The epigastrocele usually arises on the middle of distance between a navel and bottom edge of a xiphoidal shoot of a breast. This type of hernias is rare, clinically in many respects reminds umbilical hernia. If the preperitoneal fatty tissue is restrained in a hernial bag, then there is an acute pain. Treatment is surgical.
Postoperative hernia should be eliminated surgically as soon as the condition of a wound and the general condition of the patient allows. These hernias tend to increase and infringement.
Distinguish inborn (fig. 12-35) and the acquired phrenic hernias. The last, as a rule, have a traumatic origin and here are not considered. / Inborn hernias at which abdominal organs drop out in a thorax can cause heavy disorders of breath that often is the indication for urgent surgical intervention in the neonatal period. Communication between the slowed-down display of the right phrenic hernia and the infection caused by streptococci of group B is noticed. Sometimes respiratory symptoms are expressed poorly or in general are absent therefore hernia within several years is not found. In addition to a prolapse through defect in a diaphragm (see below), perhaps partial protrusion of a stomach through an esophageal opening of a diaphragm (see section 12.20), and also a phrenoplegia with the shift of contents of an abdominal cavity up, but without its loss (section 7.25). Phrenic hernia can be combined with diaphragm eventration. Eventration is not hernia, but shift of contents of an abdominal cavity up in the sacculate education in a diaphragm which arose owing to weakness or lack of phrenic muscles. Clinic eventratsip same, as phrenic hernia. Very seldom the diaphragm completely is absent. Etiology. Hernial protrusion is most often localized in posterolateral segments of a diaphragm, mainly at the left. Defect is caused by incomplete closing of the embryonal pleuroperitoneal channel. Much less often hernia is formed in front part of a diaphragm behind a breast. Such hernia arises owing to incomplete influence on the average line of two legs of a diaphragm with pericardium elements. As a result of a loop of intestines drop out in a pericardiac bag or, on the contrary, heart is displaced in an abdominal cavity. Hernia Blinking is often combined with umbilical hernia. Pathogeny. The protrusion of abdominal bodies in a phrenic hernial bag can be expressed in different degree. In hard cases a stomach, the most part of intestines and even (very seldom) the spleen, a liver and kidneys drop out in a thoracic cavity and displace heart and lungs. Phrenic hernia can be combined with incomplete turn of a caecum, umbilical hernia, commissural impassability of a duodenum. On the party of defeat the lung is squeezed, gipoplastichno, the quantity of pneumatic ways and vessels is reduced, the volume of a lung is reduced. Also the hypoplasia of other lung is possible. Clinical manifestations. The heavy respiratory insufficiency which is shown short wind and cyanosis arises right after the birth. If at newborns these symptoms are absent, the illness can be shown at any time in the neonatal period or later. Along with an asthma the main symptoms include vomiting, severe kolikoobrazny pains, feeling of discomfort after food and locks. At any time there can be an acute impassability of intestines. Cases when hernia did not give any symptomatology are known and only accidentally it was found at X-ray inspection.
Fig. 12-35. Inborn phrenic hernia. and. The roentgenogram is made right after the birth: shift of the left dome of a diaphragm the big dense education which is pushing aside heart to the right. The roentgenogram made in 20 min. after the first. As a result of swallowing air in the left half of a thorax loops of a small bowel became visible. Contours: a gullet are designated by a contrast agent. Owing to heavy frustration, breath an attempt of surgical correction is made. The child died in 5,5 h after operation. Weight of symptoms depends on degree of shift of abdominal bodies in a thorax. At their considerable shift at the newborn a stomach of the small size, will involve; cyanosis and the convulsive respiratory movements are noted. If not to liquidate respiratory frustration, then shock and quickly accruing hypoxia develops. In mild cases respiratory and digestive frustration are expressed in the minimum degree or in general are absent. Perkutorno over the stomach which dropped out in a thorax or intestines is defined more expressed tympanites or more stupid sound, than usually. Auskultativny respiratory noise are absent, are weakened or strengthened. Sometimes at auscultation of a thorax intestinal peristaltic noise are listened. The diagnosis is made, as a rule, on the basis of X-ray inspection, it is frequent without use of contrast means and if those are necessary, then it is enough to insufflirovat air in a stomach. Filled with liquid and air the loops of intestines which dropped out in a thoracic cavity can imitate a picture of a polycystosis of lungs. The mediastinum is displaced in not struck party, usually to the right. For the differential diagnosis of hernia, adenomatous cysts and inborn share emphysema of lungs it is necessary to conduct X-ray contrast research to be convinced that the stomach and intestines are in an abdominal cavity. Treatment. Before liquidating hernia and to close defect in a diaphragm, it is necessary to take the measures directed to recovery of breath of the newborn. As soon as phrenic hernia is suspected, the patient needs to give such situation that the head and a thorax were above an abdominal cavity and legs. This pose has to facilitate the shift of belly bodies down. Suction of air and liquid by means of the gastric tube entered through a nose promotes improvement of ventilation of the lungs. Forced ventilation of the lungs under pressure through an endotracheal tube should be carried out carefully as it is fraught with pheumothorax owing to uneven distribution of pressure in lungs at a compression atelectasis or a hypoplasia. Before operation it is necessary to estimate the partial pressure of gases and pH in an arterial blood and to eliminate a metabolic and respiratory acidosis by means of intravenous administration of the corresponding solutions. Urgent and radical surgical intervention is shown. The section on bottom edge of a costal arch provides fine access to a diaphragm. Contents of a hernial bag are displaced down when pressure in a chest and abdominal cavity is leveled. Mortality at inborn phrenic, the hernias diagnosed in the first days after the birth exceeds 50%. The hypoplastic ipsilateralny lung finishes hardly; during the postoperative period pulmonary hypertensia and a syndrome of fetalis blood circulation is often noted. At this time it is necessary to control carefully respiratory function and water-salt balance. Attempts to straighten a lung by forcing of air under pressure can lead to pheumothorax.