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| Deforming sliding hiatal hernia treatment. Applied surgical techniques. Symptoms of diaphragmatic hernia. |
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A sliding is a specific type of hernia, in which one of the walls of the hernial sac is a hollow (less commonly parenchymal) organ covered with a sheet of peritoneum. In case of hernia esophageal opening the diaphragm of this organ is most often the stomach, less often the intestine and the omentum. Like any other, sliding hernias of the esophageal opening of the diaphragm are divided into congenital and acquired. The congenital variant is most typical for young children, and acquired ones can be diagnosed in adults of any age, in females more often than in males. Depending on the location of the protrusions, we recognize the type of chondro-dandolar and chondromanubrial, the defect can be symmetrical and asymmetrical with different feed rotation. Symptomatology is minimal, the most big problem for teens is an aesthetic impression and the resulting psychosocial problems. This is a rare disease characterized by hypoplasia of aplasia structures. chest front wall, often accompanied by anomalies of the chest and finger. Symptoms can range from hypoplasia of the pectoralis major muscle to the preserved skeleton, to complete aplasia of both chest muscles, accompanied by a lack of anterior rib sections and associated with an impression of the chest wall. Sliding hernia of the esophageal opening of the diaphragm is insidious because it may not cause a person any significant discomfort and problems for a long time, while the hernial ring (that is, the esophageal opening in the respiratory muscle) will gradually expand. Accordingly, more and more of the content abdominal cavity will fall into the chest cavity. This pathology has no characteristic external signs of a hernia (protrusion of the anterior abdominal wall), can be diagnosed by chance or during the examination of the entire gastrointestinal tract. The corresponding breast may be hypoplastic or absent, including the nipple. Symptoms include finger deformities. In the case of less serious defects, reconstruction is not required, breast augmentation is only suitable for girls, provided that a stable chest wall is used. If a segment of the anterior chest wall is missing, a reconstruction operation is indicated using rib cavities on the other hand or foreign material. Because of the usual lack or hypoplasia of soft tissues, plastic surgery methods are used here. ClassificationThere is no special classification of a sliding hernia. The basis is traditionally based on the anatomical principle, that is, the degree of violation of the natural anatomical location of organs. The sliding hernia of the esophageal opening in modern gastro-surgery is classified as follows: Congenital malformations of the stern are rare, but can have a dramatic image and critical development. Chevral cleft, cervical ectopia of the heart, thoracic ectopia of the heart, thoracoabdominal ectopia of the heart. In the pectoral fissure, the heart is in its own anatomical position. Cervical ectomy weakens the heart with a defect in the upper half of the sternum, often associated with the head. In thoracic ectopic, the heart is forced out of the defect of the sternum, not covered soft tissue. In thoracoabdominal ectopia, the heart is covered and dislocated into the abdominal cavity with a defect of the diaphragm.
Sometimes, in quite advanced cases, not only the stomach is involved in the pathological process, but also other organs located inside the abdominal cavity. Allocate accordingly: Reconstruction of the eternal gap is easy for newborns, when the elasticity of the chest allows a straight seam of coarse wire or synthetic fiber to be absorbed without ejaculating the heart. At a later age, the rectification is more complicated, it can be helped by parastatic chondrotomy, which allows to bring both halves of the sternum closer. If necessary, you can use autologous grafts of cartilage and ribs. Implantation of foreign materials is not recommended due to the increased risk of infectious complications and problems caused by further development of the skeleton.
There is another classification. It is based on the degree of penetration of a purely stomach into the cavity of the chest: It affects only the abdominal esophagus, the stomach itself is pulled up, located directly under the main respiratory muscle, but does not penetrate into the chest cavity. The solution of cardiac ectopia is much more demanding due to the lack of soft tissues, the skin to cover the heart, often there is a defect in the abdominal wall. The operation itself is usually two-stroke, first the heart is covered with skin or muscle bone, the second time the heart is restored and restores the defect in the anterior wall of the chest. Despite the success of perinatology and neonatal surgery, the postoperative course is often unfavorable due to compression of the heart during its coverage and related defects. Some preventive treatment of such conditions is the ideal prenatal diagnosis and final termination of pregnancy. The syndrome of the upper thoracic aperture is a set of symptoms due to the suppression of the vessels of the vessels and the brachial plexus in the cervixaxial course in anatomically defined straits. Previously, he had several subtypes and synonyms. However, since the symptoms of individual entities overlap, as well as their anatomical and pathophysiological background, the general concept of upper thoracic aperture syndrome is currently used. Sliding hiatal hernia 2 degrees. The next stage of the process is characterized by the fact that all parts of the esophageal tube are located inside the chest cavity, and part of the (small) stomach is almost always located within the esophageal opening of the main respiratory muscle. Sliding hiatal hernia 2 degrees. The final part of the disease, in which a significant part of the stomach and other organs is not located at the location prescribed by normal anatomy, but inside the cavity of the chest. The cervical coaxial tunnel, which passes through the blood vessels and nerve structures on the arm, divides the rib into two parts: the proximal, which is further divided into coccidial space and a scalar triangle, as well as a distal self-sheeting. Compression of neurovascular structures predisposes to both sites of the proximal part. Cococlavicular space is limited by the key and the first edge, the ant's tire. it divides into the anteroposterior part, where the sub-vein passes, and the posterior-lateral part — with the passage of the artery and the brachial plexus. SymptomsSuch a hernia has no typical clinical symptoms characteristic only for this disease. Complaints of the patient are in many respects similar to those in various diseases of the alimentary canal. A person may celebrate:
As a result of a long-existing hernia of the diaphragmatic opening, an ulcerative lesion may form lower divisions the esophagus and the subsequent replacement of epithelial tissue with connective tissue (scarring and stricture of the esophagus). Fig. 4 Double triangle. There are many causes of compression of the nervous vein, the most common of which is anatomical, congenital or traumatic. Symptomatology is caused by pressure of blood vessels or more often by nerves, it can be combined. Typical manifestations are paraesthesia and pain of the affected limbs, expressed in the area of the ulnar innervation. Compression of the subartery causes coldness of the limbs, hypostezia, mild fatigue and diffuse pain. All symptoms usually appear or worsen during abduction of the arm and hyperextension of the neck. Diagnostics is based on a variety of (available) instrumental research methods. Apply to:
The identified endoscopic signs of a hernia of the esophageal opening of the diaphragm allow not only to diagnose the hernia itself, but also to assess the degree of impairment of the esophageal and gastric mucosa, as well as changes in the motility of the digestive tube. In addition to searching for skeletal abnormalities, clinical trials can be used to monitor the weakening or disappearance of impulse in art. radial. Scalar test - tongue, neck widening, head turning to the side, bone test - military posture - shoulders back and forth, hyperabductive test - hand hyperabduction up to 180 degrees. Neurophysiological or neurophysiological research is of paramount importance. electromyographic - monitoring the transmission rate of the ulnar nerve potential. Therapy may be conservative: physiotherapy, rehabilitation. If the operation failed, the operation is indicated. Many complex procedures have been developed for cervical ribs, elongated transverse projections or head muscles. Gradually, the main and common anatomical background of most problems is the first rib, and its removal leads to success in approximately 90% of patients. The remaining issue was resolved in favor of transaxial resection, which gives best review and least complications. In the case of re-intervention, the first edge, respectively. its remainder, the usual posterior transmucular approach. TreatmentAs in many other situations, there are conservative and operational tactics of treating a sliding hernia of the esophageal opening of the diaphragm. Conservative tactics can not eliminate the hernia itself, but can significantly reduce its clinical manifestations. A mandatory component of the treatment of a sliding hernia of the esophageal opening of the diaphragm is a diet with the exception of overly fried and spicy food, extra active substances, and also careful observance of a diet. Poststentotomic osteomyelitis with posterior external abscess. The chest wall can be affected by inflammation, either through the entire thickness, or the inflammation is limited to individual layers. The course of inflammation of the skin, subcutaneous tissue and soft tissue does not differ from similar diseases elsewhere in the body, and skeletal attachment has its typical consequences. The spectrum of pathogens is widespread, mainly staphylococcus, streptococcus, E. coli, pseudomonads, previously tuberculosis infections, even today we find actinomycosis or bacterioids. The following mandatory component of the treatment of a sliding hernia of the esophageal opening of the diaphragm is medicamentous drugs:
The need for surgery for sliding hernia of the esophageal opening of the diaphragm occurs in the following situations: Abscesses can develop under a thick layer of muscles or under the shoulder, when clinical symptoms are quite common, local detection is inconclusive, and assistance in imaging methods is necessary. Primary skeletal infections are extremely rare, and in patients with diabetes mellitus osteoarthrosis with sternoclavicularis is noted. Most often, we are confronted with inflammatory lesions of solid structures of the chest wall after cardiac or thoraco-surgical surgery. The most common of these complications is the infarction convulsive disappearance after cardiac surgery, in which osteomyelitis contributes to the depletion of cerebral circulation due to the binding of the mammary glands and frequent concomitant diseases.
Various variants of operations involve suturing the formed hernial ring and restoring the natural anatomical location of the organs of the alimentary canal. Rare osteomyelitis after thoracotomy is rare. Inflammation can spread to the chest wall along stitches, chests in the chest, or along the lobes in the chest. Treatment of soft tissue inflammation consists of proper drainage, removal of necrotic tissue and, in the case of a phlegmonous lesion with common symptoms, also with the introduction of effective antibacterial therapy. Sclerosis is usually prolonged and requires resection of the affected bones and cartilage. In the case of osteomyelitis sterna, tissue loss is significant, and methods of reconstructive surgery come to the word. A specific treatment option for a sliding hernia of the esophageal opening of the diaphragm is determined individually for each individual patient. The gastroenterologist is engaged in the treatment of diseases of the esophagus and stomach. Want to find the best doctor gastroenterologist In your city? Recently, many such defects have been successfully healed with the help of a closed drainage system. Fig. 6 Skeletal metastases of renal carcinoma. Primary tumors of the chest wall are rare, and most often we find another primary site in the thoracic skeleton of tumor metastasis. Unusual is neither direct proliferation of lung and breast tumors in the chest, as well as local repetition of these tumors in the chest. Primary tumors of the chest wall include wide range benign and malignant mesenchymal neoplasias, epithelial tumors and hemoblastomas. Sliding hernia covered with a sheet of peritoneum on one side only. That is, unlike true hernia, sliding - do not have additional shells that make up the hernia crayon. Otherwise, sliding hernias are no different from classical hernia. They can be fixed and not fixed. Sliding hernia of the esophageal orifice of the diaphragm is characterized by the formation of a hernial sac consisting of the upper part of the stomach. Overview of the most common primary diagnoses. Malignant histiocytoma plasmacytic myeloma lymphoma Sarcoma Liviosarcoma Leviosarcoma Ewing rhabdomyosarcoma chondrosarcoma osteosarcoma neurofibrosarcoma hemangiosarcoma. Osteochondroma chondroma lipoma fibroma neuramoma. . Osteochondroma is the most common benign bone tumor, which is about 50% of benign rib tumors. It is formed in childhood, and its growth continues until the end of bone maturation. It grows out of the cortex as an exostosis in the area of the ribbed metaphysis and is covered with a cartilaginous lid. A painful tumor that grows even in adulthood, prone to malignancy, must be removed. Chondrome is also quite common. It consists of the shares of hyaline cartilage, most often growing in the area of the anterior bone of intoxicating rubbish. Its differentiation from low pride chondrosarcoma is difficult to make impossible and should always be cut at safe boundaries. The reasons for the appearance of any hernias, and the sliding diaphragmatic hernia of the esophagus is not an exception, there are only two factors:
With the weakening of the barrier tissue, a hernial ring is formed, through which, under internal pressure, parts of the organs are squeezed out beyond the limits of normal, anatomical localization. Desmoid is most often located on the chest, in the shoulder area and under the sculpture. As a rule, it covers the nervous structures and vessels of the upper thoracic opening, arms and throat. It consists of spindle cells, grows out of the muscles and fascia and spreads along them. After an incomplete removal, he or she does not do this. Redivism must be resolved by redistributing, encapsulating the important structures of radiation therapy. Malignant fibrous histiocytoma is the most common malignant tumor of the chest wall. It appears between the decision. It consists of spindle fibroblasts in lobular or matrix formations, including mononuclear heteocytes and osteoclasts. It is characterized by radioresistance and chemoreality, the only solution is a fairly wide resection. When sliding hernia formed due to contraction of the muscles of the esophagus, it is called traction. If a hernia is formed due to weakening connective tissue tendon ring, the mechanism of the formation of the hernial protrusion - pulsation. Such a sliding hernia of the esophagus is formed under the following conditions of the body:
That is, a pulsating axial hernia the esophageal opening of the diaphragm is formed with increased intra-abdominal pressure. A separate type of sliding diaphragmatic hernia appears when the esophagus sphincter is deficient. A special form, the axial hernia of the esophageal opening of the diaphragm, the so-called adjacent areas, is also highlighted. Diaphragmatic hernia, for example.
Regardless of the mechanism of formation, a sliding hernia of the esophageal opening of the diaphragm has the same symptoms. And they manifest in the development of reflux esophagitis. The word "reflux" in Russian means "reverse current" or "return throw". Reflux esophagitis manifests as inflammation of the esophagus (esophagitis) caused by irritation and damage to mucosal cells with hydrochloric acid. As a result, ulcers and cracks on the mucous membrane appear, which provoke pain syndrome. People who develop axial hiatal hernia note burning pains behind the sternum, similar to the heart. At the same time it hurts in the epigastric region and in both hypochondria. Often, the pain gives - radiating - in the left shoulder girdle and forearm. Such symptoms are often misleading, and the person believes that he has a heart ache. Moreover, taking medications for angina. Of course, they do not bring relief.
At the same time, belching appears, similar to regurgitation of stomach contents, like in babies. Heartburn hurts constantly. If the sliding hernia of the esophagus continues to progress, it becomes difficult for the person to swallow. Ulcerative lesions of the mucous membrane of the esophagus begin to bleed. As a result, coffee-colored vomiting appears. More rarely, when corroding the vessel wall is larger than the capillaries, more massive bleeding occurs. Then the vomiting becomes scarlet, and the feces become dark. If only small vessels are damaged, latent bleeding can be recognized only indirectly, by blood tests. Persistent bleeding, although in small portions, leads to a state of anemia. Diagnosis and conservative treatment of sliding hernia of the esophagusTo confirm the diagnosis, the following are carried out additional methods research:
With the help of objective research methods, it is possible to identify the length of the esophagus, the expansion of its mouth above the fibrous ring. The pattern of the mucous membrane is also clearly visible, defects and ulcers are visible. With a confirmed diagnosis, a sliding hernia of the esophageal opening of the diaphragm, the treatment is carried out conservatively. Are applied modern drugs, neutralizing hydrochloric acid and reducing its production - proton pump inhibitors (omeprazole group), antacid drugs that reduce the aggressive action of hydrochloric acid (Almagel group), prokinetics (ranitidine, domperidone). With a small amount of hernia and preserving the function of the sphincter conservative treatment turns out to be successful, but requires regularity. Each break in medication can cause reflux esophagitis even more power than before treatment. Methods of surgical treatment of sliding diaphragmatic herniaIf complicated axial hernia develops, treatment is indicated only operative. In cases of bleeding, surgery is performed on an emergency basis. The operation is performed under general anesthesia using laparoscopic instruments. Under the control of vision, the surgeon creates a ring in the form of a clutch, “put on” the esophagus tube, from the stomach walls. Cuff prevents tightening the esophagus up and relax the sphincter. As a result, reflux disappears, and the contents of the stomach will not enter the esophagus. After the operation, three small scars remain on the skin, up to 10 mm long. In the absence of complications, discharge from the hospital is made on the third day after the operation. The disability sheet closes in two to three weeks. Prevention of axial hernia recurrenceFood for sliding hernia of the esophagus after surgical treatment provides for a strict diet as in gastric ulcer for the first month. Then the diet becomes softer and includes restrictions on spicy and salty foods, as well as alcohol. Sparkling water is not recommended. After six months, the patient returns to his usual life, that is, all dietary restrictions are lifted. |
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