies depend on the localization of the defect and the anatomical features of the patient.
- In pediatric practice: in children, a transabdominal approach is typically used to correct congenital diaphragmatic hernias.
- Local defects: if the hernia is located in the sternocostal or lumbocostal triangle, the defect is sutured. For this, surgeons use interrupted or mattress sutures.
- Eventration of the diaphragm: this condition requires strengthening of the thinned area. To achieve this, alloplasty is performed using a Dacron mesh or polyvinyl alcohol-based plastic materials. In some clinical situations, biological tamponade of the defect is performed using the patient's own organs — the liver or spleen.
Surgical tactics in diaphragmatic injuries
In mechanical injuries of the diaphragm, the surgeon's algorithm of actions is determined by the scale of the injury and the condition of the wound edges.
| Type of injury | Surgical tactics |
|---|---|
| Stab and incised wounds | The wound is sutured with interrupted sutures. The optimal distance between the placed sutures should be 0.5–1.0 cm. |
| Extensive wounds and lacerations/crush injuries | Require a two-stage approach. First, mandatory preliminary excision of all non-viable tissues at the wound edges is performed. Then, special traction sutures (stay sutures) are applied to carefully approximate the edges before final closure. |
Plasty for large defects
If the trauma has led to a massive defect and the approximation of the wound edges is physically impossible, prosthetics is used. Plastic plates made of polyvinyl alcohol serve as prostheses.
Technique of plasty performance:
- The plastic plate is securely sutured to healthy, undamaged parts of the diaphragm. Sutures (interrupted ones are used) are placed at a significant distance from the edges of the defect itself.
- After fixing the prosthesis, the edges of the diaphragmatic defect are pulled up and sutured directly to the plastic plate, piercing them thoroughly.
Briefly: answers to topical questions
Which nerves innervate the diaphragm and must be preserved during surgical interventions?
The sources do not specify which nerves require mandatory preservation during surgeries on the diaphragm.
- Phrenic nerves (n. phrenicus) run between the pericardium and the mediastinal pleura.
- Branches of the phrenicoabdominal nerves (rr. phrenicoabdominales) pass through the celiac plexus.
The sources do not explicitly state that the listed structures innervate the diaphragm or require mandatory preservation during surgeries.
Which arteries provide blood supply to the diaphragm?
The materials do not provide an exhaustive list of arteries supplying the diaphragm. The following vessels in the region of the diaphragm are mentioned:
- Inferior phrenic artery — gives off the superior suprarenal artery (a. suprarenalis superior).
- Internal thoracic vessels (vasa thoracica interna) — pass in the sternocostal triangle.
- Pericardiophrenic vessels (vasa pericardiacophrenica) — accompany the phrenic nerves.
Through which natural openings and weak spots of the diaphragm can hernias form?
Diaphragmatic hernias emerge through natural openings and anatomical "weak spots" where muscle bundles are absent and fascias come into contact.
- Esophageal hiatus (hiatus esophageus) — the site of emergence of hernias of the cardiac part of the stomach (sliding hernias).
- Sternocostal triangle (trigonum sternocostale) — also known as Larrey's slit or Morgagni's triangle.
- Lumbocostal triangle (trigonum lumbocostale) — Bochdalek's triangle.
What types of congenital diaphragmatic hernias exist according to localization?
The cited sources explicitly indicate that congenital diaphragmatic hernias in newborns most often form through the lumbocostal triangle — Bochdalek's triangle.
The sources also indicate the sternocostal triangle (Larrey's slit, Morgagni's triangle) and the lumbocostal triangle as weak spots of the diaphragm through which diaphragmatic hernias can emerge.
For quick memorization of the four approaches to the diaphragm, use the acronym TTTC: Transabdominal, Transthoracic, Thoracoabdominal, Combined.
Class and exam questions
Which surgical approach is most commonly used for congenital diaphragmatic hernias in children?
In pediatric surgery for the treatment of congenital hernias, traditional preference is given to the transabdominal approach.
At what intervals should sutures be placed when closing stab and incised wounds of the diaphragm?
When suturing such injuries, interrupted sutures are used, the distance between which must strictly be from 0.5 to 1.0 centimeters.
What does the first stage of debridement for extensive wounds with crushed edges involve?
Before attempting to approximate the wound edges, a preliminary excision of all non-viable tissues must be performed to prevent necrosis and the development of infection.
What material are plates for closing large diaphragmatic defects made of?
For the alloplasty of extensive defects, when edge approximation is impossible, plastic plates made of polyvinyl alcohol are used.
What else to study on this topic
- Technique of placing mattress sutures for defects of the sternocostal triangle.
- Features of biological tamponade of the diaphragm with the liver or spleen.
- Step-by-step analysis of the combined approach: transition from laparotomy to thoracotomy.
- Comparative characteristics of Dacron mesh and polyvinyl alcohol in alloplasty.
- Rules for placing stay sutures in crush injuries of diaphragmatic tissue.
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