Surgical approach to diaphragmatic hernias treatment

Dijafragmalne hernije predstavljaju izazov za abdominalnu i torakalnu kirurgiju u postizanju zadovoljavajućeg anatomskog i funkcionalnog rezultata u pacijenata. Dijafragma služi kao anatomski zid između pozitivnog abdominalnog i negativnog torakalnog tlaka, te je najvažniji respiratorni mišić. Hernije mogu nastati u odrasloj dobi ili kongenitalno, izolirane ili kao dio nekih sindroma. 85% dijafragmalnih hernija otpada na tip I hijatalne hernije ili kližuće hernije, koje su udružene s pojavom gastroezofagealne refluksne bolesti. Osim njih, u stečene dijafragmalne hernije spadaju i paraezofagealne hijatalne hernije ili tip II. Najpoznatije kongenitalne dijafragmalne hernije su Bochdalekova hernija te hernija Morgangi, koje se prema europskim registrima pojavljuju u 2.3 na 10 000 živorođenih. Kod kongenitalnih dijafragmalnih hernija kliničke manifestacije nastaju zbog patoloških promjena na plućima i mogu dovesti do plućne hipertenzije, dok su stečene najčešće asimptomatske, ali se mogu prezentirati disfagijom, regurgitacijom, povraćanjem, gubitkom težine, anemijom i respiratornim simptomima. Bochdalekova hernija je, ako se prepozna, indikacija za hitnu operaciju. Morgangijeva je najčešće neprepoznata do odrasle dobi. Za hijatalnu i paraezofagealnu hijatalnu herniju preporuča se elektivni operacijski zahvat. Najčešći pristup je laparoskopski, iako je moguć i otvoreni transabdominalni i transtorakalni pristup. Laparoskopija pruža prednosti minimalno invazivne kirurgije, kao što su manja rana, kraći postoperativni boravak i smanjen mortalitet. Sadržaj hernije se reponira, te se defekt zatvara metodom bez napetosti, šavovima ili primjenom kirurške mrežice. Kod hijatalnehernije radi se i fundoplikacija, najčešće metodom po Nissenu.Diaphragmatic hernias present a challenge for abdominal and thoracic surgery in terms of achieving adequate anatomical and functional results in patients. The diaphragm is an anatomical wall that separates positive intraabdominal and negative intrathoracic pressure, as well as being the most significant respiratory muscle. Hernias can develop in adults or congenital, either isolated or as a part of genetic syndromes. Eighty-five percent of hernias are sliding hiatal hernias, or type I hernias. They are acquired hiatal hernias, often presented with gastroesophageal reflux disease. Type II or paraesophageal hiatal hernias are also considered acquired diaphragmatic hernias. The most commonly known congenital diaphragmatic hernias include Bochdalek and Morgangi hernias, which are presented in 2.3 per 10 000 live births, according to European registers. Clinical manifestations of congenital diaphragm hernias develop as a result of a lung pathology and possibly lead to pulmonary hypertension. In most cases, adult hernias are asymptomatic, but can present with dysphagia, regurgitation, vomiting, weight loss, anemia, or respiratory issues. With an early diagnosis, Bochdalek hernias present a surgical emergency and should be treated at once. Morgangi hernias are commonly undiagnosed until an adult age. For hiatal hernias, elective operative procedures are recommended. The most common approach is laparoscopic, however, laparotomy or thoracotomy are also possible. Laparoscopy provides significant benefits of minimally invasive surgery, for instance, smaller wounds, shorter postoperative stay, as well as lower mortality rates. Hernial content is repositioned, and a tension-free repair is performed, either by using a surgical mesh or sutures. The fundoplication procedure is also performed in hiatal and paraesophageal hernias, generally using the Nissen method