Predescu Dragos, Achim Florin, Socea Bogdan, Ceaușu Mihail Constantin, Constantin Adrian
Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania.
General and Esophageal Clinic, "Sf. Maria" Clinical Hospital, 011192 Bucharest, Romania.
Diagnostics (Basel). 2023 Dec 29;14(1):85. doi: 10.3390/diagnostics14010085.
A rare entity of non-hiatal type transdiaphragmatic hernias, which must be clearly differentiated from paraoesophageal hernias, are the phrenic defects that bear the generic name of congenital hernias-Bochdalek hernia and Larey-Morgagni hernia, respectively. The etiological substrate is relatively simple: the presence of preformed anatomical openings, which either do or do not enable transit from the thoracic region to the abdominal region or, most often, vice versa, from the abdomen to the thorax, of various visceral elements (spleen, liver, stomach, colon, pancreas, etc.). Apart from the congenital origin, a somewhat rarer group is described, representing about 1-7% of the total: an acquired variant of the traumatic type, frequently through a contusive type mechanism, which produces diaphragmatic strains/ruptures. Apparently, the symptomatology is heterogeneous, being dependent on the location of the hernia, the dimensions of the defect, which abdominal viscera is involved through the hernial opening, its degree of migration, and whether there are volvulation/ischemia/obstruction phenomena. Often, its clinical appearance is modest, mainly incidental discoveries, the majority being digestive manifestations. Severe digestive complications such as strangulation, volvus, and perforation are rare and are accompanied by severe shock, suddenly appearing after several non-specific digestive prodromes. Diagnosis combines imaging evaluations (plain radiology, contrast, CT) with endoscopic ones. Surgical treatment is recommended regardless of the side on which the diaphragmatic defect is located or the secondary symptoms due to potential complications. The approach options are thoracic, abdominal or combined thoracoabdominal approach, and classic or minimally invasive. Most often, selection of the type of approach should be made taking into account two elements: the size of the defect, assessed by CT, and the presence of major complications. Any hiatal defect that is larger than 5 cm (the hiatal hernia surface (HSA)) has a formal recommendation of mesh reinforcement. The recurrence rate is not negligible, and statistical data show that the period of the first postoperative year is prime for recurrence, being directly proportional to the size of the defect. As a result, in patients who were required to use mesh, the recurrence rate is somewhere between 27 and 41% (!), while for cases with primary suture, i.e., with a modest diaphragmatic defect, this is approx. 4%.
一种罕见的非裂孔型经膈疝，必须与食管旁疝明确区分，即分别称为先天性疝——博赫dalek疝和拉雷 - 莫尔加尼疝的膈缺损。其病因相对简单：存在预先形成的解剖开口，这些开口允许或不允许各种内脏器官（脾脏、肝脏、胃、结肠、胰腺等）从胸部区域进入腹部区域，或者最常见的是从腹部进入胸部。除了先天性起源外，还描述了一组较为罕见的病例，约占总数的1 - 7%：创伤性后天变异型，通常通过挫伤型机制，导致膈肌拉伤/破裂。显然，其症状表现多样，取决于疝的位置、缺损大小、通过疝孔累及的腹部脏器、其移位程度以及是否存在扭转/缺血/梗阻现象。通常，其临床表现不明显，主要为偶然发现，多数为消化系统表现。严重的消化系统并发症如绞窄、肠扭转和穿孔很少见，且伴有严重休克，在数种非特异性消化系统前驱症状后突然出现。诊断结合影像学评估（普通放射学、造影、CT）和内镜检查。无论膈肌缺损位于哪一侧或因潜在并发症导致何种继发症状，均建议进行手术治疗。手术入路选择有胸部、腹部或胸腹联合入路，以及经典或微创方式。大多数情况下，入路类型的选择应考虑两个因素：通过CT评估的缺损大小以及是否存在主要并发症。任何大于5厘米的裂孔缺损（裂孔疝面积（HSA））都正式推荐使用补片加强。复发率不可忽视，统计数据表明术后第一年是复发的高发期，与缺损大小成正比。因此，在需要使用补片的患者中，复发率在27%至41%之间（！），而对于采用一期缝合的病例，即膈肌缺损较小的情况，复发率约为4%。
