Everything about diaphragm

4.3
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Development of diaphragm:

Diaphragm originates from 4 strucures:
1. Septum transversum
2. Dorsal & ventral mesentery of esophagus
3. Body wall
4. Pleuro-peritoneal membrane.
Muscles are derived from cervical myotomes.

Non-fusion of pleuro-peritoneal membrane: Bochdalek’s hernia.

 

Technique to remember diaphragmatic opening:

  • Mnemonic to remember the opening level and structures passing is “VEA
  1. T8: (V)ena caval opening
  2. T10: (E)sophageal opening
  3. T12: (A)ortic opening.
  • Through Aortic opening, 3 structures pass. Mnemonic is “ATA” (most likely to come as an “all except” MCQ):
  1. (A)orta
  2. (T)horacic duct
  3. (A)zygous vein.
  • Through Vena caval opening, beside vena cava, passes right (P)hrenic nerve. Mnemonic is “VP”.
  • You just have to remember one thing, that is, through the esophageal opening, beside esophagus, passes both vagus.

 

Important MCQs about congenital diaphragmatic hernia:

  • MC congenital diaphragmatic hernia is Bochdalek hernia, which is a posterolateral defect; more common in the left side
  • Another type of diaphragmatic hernia is Morgagni hernia, through which the superior epigastric vessels come into abdomen.

 

  • Honeymoon period in congenital diaphragmatic hernia is 2-14 days, because in this time symptoms are often not manifested
  • The more early the diagnosis, the more poor the prognosis (early symptoms = more severe defect).

 

Management:

  • Bag & mask ventilation is absolutely contraindicated in congenital diaphragmatic hernia
  • If child is asymptomatic, put a nasogastric tube and keep the upper end open
  • If child is symptomatic, intubation is done & ventilation is started (SIMV)
  • Regarding surgery: Surgery is never done in acute cases; surgery is only done after stabilization and beyond the 1st week of life.

 

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