The diaphragm (synonym chest-abdominal barrier) is a muscular aponeurotic plate that separates the chest cavity from the abdominal; It has the shape of a dome, convex upward (Fig.). The muscular part of the diaphragm starts from the sternum, lower (VII - XII) ribs and lumbar vertebrae. Muscle bundles converge along the radii to the middle and end at the tendon center. Through the hole in the tendon center of the diaphragm passes the inferior vena cava, through the holes in the muscle section - the aorta and thoracic lymphatic duct, esophagus and vagus nerves. Sympathetic nerve trunks, celiac nerve, unpaired vein to the right and semi-unpaired vein to the left pass through separate slits on each side of the diaphragm. From above the diaphragm is covered with a pleura and a pericardium, from below - a peritoneum. The height of the standing of the diaphragm is changeable. On average, in an adult, the highest point of the right dome of the diaphragm is on the horizontal, passing through the point of attachment of the IV costal cartilage to the sternum, and the left - one edge below. The blood supply to the diaphragm is the upper and lower diaphragmatic, as well as muscular and pericardo-diaphragmatic arteries. They are accompanied by the same vein. The diaphragm is innervated by the phrenic nerve.
Aperture (bottom): 1 - sternal portion;
2 - esophageal opening; 3 - rib part; 4 - lumbar-rib triangle; 5 - aortic opening; b - medial leg; 7 - lumbar part; 8 - opening of the inferior vena cava; 9 - tendon center.
Fig. 1. The diaphragm from the side of the abdominal cavity: 1 and 18 - m. psoas major; 2 - v. azygos; 3 - eras lat. (BNA); 4 - eras intermed. (BNA); 5 - cras med. (BNA); 6 - n. spianchnicus major; 7 - a. phrenica dext .; S - vv. phrenicae dext .; 9 - v. cava inf .; 10 - vv. phrenicae sin .; 11 - centrum tendineum; 12 - esophagus; 13 - a. phrenica sin .; 14 - glandula suprarenalis sin .; 15 - aorta; 16 - ren sin .; 17 - v. hemiazygos.
Fig. 2. Aperture from the chest cavity: 1 - aorta; 2 and 15 —aa. pericardiacophrenicae sin. et dext .; 3 and 13 — nn. phrenici sin. et dext .; 4 and 14 - vv. pericardiacophrenicae sin. et dext .; 5 - diaphragmatic part of the pericardium; 6 and 12 —vv. musculophrenicae sin. et dext .; 7 and 11 - a. musculophrenica; 8 - esophagus; 9 - sternum; 10 - v. cava inf.
The main physiological function of the diaphragm is respiratory. The basis of the rhythmic contractions of the diaphragm during breathing are reflex mechanisms (see Breathing). The impulses coming through the phrenic nerves lead to a contraction and flattening of the diaphragm, thereby inhaling.
Closed damage to the diaphragm occurs when chest compressions, with blows with blunt objects. Open injuries, often puncture-cutting, are localized in the posterior-lateral parts of the diaphragm; In wartime, damage to the diaphragm most often occurs with gunshot lesions of the chest wall or abdomen. Damage to the diaphragm is often combined with injury to the organs of the chest and abdominal cavities, may be accompanied by prolapse of the abdominal organs ( omentum , stomach, large intestine, spleen, etc.) into the pleural cavity, and outward (see Thoraco-abdominal damage ) . Symptoms of damage to the diaphragm: pain in the abdomen and chest, radiating to the shoulder , shortness of breath , cyanosis , rapid pulse ; quite often damages of a diaphragm are followed by shock. The undoubted sign of damage to the diaphragm is the detection of abdominal organs in the chest cavity (by X-ray examination), their loss from the wound of the chest wall or the discharge of the contents of the abdominal cavity from it.
First aid: in case of a wound in the abdominal or chest wall, its toilet is produced and a dry aseptic bandage is applied. When the chest wall of the abdominal organs falls out of the wound, they are not repositioned, limited to imposing an aseptic dressing. The patient is injected subcutaneously with heart remedies (camphor, caffeine ), give inhale humidified oxygen. Drugs are prohibited, as they may obscure the clinical picture of damage. The patient is immediately transported (in the supine position) to the hospital.
Treatment in a surgical hospital: an operation with anti-shock measures, starting with the vago-sympathetic cervical blockade (see Novocainic blockade). The wound of the chest wall is widened, the dropped out organs are brought down into the abdominal cavity and stitched onto the diaphragm, then a laparotomy is done (revision of the abdominal organs and the necessary interventions).
Diaphragmatic hernias occur with the pathological expansion of the natural openings at the points of passage through the diaphragm of the aorta, esophagus, inferior vena cava (congenital hernia). More often the formation of hernias contribute to the former wound of the diaphragm (traumatic hernia). Symptoms of herniated diaphragm: chest pains, belching and vomiting due to movement of the stomach into the chest cavity, shortness of breath, palpitations and cyanosis due to compression of the lungs, displacement of the heart and restriction of movement of the diaphragm. Diaphragmatic hernias can be infringed, causing symptoms of intestinal obstruction (see Intestinal Obstruction). Important in the diagnosis of hernia of the diaphragm is an x-ray examination . Treatment for traumatic hernia of the diaphragm surgical; in case of congenital hernia, the question of surgery is solved individually.
Tumors of the diaphragm are most often secondary due to their spread from neighboring organs (liver, stomach).
Inflammation of the diaphragm , as a rule, occurs when the process spreads from the subphrenic space (see Subphrenic abscess ) or from the chest cavity (for purulent diseases of the lungs, pleura , and pericardium).