Diaphragmatic Eventration vs Diaphragmatic Hernia PDF

DIAPHRAGMATIC EVENTRATION vs Diaphragmatic Hernia Prof. azza fekry 10-10-2024  Learning objectives of this lecture Types of diaphragm in body. Background about anatomy of diaphragm. Common problems of diaphragm. Diaphragm hernia VS. diaphragm event ration. Ro...

DIAPHRAGMATIC EVENTRATION vs Diaphragmatic Hernia Prof. azza fekry 10-10-2024  Learning objectives of this lecture Types of diaphragm in body. Background about anatomy of diaphragm. Common problems of diaphragm. Diaphragm hernia VS. diaphragm event ration. Role of physical therapy pre & post operative for correction of diaphragmatic problems. Role of physical therapy for mild condition of diaphragmatic problems.  How many diaphragms are there in our body? THE DIAPHRAGM PELVIC DIAPHRAGM UROGENITAL DIAPHRAGMA DIAPHRAGMA DIAPHRAGM ORIS SELLA Present at the Present at the Present at This is a It covers the junction of junction of the junction muscle bulk pituitary thoracic and abdomen proper of greater formed by the gland,present abdominal cavity. above and pelvic pelvis above myelohyoid inside the cavity below. and perineum muscle which middle cranial below bears the fossa. weight of the tongue. This diaphragm This diaphragm This diaphragm regulates the regulates the is responsible friction between friction between for maintaining the thorax and the pelvis and the cranium the abdomen. abdomen. pressure and controlling cerebral spinal fluid flow through the ventricles.  UROGENITAL DIAPHRAGM PELVIC DIAPHRAGM DIAPHRAGMA SELLA DIAPHRAGMA ORIS  Transverse Diaphragms We can now look closely at the four main diaphragms known as the transverse diaphragms. These occur at junctions in the body where there are changes to the function of the spinal column. It also acts as a flexible layer, separating each space of the four cavities within the body: the cranial base, thoracic inlet, respiratory diaphragm and the pelvic floor. Each one of the diaphragms stretches from the front to the back of the body.  Thoracic Inlet - Also known as the superior thoracic aperture, refers to the opening at the top of the thoracic cavity BOUNDS Anteriorly: Superior border of manubrium sterni. Posteriorly: Anterior border of the superior surface of the body of T1 vertebra. Laterally: Medial border of first rib and its cartilage. Thoracic Inlet - Also known as the superior thoracic aperture, refers to the opening at the top of the thoracic cavity Thoracic outlet” is an anatomical term that refers to the opening between your neck and chest. This opening (also called your thoracic inlet or superior thoracic aperture) is a passageway for many important structures. Thoracic Outlet - The ring formed by the top ribs, just below the collarbone  Diaphragm anatomy and function The diaphragm is a thin skeletal muscle that sits at the base of the chest and separates the abdomen from the chest. It contracts and flattens when you inhale. This creates a vacuum effect that pulls air into the lungs. When you exhale, the diaphragm relaxes and the air is pushed out of lungs. It also has some non-respiratory functions as well. The diaphragm increases abdominal pressure to help the body get rid of vomit, urine, and feces. It also places pressure on the esophagus to prevent acid reflux. The phrenic nerve, which runs from the neck to the diaphragm, controls the movement of the diaphragm. There are three large openings in the diaphragm that allow certain structures to pass between the chest and the abdomen.  THE DIAPHRAGM The most popular and well-known diaphragm that divides the thoracic cage from the abdomen. The diaphragm is the major respiratory muscle of the body. The diaphragm is the largest muscle used in respiration, which is the breathing operation. Just below the lungs and heart lies this dome-shaped muscle. When you breathe in and out it contracts constantly. The diaphragm muscles come from the lower portion of the spine (breastbone), the lower six ribs, and the lumbar vertebrae of the spine, and are connected to the central tendon of the membrane.  Many components, such as the esophagus, aorta, and inferior vena cava, pierce the diaphragm and are rarely subject to rupture.  Origin of the diaphragm A sternal part arising from the posterior surface of the xiphoid process A costal part arising from the deep surfaces of the lower six ribs and their costal cartilages & forms the right & left domes A vertebral/lumbar part arising from upper three lumbar vertebrae; forms the right & left crura & the arcuate ligaments Insertion of the Diaphragm The diaphragm is inserted into a central tendon. The superior surface of the tendon is partially fused with the inferior surface of the fibrous pericardium. Some of the muscle fibers of the right crus pass up to the left and surround the esophageal orifice in a slinglike loop. These fibers appear to act as a sphincter and possibly assist in the prevention of regurgitation of the stomach contents into the thoracic part of the esophagus Functions of the Diaphragm Muscle of inspiration: On contraction the diaphragm pulls its central tendon down and increases the vertical diameter of the thorax. The diaphragm is the most important muscle used in inspiration. Muscle of abdominal straining: The contraction of the diaphragm assists the contraction of the muscles of the anterior abdominal wall in raising the intra- abdominal pressure for micturition, defecation, and parturition. Weight lifting muscle: In a person taking a deep breath and holding it (fixing the diaphragm), the diaphragm assists the muscles of the anterior abdominal wall in raising the intra-abdominal pressure. Before doing this make sure that a person have adequate sphincteric control of the bladder and anal canal under these circumstances. Thoracoaabdominal pump: The descent of the diaphragm decreases the intrathoracic pressure & increases the intra-abdominal pressure. This compresses the blood in the inferior vena cava and forces it upward into the right atrium of the heart. Within the abdominal lymph vessels is also compressed, and its passage upward within the thoracic duct is aided by the negative intrathoracic pressure. The presence of valves within the thoracic duct prevents backflow. Openings in the Diaphragm The diaphragm has three main openings: The caval opening lies at the level of the T 8 vertebra in the central tendon. Inferior vena cava & branches of the right phrenic nerve. The esophageal opening lies at the level of the T 10 vertebra in a sling of muscle fibers derived from the right crus at the left of median plane. Esophagus, the right and left vagus nerves, the esophageal branches of the left gastric vessels, & the lymph vessels. The aortic opening lies anterior to the body of the T 12 vertebra between the crura. Aorta, thoracic duct, & azygos vein. Nerve Supply of the Diaphragm Motor nerve supply: The right and left phrenic nerves (C3, 4, 5) Sensory nerve supply: The parietal pleura and peritoneum covering the central surfaces of the diaphragm are from the phrenic nerve and the periphery of the diaphragm is from the lower six intercostal nerves. Phrenic nerve damage Several things can damage the phrenic nerve, including  traumatic injuries  surgery  cancer in the lungs or nearby lymph nodes  spinal cord conditions  autoimmune disease  neuromuscular disorders, such as multiple sclerosis  certain viral illnesses This damage can cause dysfunction or paralysis of the diaphragm. But phrenic nerve damage doesn’t always cause symptoms. When it does, possible symptoms include:  shortness of breath when lying flat or exercising  morning headaches  Structure of the Posterior Abdominal Wall Boundaries Midline 5 lumbar vertebrae & their IV discs On each side 12th Rib, upper part of the bony pelvis, the psoas muscles, the quadratus lumborum muscles, and the aponeuroses of origin of the transversus abdominis muscles. The iliacus muscles lie in the upper part of the bony pelvis.  Muscles of the Posterior Abdominal Wall Psoas Major Arises T 12 to L 5 vertebrae. The fibers run downward and laterally and leave the abdomen to enter the thigh. The muscle is inserted into the lesser trochanter of the femur. The psoas is enclosed in a fibrous sheath that is derived from the lumbar fascia. The sheath is thickened above to form the medial arcuate ligament  Muscles of the Posterior Abdominal Wall Quadratus Lumborum Is quadrilateral-shaped muscle, lies alongside the vertebral column. It arises below from the iliolumbar ligament, the adjoining part of the iliac crest, & the tips of the transverse processes of the lower lumbar vertebrae. Inserted into the lower border of the 12th rib & the transverse processes of the upper four lumbar vertebrae. The anterior surface of the muscle is covered by lumbar fascia, which is thickened above to form the lateral arcuate ligament & below to form the iliolumbar ligament. Symptoms of a diaphragm condition: A condition affecting the diaphragm can cause symptoms similar to those of a heart attack. Seek emergency treatment if you experience chest pain or pressure that extends to your jaw, neck, arms, or back. Symptoms of a diaphragm condition may include:  difficulty breathing when lying down  shortness of breath  chest, shoulder, back, or abdominal pain  pain in your lower ribs  a fluttering or pulsing sensation in the abdomen  bluish-colored skin  heartburn  trouble swallowing  regurgitation of food  upper abdominal pain after eating  hiccups  side pain Tips for a healthy diaphragm: The diaphragm is one of the body’s most important muscles because of its crucial role in breathing. Protect your diagram by:  limiting foods that trigger heartburn or acid reflux  eating smaller portions of food at a time  stretching and warming up before exercise  exercising within your limits Like any muscle, you can also strengthen your diaphragm with special exercises. Diaphragmatic breathing or abdominal breathing is the best way to do this. It involves inhaling deeply and slowly through the nose so that your lungs fill with air as your belly expands. Along with strengthening your diaphragm, diaphragmatic breathing can also reduce stress and lower blood pressure.  Clinical Notes Hiccup Hiccup is the involuntary spasmodic contraction of the diaphragm accompanied by the approximation of the vocal folds and closure of the glottis of the larynx. It is a common condition in normal individuals and occurs after eating or drinking as a result of gastric irritation of the vagus nerve endings. It may, however, be a symptom of disease such as pleurisy, peritonitis, pericarditis, or uremia. Paralysis of the Diaphragm A single dome of the diaphragm may be paralyzed by crushing or sectioning of the phrenic nerve in the neck. Occasionally, the contribution from the fifth cervical spinal nerve joins the phrenic nerve late as a branch from the nerve to the subclavius muscle. This is known as the accessory phrenic nerve. To obtain complete paralysis under these circumstances, the nerve to the subclavius muscle must also be sectioned. Penetrating Injuries of the Diaphragm Any penetrating wound to the chest below the level of the nipples should be suspected of causing damage to the diaphragm until proved otherwise. The arching domes of the diaphragm can reach the level of the fifth rib (the right dome can reach a higher level). Diaphragm conditions. Hiatal hernia A hiatal hernia happens when the upper part of the stomach bulges through the oesophageal opening of the diaphragm. Experts aren’t sure why it happens, but it could be caused by: age-related changes in the diaphragm injuries or birth defects chronic pressure on surrounding muscles from coughing, straining, or heavy lifting They’re more common in people who are over the age of 50 or obese. Small hiatal hernias usually don’t cause any symptoms or require treatment. But a larger hiatal hernia may cause some symptoms, including:  heartburn  acid reflux  trouble swallowing  chest pain that sometimes radiates to the back Larger hiatal hernias sometimes require surgical repair, but other cases are usually manageable with over-the-counter antacid medication. Proton pump inhibitors can also help to reduce acid production and heal any damage to the esophagus Cramps and spasmsA diaphragmatic cramp or spasm can cause chest pain and shortness of breath that can be mistaken for a heart attack. Some people also experience sweating and anxiety during a diaphragm spasm. Others describe feeling like they can’t take a full breath during a spasm.During a spasm, the diaphragm doesn’t rise back up after exhalation. This inflates the lungs, causing the diaphragm to tighten. This can also cause a cramping sensation in the chest. Vigorous exercise can cause the diaphragm to spasm, which often results in what people call a side stitch. Diaphragm spasms usually go away on their own within a few hours or days. Diaphragmatic flutter: Diaphragmatic flutter is a rare condition that’s often mistaken for a spasm. During an episode, someone might feel the fluttering as a pulsing sensation in the abdominal wall. It can also cause:  shortness of breath  chest tightness  chest pain  abdominal pain Diaphragmatic hernia A diaphragmatic hernia happens when at least one abdominal organ bulges into the chest through an opening in the diaphragm. It’s sometimes present at birth. When this happens, it’s called a congenital diaphragmatic hernia (CDH). Injuries from an accident or surgery can also cause a diaphragmatic hernia. In this case, it’s called an acquired diaphragmatic hernia (ADH). Symptoms can vary depending on the size of the hernia, the cause, and the organs involved. They may include:  difficulty breathing  rapid breathing  rapid heart rate  blueish-colored skin  bowel sounds in the chest Both an ADH and CDH require immediate surgery to remove the abdominal organs from the chest cavity and repair the diaphragm.  Diaphragmatic Eventration Eventration is the abnormal elevation of the diaphragm resulting in a paradoxical motion during respiration that interferes with proper pulmonary mechanics and function, it characterized by an abnormal elevation of the diaphragm, usually due to a weakness or paralysis of the diaphragmatic muscle. Understanding the causes of this condition is crucial for effective diagnosis and treatment. also be acquired due to paralysis of the phrenic nerve. This can occur secondary to mediastinal tumors, congenital heart surgery, or birth trauma.. EVENTRATION  Diaphragmatic Diaphragmatic Eventration Hernia Eventration is the A diaphragmatic hernia abnormal elevation of occurs when one or more the diaphragm resulting of your abdominal organs move upward into your in a paradoxical motion chest through a hole in the during respiration that diaphragm. interferes with proper This hole is big enough pulmonary mechanics that organs can pass and function through it and poke into the chest.  Causes of Diaphragmatic Hernia: The exact cause of diaphragmatic hernias is unknown. Research suggests that a combination of nutrition, environmental factors, and genetic abnormalities can all play a role. However, this condition can also be acquired by adults through an injury. Some possible causes include: Chest or abdominal surgery Blunt injuries from traffic accidents Knife and gunshot wounds Fall injuries  Types of Diaphragmatic Hernias 1. Congenital Diaphragmatic Hernia (CDH) Description: A birth defect that occurs during fetal development, leading to an incomplete formation of the diaphragm. Common Forms: Bochdalek Hernia: The most common type, typically located posterolaterally (back and side of the diaphragm). Morgagni Hernia: Less common, located anteriorly (front part of the diaphragm). 2. Acquired Diaphragmatic Hernia Description: Develops later in life due to trauma, surgery, or other factors that cause a defect in the diaphragm. Common Causes: Blunt or penetrating trauma, surgical complications, or chronic conditions like persistent increased intra-abdominal pressure. Congenital diaphragmatic hernia (CDH) is a congenital malformation in the diaphragm. The most frequent form of CDH is really a Bochdalek hernia; other styles include Morgagni hernia, diaphragm eventration and central tendon defects in the diaphragm. Acquired Diaphragmatic Hernia  Pathophysiology 1. Diaphragmatic Defect: The abnormal opening in the diaphragm allows abdominal organs (e.g., stomach, intestines, liver, spleen) to protrude into the thoracic cavity. 2. Lung Compression: The presence of abdominal organs in the chest cavity can compress the lungs, leading to compromised respiratory function and reduced lung capacity. 3. Mediastinal Shift: The shift of mediastina structures, including the heart and major blood vessels, can occur, affecting cardiovascular function.  Clinical Presentation: The severity of symptoms with a diaphragmatic hernia can vary depending on its size, cause, and the organs involved. Some of the more common symptoms include the following 1. Neonates (Congenital Diaphragmatic Hernia) Respiratory Distress: Difficulty breathing immediately after birth due to lung compression. Cyanosis: Bluish discoloration of the skin due to inadequate oxygenation. Scaphoid Abdomen: Sunken appearance of the abdomen due to displaced abdominal organs. 2. Adults (Acquired Diaphragmatic Hernia) Respiratory Symptoms: Shortness of breath, chest pain, or chronic cough. Gastrointestinal Symptoms: Abdominal pain, nausea, vomiting, or bowel obstruction symptoms. Asymptomatic Cases: Some individuals may be asymptomatic, and the hernia is found incidentally during imaging for other reasons.  Diagnosis: More than half of all cases are diagnosed before birth. These are usually discovered during prenatal care after an ultrasound. Also, there may be an increased amount of amniotic fluid (the fluid that surrounds and protects the fetus) within the uterus. After birth, your doctor may perform one or more of the following diagnostic tests and procedures. 1. Imaging Studies: Chest X-Ray: Initial imaging modality to visualize the herniated organs and diaphragmatic defect. Computed Tomography (CT) Scan: Provides detailed images of the diaphragm and the extent of organ displacement. Ultrasound: Used in prenatal diagnosis to detect congenital diaphragmatic hernia in fetuses. 2. Arterial blood gas test Treatment of diaphragmatic hernia include 1. Surgical Repair: The primary treatment for diaphragmatic hernia, involving the closure of the diaphragmatic defect and repositioning of herniated organs. 2. Supportive Care: Includes respiratory support, stabilization of vital signs, and management of associated symptoms or complications. 3. Postoperative Care: Monitoring for complications, respiratory rehabilitation, and follow-up imaging to ensure successful repair and recovery.  Management Acquired diaphragmatic hernia is a serious condition which requires urgent surgery in the majority of cases (Surgical repair of the hernia is the most common treatment) where the hernia is closed with sutures to restore the integrity of the diaphragm. by laparotomy or thoracotomy and prevent abdominal organs from entering the thoracic cavity. surgeries such as laparotomy and thoracotomy can affect lung function, causing manifestations such as lung volume reduction, reduction in functional residual capacity, slowing of mucociliary clearance, and abnormalities in gaseous exchange. Therefore the physiotherapist can put in place active respiratory techniques and prescribe these exercises according to the assessment and patient's health state. The main techniques of this area of intervention are incentive spirometry, active cycle of breathing, and thoracic expansion exercises.  Role of Physical Therapy in Diaphragmatic Hernia Introduction Physical therapy plays a vital role in the management of diaphragmatic hernia, particularly in improving respiratory function, enhancing overall physical conditioning, and supporting postoperative recovery. This guide outlines the key components of physical therapy for patients with diaphragmatic hernia. Goals of Physical Therapy: 1. Enhance Respiratory Function: Strengthen respiratory muscles and improve breathing efficiency. 2. Increase Lung Capacity: Optimize the volume of air the lungs can hold. 3. Alleviate Symptoms: Reduce dyspnea and associated discomfort. 4. Improve Physical Fitness: Enhance overall physical conditioning and endurance. 5. Support Postoperative Recovery: Facilitate quicker and more effective recovery following surgical repair.  Chest Physiotherapy Postural Drainage: Technique: Positioning the patient to use gravity to help drain secretions from the lungs. Benefits: Clears mucus and improves lung function. Percussion and Vibration: Technique: Gentle clapping on the chest and using vibration devices to loosen mucus. Benefits: Aids in the clearance of respiratory secretions  General Physical Conditioning Aerobic Exercises: Activities: Walking, cycling, or swimming tailored to the patient's capability. Benefits: Improves cardiovascular fitness, enhances overall endurance, and promotes lung function. Strength Training: Activities: Resistance exercises focusing on both upper and lower body muscles. Benefits: Enhances muscular strength, which can support better respiratory mechanics and physical function. Flexibility Exercises: Activities: Stretching routines to improve flexibility and prevent stiffness. Benefits: Promotes better posture and reduces the risk of musculoskeletal issues.  Specific Exercises and Techniques: Thoracic Expansion Exercises Technique: Patients take deep breaths while expanding the chest wall. Benefits: Enhances lung expansion and improves rib cage mobility. Segmental Breathing Technique: Patients focus on expanding specific areas of the lungs, often with manual assistance from the therapist. Benefits: Improves ventilation in targeted lung regions. Core Strengthening Exercises: Focus on strengthening abdominal and core muscles. Benefits: Provides better support for the diaphragm and improves overall stability. Posture Training Technique: Exercises and adjustments to improve posture. Benefits: Reduces respiratory effort and enhances lung function.  Keys of Physical Therapy Interventions Breathing Exercises: Diaphragmatic Breathing: Technique: Patients are taught to breathe deeply, focusing on expanding the diaphragm rather than the chest. Benefits: Strengthens the diaphragm and reduces shallow, inefficient breathing patterns. Pursed-Lip Breathing: Technique: Inhaling through the nose and exhaling slowly through pursed lips. Benefits: Helps maintain airway pressure, improves gas exchange, and reduces breathlessness. Incentive Spirometer: Technique: Using a device to encourage deep breathing and increase lung volumes. Benefits: Prevents atelectasis and promotes lung expansion  causes of diaphragmatic eventration 1. Congenital Diaphragmatic Eventration: Genetic Factors: Congenital eventration results from the incomplete development of the central tendon or muscular portion of the diaphragm. Most commonly left side, often results from genetic mutations or developmental anomalies during fetal growth, commonly an isolated condition. Sometimes it is associated with other developmental defects such as: Cleft palate. It is more common in males than in females. Incomplete Muscularization: During fetal development, if the diaphragm does not fully muscularize, it can lead to eventration 2. Acquired Diaphragmatic Eventration: Phrenic Nerve Injury: Damage to the phrenic nerve, which controls the diaphragm, can result in its paralysis or weakness. Trauma: Physical trauma from accidents or surgeries can damage the phrenic nerve. Surgical Complications: Thoracic surgeries, particularly those involving the heart or lungs, may inadvertently damage the phrenic nerve Neuromuscular Diseases: Conditions such as muscular dystrophy, myasthenia gravis, and amyotrophic lateral sclerosis (ALS) can weaken the diaphragm.Infections: Certain infections, including viral infections like herpes zoster, can affect the phrenic nerve, leading to eventration.Tumors: Tumors in the chest or neck region can compress or infiltrate the phrenic nerve, causing diaphragmatic dysfunction. 3. Idiopathic Causes In some cases, the exact cause of diaphragmatic eventration cannot be determined. These instances are labeled as idiopathic. Despite extensive testing, the underlying reason for the diaphragmatic weakness or paralysis remains unidentified. 4. Iatrogenic Causes Post-Surgical: Procedures such as cardiac surgeries (e.g., coronary artery bypass grafting) can sometimes result in diaphragmatic eventration due to inadvertent nerve damage or other complications. 5. Other Medical Conditions Chronic Respiratory Diseases: Chronic obstructive pulmonary disease (COPD) and other long-term respiratory conditions can lead to changes in diaphragm structure and function. Severe Malnutrition: Prolonged malnutrition can weaken all muscles, including the diaphragm, leading to eventration.  Assessing diaphragmatic eventration involves a combination of clinical evaluation, imaging studies, and sometimes electrophysiological test.. Diaphragmatic eventration may be asymptomatic but typically presents acutely as respiratory distress and tachypnea in the newborn or more indolently with recurrent respiratory infections and wheezing. Neonates may have feeding intolerance due to discoordinated sucking and breathing. Older children may demonstrate exercise intolerance. Both lungs are usually affected by the paradoxical motion. On inspiration, the eventrated diaphragm rises, which causes the mediastinum to shift and compress the contralateral lung 1.Clinical Evaluation: Patient History: Collect detailed information about symptoms, onset, and progression. Important symptoms to note include: Shortness of breath (dyspnea). Orthopnea (difficulty breathing when lying flat Recurrent respiratory infections. Fatigue and reduced exercise tolerance. Physical Examination: Look for signs such as: Asymmetry in chest movement. Diminished breath sounds on the affected side. Abdominal paradox (inward movement of the abdomen during inspiration(.  Normal vs. Abnormal Findings: Normal Diaphragmatic Diaphragmatic Eventration: Movement: Downward Movement: Reduced Movement: The Both hemidiaphragms eventrated diaphragm shows move downward during reduced excursion compared to inspiration. the normal side but does not Symmetry: The exhibit paradoxical movement. movement of both Elevation: The hemi diaphragm hemidiaphragms is remains elevated but moves symmetrical, showing downward slightly during equal excursion. inspiration. Smooth Contour: The elevated diaphragm maintains its smooth contour throughout the movement.  Treatment Procedures for Diaphragmatic Eventration The guide outlines the main treatment procedures for diaphragmatic eventration. A. Non-Surgical Management: 1. Observation and Monitoring: Mild Cases: Patients with mild symptoms or incidental findings may not require immediate intervention. Regular Follow-Up: Routine imaging and clinical assessments to monitor progression. Respiratory Therapy Breathing Exercises: Techniques to strengthen respiratory muscles and improve lung capacity. Pulmonary Rehabilitation: Comprehensive program including exercise training, education, and behavioral interventions. Medical Management Symptom Relief: Medications to manage symptoms like pain, dyspnea, or associated gastrointestinal issues. Infection Control: Prompt treatment of respiratory infections to prevent complication.  B. Surgical Management Diaphragmatic Plication: Indication: Severe symptoms, significant dyspnea, or recurrent respiratory infections due to poor diaphragmatic function. Procedure: Anesthesia: General anesthesia is administered. Incision: A surgical incision is made in the chest wall (thoracotomy or minimally invasive approach). Plication: The diaphragm is folded and sutured to reduce its elevated position and restore tension, thereby improving its function. Closure: The incision is closed, and postoperative care is initiated. Outcome: Improved respiratory mechanics, reduced symptoms, and better quality of life.. Video-Assisted Thoracoscopic Surgery (VATS): Indication: Preferred for less invasive approach, suitable for selected patients with symptomatic eventration. Procedure: Anesthesia: General anesthesia is administered. Small Incisions: Several small incisions are made to insert a thoracoscope and surgical instruments. Plication: The diaphragm is visualized and plicated using minimally invasive techniques. Closure: Incisions are closed, and postoperative care is initiated. Outcome: Shorter recovery time, less postoperative pain, and similar benefits to open plication. Laparoscopic Diaphragmatic Plication: Indication: Suitable for patients with eventration affecting the lower part of the diaphragm. Procedure: Anesthesia: General anesthesia is administered. Trocar Insertion: Several small incisions are made to insert laparoscopic instruments. Plication: The diaphragm is accessed from the abdominal cavity and plicated. Closure: Incisions are closed, and postoperative care is initiated. Outcome: Minimally invasive, faster recovery, and effective symptom relief  Post operative care Generally the main aims in the postoperative phase are to maintain adequate ventilation, to assist in the removal of any excess lung secretions and to aid in the general positioning, bed mobility and early ambulation of the patient. Prevention of reduced joint movements or poor posture secondary to incisions or tubes, monitoring of adequate pain relief and appropriate oxygen therapy and humidification are also very important.  Postoperative Care 1. Pain Management: Medications: Analgesics and anti-inflammatory drugs to manage postoperative pain. Monitoring: Regular assessment to adjust pain management strategies as needed. 2. Respiratory Support: Supplemental Oxygen: If needed, to support breathing immediately after surgery. Incentive Spirometry: Exercises to encourage deep breathing and prevent lung complications. 3. Physical Therapy: Early Mobilization: Encouraging movement to prevent complications like deep vein thrombosis. Breathing Exercises: Continued respiratory therapy to enhance recovery.  Role of Physical Therapy in Diaphragmatic Eventration Following Laparatomy and thoracotomy, there is overwhelming evidence of changes in lung function and associated clinical manifestations. These changes include characteristic reduction in lung volume which is primarily restrictive in nature, reduction in functional residual capacity, slowing of mucociliary clearance, and abnormalities in gaseous exchange] Other frequently observed postoperative complications are post-thoracotomy pain syndrome and ipsilateral reduction in upper extremity range of motion and strength. Assessment is primarily focused on physical examination, chest expansion ABG analysis, pulmonary function test, chest X-ray, SpO2 (oxygen saturation),  peripheral muscle strength and cardiopulmonary exercise testing In the preoperative phase, physical examination should address the presence of dyspnoea, exercise tolerance, cough, and expectoration. Examination should also focus on respiratory rate, pattern of breathing, and wheezing. Patient may show either normal or altered breathing pattern on physical examination. Postoperatively, patients usually present with monotonous shallow breathing without spontaneous deep breaths, increase in respiratory rate, decreased tidal volume, and significant change in minute ventilation. Wheeze, rales, or prolonged breath sounds will be revealed on auscultation  Key Physical Therapy Interventions A. Breathing Exercises Deep breathing exercises are taught to the patients and can help to obtain full expansion of the chest wall during spontaneous breathing. This is essential to help restore lung function and to prevent subsequent chest deformity. Incentive spirometry Active cycle of breathing (ACBT) Thoracic expansion exercises Coughing and Huffing Technique 1. Diaphragmatic Breathing: Technique: Patients are taught to breathe deeply, focusing on expanding the diaphragm rather than the chest. Benefits: Enhances diaphragm strength and reduces shallow, inefficient breathing patterns. 2. Pursed-Lip Breathing: Technique: Patients inhale through the nose and exhale slowly through pursed lips. Benefits: Helps maintain airway pressure, improves gas exchange, and reduces breathlessness. 3. Inspiratory Muscle Training: Technique: Using devices like incentive spirometers or resistive breathing trainers to strengthen inspiratory muscles. Benefits: Increases the endurance and strength of the respiratory muscles. B. Chest Physiotherapy: 1. Postural Drainage: Technique: Positioning the patient to use gravity to help drain secretions from the lungs. Benefits: Clears mucus and improves lung function. 2. Percussion and Vibration: Technique: Gentle clapping on the chest and using vibration devices to loosen mucus. Benefits: Aids in the clearance of respiratory secretions.  C. General Physical Conditioning 1. Aerobic Exercises: Activities: Walking, cycling, or swimming tailored to the patient's capability. Benefits: Improves cardiovascular fitness, enhances overall endurance, and promotes lung function. 2. Strength Training: Activities: Resistance exercises focusing on both upper and lower body muscles. Benefits: Enhances muscular strength, which can support better respiratory mechanics and physical function. 3. Flexibility Exercises: Activities: Stretching routines to improve flexibility and prevent stiffness. Benefits: Promotes better posture and reduces the risk of musculoskeletal issues. D. Postoperative Physical Therapy : 1. Early Mobilization: With the development of laparoscopic surgery, improved anaesthetic and pain management many patients are often able to mobilize independently from a very early stage postoperatively. A graduated walking programmed adapted to suit each patient should be encouraged with the introduction of stair climbing at an appropriate stage. It is established that delaying early mobilization caused an increase in post- operative pulmonary complications. Technique: Encouraging patients to get out of bed and move as soon as possible after surgery. Benefits: Reduces the risk of complications like deep vein thrombosis and accelerates recovery. 2. Breathing Exercises: Technique: Continued focus on diaphragmatic breathing and incentive spirometry. Benefits: Maintains and improves respiratory function during recovery. 3. Gradual Increase in Activity: Technique: Step-by-step increase in physical activities based on patient tolerance and recovery progress. Benefits: Ensures safe and effective recovery while rebuilding strength and endurance. 4. Transcutaneous electrical nerve stimulation (TENS): TENS is a non- invasive analgesia technique that produces a significant reduction in pain. The use of TENS has been shown to decrease pain from shoulder flexion in patients undergoing axillary thoracotomy.  E. Education and Self-Management: 1. Patient Education: Includes Information on the importance of physical therapy, correct breathing techniques, and exercise routines. Benefits: Empowers patients to take an active role in their recovery and long-term management. 2. Self-Management Strategies: Techniques to manage symptoms, use of assistive devices, and incorporating exercises into daily routines. Benefits: Promotes long-term adherence to therapeutic exercises and lifestyle modifications.  Questions Enumerate functions of diaphragm? How many diaphragm in human body? Mention origin & insertion & nerve supply for diaphragm? Define bounders of thoracic inlet? Mention structures passing in diaphragm? Compare between diaphragmatic hernia & eventration. What are roles of physical therapy post-operative for diaphragmatic hernia? 1. References KuoJen Tsao MD, Kevin P. Lally MD, in Ashcraft's Pediatric Surgery (Fifth Edition), 2010 2. Welsford. 2015. [online] Emedicine.medscape.com. Available at: https://emedicine.medscape.com/article/ 822999- treatment [Accessed 15 Feb. 2020] 3. González PE, Novoa NM, Varela G. Transcutaneous Electrical Nerve Stimulation Reduces Post-Thoracotomy Ipsilateral Shoulder Pain. A Prospective Randomized Study. Archivos de Bronconeumología (English Edition). 2015;51(12):621-6. 4. Haines KJ, Skinner EH, Berney S, Austin Health POST Study Investigators. Association of postoperative pulmonary complications with delayed mobilisation following major abdominal surgery: an observational cohort study. Physiotherapy. 2013;99(2):119-25. 5. González PE, Novoa NM, Varela G. Transcutaneous Electrical Nerve Stimulation Reduces Post-Thoracotomy Ipsilateral Shoulder Pain. A Prospective Randomized Study. Archivos de Bronconeumología (English Edition). 2015;51(12):621-6. 6. Chandrasekharan, P. K.,Rawat, M., Madappa, R., Rothstein, D. H., & Lakshminrusimha, S. (2017).Congenital diaphragmatic hernia – a review DOI: http://doi.org/10.1186/s40748-017-0045-1 7. Congenitaldiaphragmatic hernia. (n.d.). http://www.hopkinschildrens.org/congenital-diaphragmatic-hernia.aspx 8. Congenitaldiaphragmatic hernia. (n.d.) Johnson,C. D., & Ellis, H. (1988). Acquired hernias of the diaphragm. DOI: http://www.mottchildren.org/conditions-treatments/congenital-diaphragmatic-hernia 9. Katukuri, G. R., Madireddi,J., Agarwal, S., Kareem, H., & Devasia, T. (2016). Delayed diagnosis ofleft-sided diaphragmatic hernia in an elderly adult with no history of trauma.DOI: http://doi.org/10.7860/JCDR/2016/17506.7544