Diaphraqmatic Hernia of the Stomach

Abstract

Diaphragmatic hernia is a protrusion of the abdominal contents into the chest through an abnormal opening in the diaphragm which results from imperfect development, anatomical weakness, or trauma. Recent statistics show that diaphragmatic hernia due to trauma is relatively uncommon, comprising less than one-third of the reported cases. In the author's series of 26 cases, 4 were considered as acquired diaphragmatic hernias of the stomach. It was noted in this study, in agreement with the reports of others, that protrusion of a portion of the cardiac end of the stomach through the esophageal hiatus was the most common type of hernia. In the congenital type the defect is usually caused by a failure of fusion mainly in four parts of the embryonic diaphragm, and the herniated organs may lie free in the chest with or without a peritoneal sac. A hernia may occur after fusion has taken place when a subsequent increase in abdominal pressure causes a protrusion through some weak area. Classification Numerous classifications have been presented based on embryology, anatomy, etiology, etc., but since it is often impossible to distinguish the various classes clinically, it is better, for academic reasons, to consider hernias as of two types, congenital and acquired. The congenital group may be subdivided into (a) the form in which there is a complete absence of the diaphragm or a portion of the diaphragm; (b) the type which is due to a partial defect in the musculature of one leaf; (c) the form which is due to a congenital enlargement of one or more of the diaphragmatic hiatuses. The acquired type may be considered under the following subdivisions: (a) the form which is produced by a dilatation or relaxation of the various hiatuses of the diaphragm; (b) the form which is a result of trauma. Not to be confused with the above conditions are (1) the thoracic stomach associated with a short esophagus, as in this instance the stomach has never been a part of the abdominal cavity and, therefore, cannot have herniated, and (2) so-called eventration of the diaphragm (in which the stomach, as well as the rest of the abdominal contents, is below the diaphragm) except in the presence of a congenital diaphragmatic defect. The author has one such case in his series. Incidence of diaphragmatic hernia This condition can no longer be considered as a pathological curiosity, since Hedblom, in 1931, was able to collect 1,003 cases reported in the literature after 1900. From 1900 to 1925 only 30 cases of diaphragmatic hernia were clinically recognized at the Mayo Clinic; from 1925 to 1933, 147 cases were recognized, five times as many in a period of eight years as in the previous twenty-four years. Truesdale in 1935 collected 303 cases which occurred in infants and children; of this number, 165 were found at autopsy, 90 by x-ray examination, and 13 at operation.