Diaphragmatic hernia after surgery

Introduction after surgery Postoperative diarrhea (postoperativediaphragmatichernia) refers to the operation through the diaphragm, because the intraoperative repair is not strict or postoperative rupture, abdominal organs (gastrointestinal) protrude into the chest and the internal hemorrhoids. Most occur after esophageal cancer or cardiac cancer resection, achalasia, esophageal hiatus hernia or hernia after surgery is relatively rare. basic knowledge Sickness ratio: 0.0001% Susceptible people: no special people Mode of infection: non-infectious Complications: multiple lung infections

Cause of paralysis after surgery

The diaphragmatic incision is not tight or the healing is not strong (65%):

Esophageal or cardiac cancer surgery, achalasia surgery, esophageal hiatal hernia or hernia surgery, other operations through the chest and abdomen, the need to cut the diaphragm for organ resection, or the esophagus and stomach free and reconstruction, or need to expand the diaphragm Operation of the esophageal hiatus, such as esophageal or cardiac cancer, will require reconstruction after the removal of the diseased stomach or esophagus. In order to maintain the connection and smoothness of the digestive tract, in most cases, the stomach (or residual stomach) is lifted to the chest. Or the neck and the end of the esophagus do the anastomosis, a small number of patients need to use the jejunum or colon instead of the resected esophagus and / or stomach, only a few cases through the subcutaneous or sternal pathway to empty the intestine or colon to replace the transplanted organ, In most cases, the intrathoracic approach is used for reconstructive surgery. The replacement organ is inserted into the thoracic cavity through the diaphragmatic incision or through the enlarged iliac muscle esophageal hiatus. The diaphragm is then sutured with the replacement organ, thus forming a new diaphragm. Rupture, usually, suture usually heales about 1 week after surgery, if the repair of the diaphragm is not tight enough during surgery The suture is not strong enough or the knot is detached, or the infection around the diaphragm, and the malnutrition affects the healing of the diaphragm, which can cause it to split or tear, and a new fissure occurs. Under the pressure difference between the chest and the abdomen, the stomach The intestine or other intra-abdominal organs enter the thoracic cavity through the diaphragmatic fissure, forming postoperative hernia, which occurs more than 1 week after surgery.

The pressure difference between the chest and the abdomen is too large (35%):

Under normal circumstances, the intra-abdominal pressure is slightly higher than the atmospheric pressure, while the intrathoracic pressure is slightly lower than the atmospheric pressure, forming a pressure difference to facilitate breathing and blood circulation, after transthoracic, abdominal and diaphragmatic surgery, due to anesthesia, Surgical stimulation and other factors lead to abdominal distension and abdominal pressure increase, the patient coughing and sputum, turning position, or forced defecation is particularly obvious, as well as complications such as intrathoracic insufficiency or atelectasis. The negative pressure in the thoracic cavity is further increased, and the pressure difference between the thoracic cavity and the abdominal cavity is significantly increased. In the case where the diaphragmatic muscle repair is not tight enough, the suture is not strong enough and reliable, or the diaphragm is not well healed, the pressure difference between the abdomen and the thoracic cavity may contribute to the occurrence of spasm. .

Pathogenesis

In the case of radical resection of esophageal or cardiac cancer with left thoracotomy, the most common site of postoperative ankle ring is the presence of a new hole in the diaphragm or the junction of the replacement organ and the diaphragm incision (Figure 1). Often transplanted stomach, the mesentery of the intestine and the supply of blood vessels (the right ventricle of the gastric retina) through the diaphragm, the surgeon sutures the diaphragm and the gastrointestinal tract to prevent compression of these blood vessels and affect the blood supply to the gastrointestinal tract, often avoiding these places Stitching may result in insufficient suturing. Postoperative ankle ring may also occur on the incision of the diaphragmatic closure line, or other sites where new holes occur, but it is rare.

There is no sac in the sac after operation, and the contents of the sputum are directly into the left pleural cavity, and directly contact with the organs in the thoracic cavity, and even fibrosis occurs. For example, the ankle ring of the sputum is behind the stomach, and sometimes the contents can be broken. Right pleural cavity.

Because the spleen of the colon (including partial transverse colon and descending colon) often fills the space after the stomach is transplanted into the chest, it becomes a direct adjacent organ to the ventral surface of the left semitendinosus, so the most common sputum content (into the organ) is also The spleen of the colon, and even part of the transverse colon and descending colon, also invade. As the sputum progresses, some small intestines and omentum may also break into the chest to become part of the sputum content, causing more serious pathophysiological disorders and clinical symptoms. If there is not much intrusion into the contents, no blood supply disorder and/or intestinal obstruction caused by intrusion into the organ, the patient may have only mild discomfort or no obvious symptoms, and the signs are not found, such as intrusion. When there are many organs and the ankle ring is small, incarceration and strangulation may occur, causing the intestines to inflate and accumulate, the blood flow is blocked, the capillary permeability and exudation increase, and the intestinal wall edema is rapidly aggravated. Causes blood supply disorders that break into the intestines, and even causes necrosis and perforation of the intestinal wall, causing acute chest infections, which can cause shock or even life-threatening. In addition, due to a large number of intestines invading the chest And expansion, resulting in lung collapse or compression atelectasis, expectoration obstacles and then cause lung infection, breathing difficulties, further aggravate the condition.

Postoperative sputum prevention

1. The fine and tight fixation of the diaphragm and the replacement organs (stomach or intestine) during surgery is important, and the spacing of the sutures should not be able to pass through the fingertips.

2. The junction of the new fissure and the diaphragmatic incision (triangular region) of the diaphragm should be sutured with 8 words, and the suture can pass through the avascular portion of the same omental margin to strengthen the closure of the triangle.

In addition, after suturing, the pulsation of the blood supply to the replacement organs (stomach or intestine) and the presence or absence of venous return should be checked to prevent the suture from affecting the blood supply of the replacement organs.

Complications after surgery Complications multiple lung infections

Due to lung collapse or insufficiency and poor drainage, patients are prone to secondary lung infection, fever, respiratory odor, difficulty breathing, etc., can further aggravate the condition.

Symptoms after surgery, common symptoms, bowel sounds, low bloating, stop breathing, difficulty breathing, low intestinal obstruction, shock

Postoperative sputum occurs mostly in the early postoperative period, but also occurs after l~2 years after surgery. Symptoms and signs are different due to changes in pathophysiology. In general, the later the symptoms appear after sputum symptoms, the later the disease light.

1. Intestinal obstruction performance

When there are not many intestinal tracts, no blood supply disorder and/or intestinal obstruction, the symptoms are milder, which may be long-term, mild, intermittent low-level intestinal obstruction, such as long-term intermittent abdominal pain. Abdominal distension, etc., also showed the appearance of acute intestinal obstruction on the basis of the above chronic medical history, and the condition suddenly aggravated.

2. Lung collapse performance

If the intestine is more than the intestine, the lungs may be depressed or not, and the patient may have difficulty breathing.

3. Intestinal strangulation

Intestinal incarceration and strangulation, even necrosis and perforation, can lead to acute chest infection, the symptoms are more serious, can be expressed as sudden severe abdominal cramps, progressive exacerbation, frequent vomiting, abdominal distension, anus to stop venting, Defecation, abdominal distension or abdominal bulging bulging, sometimes visible peristaltic waves, touching tender mass, bowel sounds hyperthyroidism; difficulty breathing, low respiratory sounds on the affected side, severe shock can occur.

Examination of sputum after surgery

When the atelectasis is complicated and the drainage is poor, fever and white blood cell count may increase.

1. Chest positive, lateral X-ray film, can be found in the pleural cavity of the operation side with gas or gas-containing intestinal fistula, some patients due to postoperative pleural reaction, heavier signs of effusion.

2. X-ray barium enema examination: It can be found that the expectorant has a cut-off phenomenon under the armpit, or the expectorant enters the chest cavity.

Diagnostic diagnosis after operation

There is no major difficulty in the diagnosis of postoperative delirium. For example, the symptoms and signs of spasticity appear after the operation of the diaphragm. The chest is positive and the lateral X-ray film shows that the pleural cavity of the operation side has intestinal or sputum containing gas or liquid surface. Can be clearly diagnosed, some patients due to postoperative pleural reaction, heavier enveloping effusion, etc., can mask the presence of sputum, affect the diagnosis, if necessary, should be barium enema examination, if found that the sputum has a cut-off phenomenon under the armpit, or The agent enters the chest cavity, the diagnosis of sputum can be clear, if the above is still not diagnosed, and the patient's symptoms persist, it must be repeated in a short time. Most patients with the development of the disease, the intestinal fistula into the chest can be in a short time. Expanded gas is more obvious and generally easy to find.

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