Diaphragm Conditions

The breathing muscle at the crossroads of chest and abdominal surgery

The diaphragm, the dome-shaped muscular sheet separating the chest from the abdomen, is essential for breathing and plays a critical role in thoracic and abdominal surgery. Diaphragmatic disorders range from congenital defects and traumatic ruptures to hernias and tumours, each presenting unique diagnostic and surgical challenges.

Anatomy and Function

The diaphragm is the primary muscle of inspiration, accounting for 70–80% of the work of quiet breathing. During contraction, it descends, increasing the volume of the thoracic cavity and drawing air into the lungs. It is pierced by several structures, the oesophagus, aorta, and inferior vena cava, at specific anatomical foramina. The right hemidiaphragm is slightly higher than the left (because of the underlying liver) and is elevated in hepatomegaly, pleural effusion, phrenic nerve palsy, and subphrenic abscess.

Diaphragmatic Hernia

A diaphragmatic hernia occurs when abdominal contents herniate through a defect in the diaphragm into the thoracic cavity. Hernias may be congenital or acquired.

Congenital Diaphragmatic Hernia (CDH), most commonly the Bochdalek hernia (posterolateral defect), is a neonatal surgical emergency. The herniation of intestines, stomach, and spleen into the developing chest cavity compresses the foetal lung, causing ipsilateral pulmonary hypoplasia and, often, contralateral hypoplasia. Despite advances in neonatal surgery and ECMO (extracorporeal membrane oxygenation), CDH carries significant mortality related to pulmonary hypertension and lung underdevelopment.

Morgagni hernia, through the anterior retrosternal gap, is rarer and more often diagnosed in adults, frequently as an incidental finding. It typically contains omentum or transverse colon and is repaired laparoscopically.

Hiatus Hernia and Its Distinction

Hiatus hernia, herniation of the stomach through the oesophageal hiatus, is distinct from other diaphragmatic hernias and is primarily managed by oesophago-gastric surgeons. Type I (sliding hiatus hernia) is the most common cause of gastro-oesophageal reflux disease. Types II, III, and IV (paraoeosphageal hernias) involve herniation of the gastric fundus and, in severe cases, the entire stomach and other organs into the chest, and require surgical repair due to risks of obstruction and strangulation.

Traumatic Diaphragmatic Rupture

Diaphragmatic rupture most commonly results from high-velocity trauma, road traffic accidents, falls, blast injuries, and penetrating wounds. The left hemidiaphragm is more commonly affected (80% of cases) because the liver protects the right side. Diagnosis is frequently delayed, as acute trauma obscures the diaphragmatic injury. CT chest and abdomen is the most sensitive diagnostic tool. Acute ruptures are repaired at emergency laparotomy or thoracotomy; chronic hernias (presenting months to years later with obstructive symptoms) require elective repair, which may be more complex due to adhesions.

Diaphragm Plication for Phrenic Nerve Palsy

Phrenic nerve injury, from cardiac surgery, thoracic surgery, trauma, tumour invasion, or neurological disease, causes hemidiaphragm paralysis. The affected hemidiaphragm elevates and moves paradoxically (upward during inspiration instead of downward), impairing ventilation. Symptomatic patients with significant breathlessness benefit from diaphragm plication, surgical folding, and suturing of the flaccid hemidiaphragm to create a fixed, non-paradoxically moving surface. This can be performed via VATS with excellent symptomatic results.

Diaphragmatic Eventration

Eventration is an abnormal elevation of the entire or part of the diaphragm due to congenital aplasia or atrophy of the diaphragmatic muscle fibres, with the diaphragmatic membrane remaining intact (unlike a true hernia). In children, eventration can cause significant respiratory embarrassment and failure to thrive, requiring early surgical plication. In adults, symptomatic eventration, causing breathlessness, recurrent chest infections, and orthopnoea, is similarly treated by plication.

Diaphragmatic Tumours

Primary tumours of the diaphragm are rare. Benign lesions include lipoma, fibroma, and cysts. Primary malignant tumours, fibrosarcoma, leiomyosarcoma, and malignant fibrous histiocytoma are uncommon and require wide resection with diaphragmatic reconstruction using prosthetic mesh. More commonly, the diaphragm is involved secondarily by tumours of the lung (particularly mesothelioma), liver, adrenal, or peritoneum. In cytoreductive surgery for advanced ovarian cancer and pleural mesothelioma, diaphragmatic resection and reconstruction are standard components of the operation.

Diaphragmatic Involvement in Thoracic Surgery

The diaphragm is frequently involved in chest cancer surgery. In lung cancer surgery, direct extension of lower lobe tumours to the diaphragm requires diaphragmatic resection with reconstruction. In extrapleural pneumonectomy for mesothelioma, the entire pleura, lung, pericardium, and diaphragm on one side are removed en bloc. Diaphragmatic reconstruction with Gore-Tex or polypropylene mesh restores the chest-abdomen barrier and prevents organ herniation.

Diaphragm Condition Requiring Expert Evaluation?

Dr. Bhanushali offers comprehensive assessment and surgical management of all diaphragmatic conditions, including minimally invasive plication and complex diaphragmatic reconstruction.

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