The high position of the right dome of the diaphragm is the cause. Fluorographic diagnosis of diaphragm diseases

Relaxation of the diaphragm is a thinning and displacement of it along with the organs adjacent to it abdominal cavity into the chest, which requires treatment of this disease. The diaphragm attachment line remains in its usual place. the disease can be congenital (due to underdevelopment or complete aplasia of the diaphragm muscles) and acquired (usually as a result of damage to the phrenic nerve).

Relaxation can also be complete (total) when struck and moved to chest the entire dome of the diaphragm (usually the left) or partial (limited) with thinning of any of its sections (usually the anteromedial right). In this article we will discuss the treatment of the disease using modern methods.

Symptoms of development of diaphragm relaxation

With this disease, compression of the lung on the affected side and displacement of the mediastinum to the opposite side occurs. As a result of this, transverse and longitudinal volvulus of the stomach (the cardiac and antral sections are located at the same level) or volvulus of the splenic flexure of the colon may occur.

Limited right-sided relaxation of the diaphragm is asymptomatic. If it is left-sided, the symptoms are the same as with a diaphragmatic hernia. Due to the absence of a hernial orifice, strangulation is impossible.

Diagnosis of diaphragm relaxation

The diagnosis is made based on the presence of classic symptoms of diaphragm relaxation:

movement of the abdominal organs to the corresponding half of the chest,

compression of the lung,

displacement of mediastinal organs.

X-ray examination and computed tomography are the main methods that confirm the symptoms of the disease. When applying diagnostic pneumoperitoneum over organs displaced into the chest, the shadow of the diaphragm is determined. The limited right-sided form of the disease is differentiated from

tumors

And lung cysts,

pericardium,

Features of diaphragm relaxation treatment

Treatment of the disease in the presence of pronounced clinical symptoms is surgical. The operation consists of bringing down displaced abdominal organs V normal position and the formation of a duplication of a thinned diaphragm or its plastic strengthening with a mesh of synthetic non-absorbable materials. Timely relaxation treatment promises complete recovery.

Relaxation of the diaphragm - thinning of the diaphragm and its displacement along with the adjacent

from the abdominal organs into the chest. The diaphragm attachment line remains

in the usual place.

Relaxation can be congenital (due to underdevelopment or complete muscle aplasia

diaphragm) and acquired (usually as a result of damage to the diaphragm

Relaxation can be complete (total) when it is struck and moved to the chest

cell the entire dome of the diaphragm (usually the left one), and partially (limited) with

thinning of any of its sections (usually the anteromedial right).

When the diaphragm relaxes, compression of the lung on the affected side occurs and

displacement of the mediastinum to the opposite side, transverse and

longitudinal volvulus of the stomach (cardiac and antral sections are located on

one level), volvulus of the splenic flexure of the colon.

Clinic and diagnosis: limited right-sided relaxation occurs

asymptomatic. With left-sided relaxation, the symptoms are the same as with

diaphragmatic hernia. Due to the absence of a hernial orifice, strangulation is impossible.

The diagnosis is made based on the presence of symptoms of movement of the abdominal organs into

the corresponding half of the chest, compression of the lung, displacement of organs

mediastinum. X-ray examination is the main method

confirming the diagnosis. When applying diagnostic pneumoperitoneum over

The shadow of the diaphragm is determined by the organs moved into the chest. Limited

right-sided relaxation is differentiated from lung tumors and cysts,

pericardium, liver.

Treatment: in the presence of severe clinical symptoms, surgical

treatment. The operation consists of bringing down the displaced abdominal organs into

normal position and formation of duplication of a thinned diaphragm or

its plastic strengthening with a mesh of polyvinyl alcohol (Ayvalon), skin,

muscle or musculoperiosteal-pleural flap (autoplasty).

More on the topic DIAPHRAGM RELAXATION:

FUNCTIONAL INSUFFICIENCY OF THE MUSCLES OF THE PELVIC DIAPHRAGM AND DESCRIPTION OF THE INTERNAL FEMALE GENITAL ORGANS
Abstract. Hiatal hernia Chelyabinsk State Medical Academy, Department of Faculty Therapy, Head of the Department, Doctor of Medical Sciences, Professor Sinitsyn S.P. Teacher Candidate of Medical Sciences Evdokimov V.G., Chelyabinsk 2005, 2005

DIAPHRAGM RELAXATION

Relaxation of the diaphragm was first described by Jean Petit in 1774, meaning by this concept complete relaxation domes and its high standing. IN clinical practice They also use terms such as “eventration of the diaphragm”, “primary diaphragm”, “megaphrenia”, and to designate limited protrusions of the dome of the diaphragm - the terms “limited relaxation of the diaphragm”, “partial eventration”, “soft” diaphragm, “diaphragm diverticulum” etc. The term diaphragm relaxation has received the greatest clinical recognition.

The basis of this disease is the inferiority of the muscular elements of the diaphragm. Relaxation can be congenital or acquired. Neuman (1919) considered aplasia or intrauterine injury of the phrenic nerve to be the cause of congenital underdevelopment of the diaphragm.

According to researchers, congenital relaxation is due to the constitutional inferiority of the diaphragm muscles, which subsequently leads to a secondary upward displacement. P. A. Kupriyanov (1960) considers the cause of relaxation to be a developmental defect consisting in the absence of muscle and tendon tissue in the dome of the diaphragm.

Relaxation of acquired character is a consequence of inferiority muscle tissue diaphragm that occurs due to atrophic and dystrophic changes in the muscles, when inflammatory changes from the serous membranes transfer to it or due to independent inflammatory processes in the diaphragm, the important point is diaphragm injury. As a result of injury to the phrenic nerve, of any origin (surgery, inflammatory or tumor process), secondary neurotic muscle dystrophy develops, thinning, impaired mobility and subsequent high standing of the dome of the diaphragm.

For a long time, relaxation of the diaphragm was considered as a low-symptomatic or even asymptomatic disease, and, in contrast to diaphragmatic hernia, did not pose a threat to the patient’s life. However, along with an asymptomatic course, there are forms that are clinically manifested by disorders in the digestive, respiratory, cardiovascular and a number of other systems.

Symptoms of relaxation depend on the displacement of the diaphragm and adjacent organs. In each individual case, what comes to the fore is certain group symptoms from those organs whose function is most impaired. Depending on this, three groups of disorders are distinguished: respiratory, cardiovascular and gastrointestinal.

In the anamnesis of persons suffering from this pathology, a long course of concomitant disease, an indication of past trauma to the abdomen or chest, pleurisy, tuberculosis. It should be emphasized that pleurisy can be simulated by the relaxation of the diaphragm itself.

B.V. Petrovsky and co-authors (1965) distinguish 4 forms clinical course relaxation of the diaphragm: asymptomatic, with erased clinical manifestations, with pronounced clinical symptoms and complicated (gastric volvulus, gastric ulcer, bleeding, etc.). In children they are isolated special form with severe cardiorespiratory disorders. Clinical symptoms depend on the location and degree of relaxation. It is known that left-sided relaxation is accompanied by more severe disorders.

General complaints are characterized by attacks of pain, weight loss, sometimes attacks of weakness, up to fainting, palpitations, shortness of breath, cough. They are caused by the displacement and rotation of the heart, as well as the exclusion of half of the diaphragm from breathing.

From the outside gastrointestinal tract the leading clinical symptoms are a feeling of heaviness after eating, frequent belching, hiccups, heartburn, rumbling in the abdomen, nausea, vomiting, flatulence and constipation, dysphagia and recurrent gastrointestinal bleeding. The cause of these complaints is loss of the dynamic function of the diaphragm, kinking of the abdominal esophagus, volvulus of the stomach with distension and impaired circulation, the presence of ulcers, erosive gastritis or venous stasis and gastric bleeding. Even cases of gastric gangrene have been described.

An objective examination reveals Hoover's symptoms - a stronger deviation of the left costal arch upward and outward when inhaling. Percussion notes the increase and upward displacement of Traube's space. Bottom line the lungs in front are raised upward to the II-IV rib, the border of cardiac dullness is shifted to the right. Auscultation reveals muffled heart sounds, decreased breathing, bowel sounds, and rumbling or splashing sounds over the chest.

Instrumental studies make it possible to identify violations external respiration, especially vital. The electrocardiogram of such patients is characterized by slowing of intraventricular conduction, impaired coronary circulation and the appearance of extrasystoles.

X-ray examination is decisive in the diagnosis of relaxation, and the following symptoms are important: 1) persistent increase in the level of location of the corresponding dome of the diaphragm to 2-3 ribs; 2) in horizontal position the diaphragm and adjacent organs shift upward; 3) the contours of the diaphragm represent a smooth, continuous arcuate line. Compression of the lung and displacement of the heart to the right are often detected.

Characteristic radiological sign is the Alyshevsky-Winbeck symptom - paradoxical movements of the diaphragm, that is, rise with deep breath and lowering as you exhale. Paradoxical movements of the diaphragm are better identified when performing a functional Müller test - inhalation with the glottis closed, in contrast to the opposite direction of movement of the diaphragm on the affected side - Wellman's symptom. Holding your breath at the height of inspiration causes the modified half of the diaphragm to move upward due to retraction force lung tissue- Dillon's sign.

With a contrast study of the stomach in the Trendelenburg position, Funstein's symptom is determined - contrast agent spreads in the stomach, following the contours of the dome of the diaphragm. An important point is also the identification of movement of the stomach into the chest, bending of the abdominal region, esophagus, displacement of the pylorus and bending of the stomach “cascade stomach”, as well as movement of the transverse colon, especially its splenic angle.

To carry out differential diagnosis, pneumoperitopeum, pyelography, X-ray kymography and various functional tests. Pneumoperitoneum is of significant value, allowing a layer of gas to separate the dome of the diaphragm from the adjacent organs.

Local or limited relaxation of the diaphragm is observed mainly on the right. In this case, the dome of the diaphragm protrudes in an arched manner towards the lung, and the liver is deformed, repeating the shape of the relaxation area, and is wedged into the area raised upward. This circumstance often causes diagnostic errors, since the area of limited relaxation of the diaphragm is often mistaken for echinococcosis of the liver.

According to a number of authors, the following diseases are the cause of limited relaxation: echinococcosis of the liver and spleen, diaphragmatic-mediastinal adhesions, subphrenic abscess, supradiaphragmatic encysted effusion, pericardial cysts, changes in the lungs, limited hypoplasia of the diaphragm and other diseases.

Anufriev Igor Ivanovich - leading specialist in the treatment of encysted pleurisy

Anufriev Igor Ivanovich Candidate of Medical Sciences, pulmonologist of the highest qualification category

Gorblyansky Yuri Yuryevich - leading specialist in the treatment of encysted pleurisy

Gorblyansky Yuri Yurievich Head of the Department of Occupational Diseases of Rostov State Medical University, Honored Doctor Russian Federation, manager therapeutic department State Healthcare Institution "Center" rehabilitation medicine and rehabilitation No. 2"

Bokhanova Elena Grigorievna – leading specialist in the treatment of encysted pleurisy

Bokhanova Elena Grigorievna Candidate of Medical Sciences, Head of the Therapeutic Department of the Federal Medical and Biological Agency of Russia, Assistant at the Department of Propaedeutics of Internal Diseases of Rostov State Medical University

Book: “Diseases of the respiratory system VOLUME 2” (N.R. Paleev; 1989)

In the area of the cardiophrenic sinuses there are paramediastinal, diaphragmatic, interlobar and paracostal pleural sacs. The liquid formed in pleural cavity at different pathological processes, accumulates in the lowest located areas and often encystes at the level of the cardiophrenic sinuses.

Most often, fluid in the inferomedial part of the main interlobar fissure at the junction with the diaphragm is subjected to encystation. Radiologically, these encysted effusions appear in direct projection as a semicircular or semi-oval darkening adjacent to the shadow of the heart and diaphragm. When sufficiently large, this darkening lengthens somewhat during deep inhalation and flattens during exhalation; at small sizes After encystation, these changes are hardly noticeable. The mobility of the corresponding dome of the diaphragm in the presence of such an encystment is usually somewhat limited, especially in the medial section. The anterior costophrenic sinus is usually obliterated.

The most demonstrative X-ray picture is in the lateral projection, especially on tomograms. In most cases, the darkening takes on a shape close to triangular. One side of this triangle is adjacent to the diaphragm, the other to the anterior chest wall, and its apex is directed towards the interlobar fissure. The pleura in this fissure is usually thickened over a considerable extent (Fig. 11.5). Careful analysis of radiographs and tomograms often reveals compaction of the pleura in other parts. The X-ray picture of diaphragmatic-interlobar encysted pleurisy when using a multi-projection study is usually so typical that there is no need to use any additional methods research to establish a diagnosis. If, in the presence of encysted effusion, the outlines of the darkening are clear, smooth and convex in places, as a result of which diagnostic difficulties may arise, then with the organization of effusion and the formation of pleural cords, the contours become unclear, angular, retracted, and the x-ray picture loses its resemblance to space-occupying formations of the cardiophrenic sinuses (tumors, cysts, etc.).

Epiphrenic diverticula of the esophagus

Epiphrenic diverticula of the esophagus are stable protrusions of its wall, forming additional cavities above the diaphragm, often projected in the area of the cardiophrenic sinuses (especially on the right). These congenital formations belong to the group of true diverticula: their walls contain all layers of the esophageal wall. Any factors contribute to an increase in their size. causing an increase intraesophageal pressure. In large epiphrenic diverticula, food may be retained for long term, which determines bad smell from the mouth, regurgitation, heaviness and pain behind the sternum.

X-ray examination of large epiphrenic diverticula in the projection of the cardiophrenic sinuses reveals an additional shadow of a semicircular or semioval shape, of medium or high intensity. If the diverticulum is filled with food. masses, the darkening structure can be uniform. When it is partially emptied of food and air penetrates, the structure becomes heterogeneous; sometimes a horizontal level is observed at the border of the liquid and gaseous media. In the lateral projection, the shadow of the diverticulum is located in the anterior part posterior mediastinum(the so-called Holtzknecht's space), usually anterior to the esophagus. In elderly and old age with a tortuous and elongated aorta, the shadow of an epiphrenic diverticulum is projected against the background anterior section mediastinum. In these cases, the esophagus moves anteriorly and the diverticulum emanating from its anterior wall turns out to be located against the background of the shadow of the heart. Sometimes the contour of the diverticulum reaches the anterior chest wall. The method of choice in clarifying the diagnosis is a contrast study using a barium suspension. The penetration of the latter into the cavity of the diverticulum resolves the differential diagnostic difficulties that often arise when analyzing the x-ray picture (Fig. 11.6).

It should, however, be borne in mind that sometimes a spasm of the neck of the diverticulum occurs or compression of the neck by its mass, and the contrast agent does not penetrate into the protrusion cavity during orthoposition. In these cases, it is advisable to conduct a study with a trochoscope with the patient in the supine position; V in some cases it is necessary to induce artificial hypotension of the esophageal muscles by inhaling amyl nitrate, subcutaneous administration atropine or taking 2-3 Aeron tablets under the tongue 20-30 minutes before the test.

Local relaxation of the right dome of the diaphragm

The source of diagnostic and sometimes therapeutic errors in the analysis pathological formations the right cardiophrenic sinus can be served by relaxation of the dome of the diaphragm in a typical place - its anteromedial section. When relaxing the right dome of the diaphragm in a limited area (for 5-7 cm or slightly more) in the corresponding cardiophrenic sinus, an additional semi-oval darkening is revealed, adjacent medially to the shadow of the heart, with a base directed downward and a convex arched clear upper border. In the lateral projection, the darkening is located anteriorly, corresponding to the anterior costophrenic sinus.

The anatomical substrate of this darkening is the liver tissue, which bulges following the relaxed portion of the dome of the diaphragm. The latter in this area is thinned, its muscle base atrophied, partially replaced connective tissue. The contractility of the diaphragm in the protruding section is weakened. The cause of relaxation of the right dome of the diaphragm may be local congenital muscle weakness, which is confirmed by the finding of this anomaly in newborns. With underdevelopment of one of the muscle groups of the diaphragm, the corresponding section of the dome turns out to be functionally defective and bulges upward under the influence of the difference between positive intra-abdominal and negative intrathoracic pressure [Manafov S. S., 1967].

Local relaxation of the right dome of the diaphragm usually does not give subjective sensations and turns out to be an accidental finding during x-ray examination. The right dome of the diaphragm forms two arched contours: medial (due to relaxation) and lateral (due to the rest of the diaphragm). The angle between these arcs is usually obtuse. The contour of the diaphragm dome is not interrupted throughout its entire length (Fig. 11.7). When inhaling, both arches descend downwards, the medial one lags slightly at the end of the inhalation phase and becomes more pronounced.

Local relaxation of the right dome of the diaphragm is sometimes regarded as a liver tumor or cyst. There are known cases of operations undertaken for suspected liver hydatid, while the patients actually had the indicated anomaly. By selection method differential diagnosis local relaxation and liver tumors, as well as tumors and cysts of the diaphragm is diagnostic pneumoperitoneum. Gas injected into the abdominal cavity separates the diaphragm from the liver and allows the condition of both organs to be assessed. In case of pronounced swelling of the liver tissue, radionuclide and ultrasonic methods research, as well as computed tomography(Fig. 11.8).

Differential diagnosis of diaphragmatic hernia or hernia hiatus diaphragms are carried out using contrast study digestive tract.

The relaxation of the diaphragm was first described by Jean Petit in 1774, meaning by this concept the complete relaxation of the domes and its high standing. In clinical practice, such terms as “eventration of the diaphragm”, “primary diaphragm”, “megaphrenia” are used, and to denote limited protrusions of the dome of the diaphragm - the terms “limited relaxation of the diaphragm”, “partial eventration”, “soft” diaphragm, “ diverticulum of the diaphragm”, etc. The term relaxation of the diaphragm has received the greatest clinical recognition.

Relaxation of an acquired nature is a consequence of the inferiority of the muscle tissue of the diaphragm, which occurs in connection with atrophic and dystrophic changes in the muscles, when inflammatory changes from the serous membranes transfer to it, or as a result of independent inflammatory processes in the diaphragm; an important point is injury to the diaphragm. As a result of injury to the phrenic nerve, of any origin (surgery, inflammatory or tumor process), secondary neurotic muscle dystrophy develops, thinning, impaired mobility and subsequent high standing of the dome of the diaphragm.

Symptoms of relaxation depend on the displacement of the diaphragm and adjacent organs. In each individual case, a certain group of symptoms from those organs whose function is most impaired comes to the fore. Depending on this, three groups of disorders are distinguished: respiratory, cardiovascular and gastrointestinal.

IN medical history persons suffering from this pathology note a long course of concomitant illness, an indication of past trauma to the abdomen or chest, pleurisy, tuberculosis. It should be emphasized that pleurisy can be simulated by the relaxation of the diaphragm itself.

B.V. Petrovsky and co-authors (1965) distinguish 4 forms clinical course relaxation of the diaphragm: asymptomatic, with erased clinical manifestations, with pronounced clinical symptoms and complicated (gastric volvulus, gastric ulcer, bleeding, etc.). In children, there is a special form with pronounced cardiorespiratory disorders. Clinical symptoms depend on the location and degree of relaxation. It is known that left-sided relaxation is accompanied by more severe disorders.

Are common complaints are characterized by an indication of attacks of pain, weight loss, sometimes attacks of weakness, even fainting, palpitations, shortness of breath, cough. They are caused by the displacement and rotation of the heart, as well as the exclusion of half of the diaphragm from breathing.

From the gastrointestinal tract, the leading clinical symptoms are a feeling of heaviness after eating, frequent belching, hiccups, heartburn, rumbling in the abdomen, nausea, vomiting, flatulence and constipation, dysphagia and recurrent gastrointestinal bleeding. The cause of these complaints is loss of the dynamic function of the diaphragm, kinking of the abdominal esophagus, volvulus of the stomach with distension and circulatory disorders, the presence of ulcers, erosive gastritis or venous stasis and gastric bleeding. Even cases of gastric gangrene have been described.

At objective examination Hoover's symptoms are determined - a stronger deviation of the left costal arch upward and outward when inhaling. Percussion notes the increase and upward displacement of Traube's space. The lower border of the lungs in front is raised upward to the II-IV rib, the border of cardiac dullness is shifted to the right. Auscultation reveals muffled heart sounds, decreased breathing, bowel sounds, and rumbling or splashing sounds over the chest.

Instrumental studies make it possible to identify disturbances in external respiration, especially vital capacity. The electrocardiogram of such patients is characterized by slowing of intraventricular conduction, impaired coronary circulation and the appearance of extrasystoles.

X-ray examination is decisive in the diagnosis of relaxation, and the following symptoms are important: 1) a persistent increase in the level of location of the corresponding dome of the diaphragm to 2-3 ribs; 2) in a horizontal position, the diaphragm and the organs adjacent to it shift upward; 3) the contours of the diaphragm represent a smooth, continuous arcuate line. Compression of the lung and displacement of the heart to the right are often detected.

A characteristic radiological sign is the Alyshevsky-Wienbeck symptom - paradoxical movements of the diaphragm, that is, rising with deep inspiration and lowering with exhalation. Paradoxical movements of the diaphragm are better identified when performing a functional Müller test - inhalation with the glottis closed, in contrast to the opposite direction of movement of the diaphragm on the affected side - Wellman's symptom. Holding your breath at the height of inspiration causes upward movement of the changed half of the diaphragm due to the retraction force of the lung tissue - Dillon's symptom.

With a contrast study of the stomach in the Trendelenburg position, Funstein's symptom is determined - the contrast agent spreads in the stomach, following the contours of the dome of the diaphragm. An important point is also to identify the movement of the stomach into the chest, the bend of the abdominal section, the esophagus, the displacement of the pylorus and the bend of the stomach “cascade stomach”, as well as the movement of the transverse colon, especially its splenic angle.

For differential diagnosis, pneumoperitopeum, pyelography, X-ray kymography and various functional tests are used. Pneumoperitoneum is of significant value, allowing a layer of gas to separate the dome of the diaphragm from the adjacent organs.

According to some authors, the causes of limited relaxation are the following diseases: echinococcosis of the liver and spleen, diaphragmatic-mediastinal adhesions, subdiaphragmatic abscess, supraphrenic encysted effusion, pericardial cysts, changes in the lungs, limited hypoplasia of the diaphragm and other diseases.

The more frequent localization of limited protrusions in the anteromedial part of the diaphragm on the right can be explained by the fact that in this area weak muscle bundles extend from the posterior surface of the sternum. On the left, this area is covered by the parietal layer of the pericardium and the apex of the heart.

As a result of the difference in pressure in the abdominal cavity and chest, a weak section of the diaphragm on the right bulges into the chest.

The main symptom of this pathology is a partial arcuate protrusion of the anteromedial part of the diaphragm, its thinning in this area and a change in function. Accordingly, relaxation of the diaphragm marks a bulging of the liver with smooth outlines. More often, the disease is asymptomatic, but sometimes there can be various disorders, such as pain in the chest and in the heart area, cough or dyspeptic symptoms.

Treatment relaxation of the diaphragm involves surgical intervention. The indication for surgery is to establish a diagnosis of relaxation, accompanied by pain, breathing disorders, cardiovascular activity and gastrointestinal tract function. Emergency indications arise when gastric volvulus, rupture of the diaphragm, acute stomach bleeding and other serious complications.

When choosing an operative approach, preference is given to a transthoracic incision in the area of the VIII intercostal space with the intersection of the costal arch. This access is the only one possible with right-sided localization of relaxation. When relaxing the diaphragm on the left, especially in the central and anterior zones, abdominal access is used. Surgery includes plastic surgery with diaphragm tissues and autograft, as well as alloplasty.

Among the various surgical methods, the most widely used is frenopplication, the formation of a duplication after dissection or resection of a thinned area of the diaphragm. However, this operation was effective only with limited relaxations, when partially preserved diaphragm muscles were used for plastic surgery. In cases of thinning of the entire dome of the diaphragm, the risk of relapse of the disease remains.

Plastic surgery using thinned diaphragm tissue by cutting it in two mutually perpendicular directions was proposed by Lamber, West and Brosnan (1948). In this case, from the resulting four flaps, a duplication is created in the transverse, then in the longitudinal direction, forming four layers in the central part.

WITH . J. Doletsky (1959) proposed stitching the thinning zone with several rows of parallel corrugated seams. When they are tightened, the diaphragm gathers into folds and thereby ensures its strengthening and lowering of the level of location.

S. M. Lutsenko (1968) developed a method of duplication-flap tripling of the diaphragm during relaxation.

Operation technique: endotracheal anesthesia with relaxants and thoracotomy in the Vll intercostal space. First, the fusion of the diaphragm with the lung is separated. From the dome of the thinned and high-standing diaphragm present in the wound, a U-shaped flap with the base towards the spine, measuring 6-8x12-14 cm, is cut out. Then the lower surface of the diaphragm is freed from adhesions with the abdominal organs. The displaced stomach is moved to the correct position. Using two rows of U-shaped silk sutures No. 5, a duplication of the diaphragm is created by suturing the lumbocostal part of the diaphragm to its sternal part.

The resulting duplication displaces the dome of the diaphragm according to the VII-VIII rib. It is sutured to the base of the cut flap and thereby eliminates the defect. The flap is sutured with separate sutures over the duplication. In this case, the threads of a knotted two-row U-shaped seam are also used, with which both halves are hemmed s diaphragms forming duplication. This technique is positively assessed by Juvan; et al (1967), characterizing the form of sewing a pedicle flap over phrenorrhaphy as a redingote.

Thus, during the operation, a tripling of the thinned diaphragm is formed by cutting out a flap with a base at the spine, forming a duplication by suturing one part of the diaphragm over the other and then strengthening the duplication with a diaphragmatic flap.

The method of duplication-flap tripling of the diaphragm, unlike other autoplastic operations, is minimally traumatic. It makes it possible not to resort to alloplasty, which causes an exudative reaction and other complications, and also reliably eliminates relaxation of the diaphragm and eliminates associated disorders of the cardiovascular, respiratory and digestive systems.

In the complete absence of the diaphragm muscles, various plastic methods are used. Michaud et al (1955) proposed plastic surgery with a pedicled periosteal flap, and Plenk (1951) and Harti (1954) proposed a pedicled flap from the latissimus dorsi muscle, passed through an intercostal incision. There are also known attempts to use a flap from the external oblique abdominal muscle with its base at the costal arch. However, the traumatic nature of creating a muscle flap and its secondary fibrous changes do not ensure the creation of a functioning muscle barrier.

S. F. Slivnykh (1973) during relaxation used plastic surgery with preserved heterogeneous parietal peritoneum placed between the leaves of the dissected diaphragm in two cases.

Daumerie and De Backer (1949) proposed a pedicled skin flap for plastic surgery of the diaphragm. Later, this method was comprehensively studied by I. D. Korabelnikov (1951). The negative aspect of skin grafting is the danger of developing necrosis of the flap when its feeding pedicle is compressed and the inevitability of scar changes. Alloplasty of the diaphragm has been used since 1951. However, various synthetic materials (nylon, nylon) cause a pronounced exudative reaction in the pleural cavity. The original method of diaphragm alloplasty was developed by B.V. Petrovsky (1957), using a prosthesis made of polyvinyl alcohol sponge (ivalon). In this case, the ivalon plate is placed between the sheets of thinning diaphragm.

According to the authors, frenoplication provides correction of the diaphragm only with partial relaxation. With total relaxation, alloplasty is indicated according to B.V. Petrovsky using porous or mesh synthetic materials (polyvinyl alcohol, Teflon and terylene), into which connective tissue grows.

Despite the achieved results, although alloplasty creates a certain strength, it does not completely solve the problem of surgical treatment of diaphragm relaxation, since it causes an exudative reaction and requires covering the allograft with the diaphragm’s own tissues.