Diaphragm

By Professor Nzarubara
 Diaphragm
• Diaphragm is a curved, musculotendinous
sheet intervening between the thoracic and
abdominal cavities.
• All those structures passing from thorax to
abdomen either penetrate the diaphragm or
pass behind it.
 Diaphragm
• Viewed from the front, the diaphragm curves
up into right and left domes.
• Right is higher than the left, ascending in full
expiration as high as the nipple (4th
intercostals space) while the left dome
reaches the 5th rib.
• Central tendon is level with the xiphisternal
joint.
 Diaphragm
• As the diaphragm contracts, the height of the
domes decreases and the volume of the
thorax increases.
 Development
• The diaphragm develops from tissues derived
from four sources: Septum transversum forms
the central tendon and most of the muscular
part of the diaphragm anterior to it.
 Development
• Dorsal mesentery of the oesophagus or
meso-oesophagus contributes to the median
portion of the diaphragm behind the central
tendon around the oesophageal and caval
openings.
 Development
• Pleuroperitoneal membranes grow from the
walls of the pleuroperitoneal canals toward
the posterolateral edge of the septum
transversum.
• They close off the communication between
the pleural and peritoneal parts of the
coelomic cavities peripherally.
 Development
• The most peripheral muscular parts of the
diaphragm are derived from the somatic
mesoderm of the body wall.
 Origin or attachments
• Fibers of the diaphragm are arranged radially
around a central tendon and their origin is
divided from three parts: sternal, costal and
lumbar portions.
Crura of the diaphragm
 Origin or attachments
• Sternal part arises from the posterior surface
of the xiphoid process and runs upward and
backward to insert into the central tendon.
 Origin or attachments
• Costal portion arises from the inner surface of
the 7th, 8th and 9th costal cartilages and the
distal ends of the last three ribs.
• Between the origin from the 12th rib and the
origin from the vertebral column, the
muscular fibers arise from arcuate ligaments.
 Origin or attachments
• Lateral ligament extends across the quadratus
lumborum from the 12th rib to the transverse
process of the 1st lumbar vertebra.
• Medial arcuate ligament extends from these
transverse processes across the psoas major
to the side body of lumbar L1 or L2 vertebra.
 Origin or attachments
• Lumbar part arises by two crura which are
tendinous in their lower parts where they are
to the front of the vertebral column and
becoming muscular as they curve upward into
the diaphragm.
• The crura are separated by a gap, the aortic
hiatus.
 Origin or attachments
• Right crus is usually wider and about one
vertebral segment longer than the left crus
and is attached to the front of the upper three
or four lumbar vertebrae.
 Origin or attachments
• At the 12th thoracic vertebra, the two crura are
united over the front of the aortic hiatus by a
tendinous arch known as the median arcuate
ligament.
• Beyond this, muscular fibres derived from the
right crus spread out to pass on both sides of
the oesophageal hiatus to form a sphincter.
Crura of the diaphragm
 Openings in the diaphragm
• Structures that pass from thoracic to
abdominal cavity do so through three large
named apertures and through several
unnamed openings. The three major openings
are aortic, oesophageal and vena caval
openings.
Attachments of the diaphragm
 aortic opening
• It is located behind rather than within the
diaphragm.
• It is enclosed by 12th thoracic vertebra, two
crura, and median arcuate ligament.
• Through it descend the aorta, changing its
name from thoracic to abdominal aorta,
thoracic duct and azygos vein.
 oesophageal hiatus
• It lies slightly to the left of the midline and is
enclosed by the insertion of the medial fibers
of the right crus into the central tendon.
• It lies at the level of the 10th thoracic vertebra.
• Through it pass oesophagus, vagal trunks,
oesophageal branches of the left gastric
vessels and the accompanying lymphatics.
 Vena caval opening
• This opening for inferior vena cava lies at the
level of the 8th thoracic vertebra just to the
right of the midline.
• Branches of the right phrenic nerve pass
through it.
 Other openings
• Greater, lesser and lowest splanchnic nerves
pierce the crura;
• Sympathetic trunks pass posterior to the
medial arcuate ligament on each side
• Superior epigastric vessels pass between the
sternal and costal origins of the diaphragm.
• Left phrenic pierces the left dome.
 Relations
• The upper surface of the diaphragm is largely
covered by pleura and pericardium and through
these it is in contact with the base of the lungs
and heart.
• The lower surface is in part adherent to the
peritoneum and thereby in contact with the
liver, stomach and spleen.
• Posteriorly are the supra renal glands and the
kidneys.
 respiration
• During inspiration, reduction of intrathoracic
pressure is brought about by increases in the
anteroposterior (pump handle movement),
lateral (bucket handle movement) and vertical
diameters of the thoracic cavity.
The different ways in which the capacity of the thoracic cavity is
increased during inspiration
 Actions of the diaphragm
1. The major role of the diaphragm is for inspiration.
2. Contractions of the diaphragm assists the anterior
abdominal in raising intraabdominal pressure for
purposes of defecation, parturition and weight
lifting
3. Descent of the diaphragm increases intra
abdominal pressure but decreases intra thoracic
pressure and this greatly aids in venous return to
the heart
 Arterial blood supply
• Arterial blood supply to the diaphragm is from
vessels that arise superiorly and inferiorly to
it.
• From above, pericardiacophrenic and
musculophrenic arteries supply the
diaphragm. These vessels are branches of the
internal thoracic arteries.
 Arterial blood supply
• Superior phrenic arteries, which arise directly
from lower parts of the thoracic aorta, and
small branches from the lower five intercostal
and subcostal arteries.
• The largest arteries supplying the diaphragm
arise from below it.
• These arteries are the inferior phrenic arteries,
which branch directly from the abdominal
aorta.
 Venous drainage
• Venous drainage of the diaphragm is by veins
that generally parallel the arteries.
• The veins drain into: the brachiocephalic veins
in the neck; the azygos system of veins; or
abdominal veins (left suprarenal vein and
inferior vena cava).
 Innervation
• Motor innervation is from the phrenic nerves
(C3, 4 and 5) only.
• Sensory innervation to the large central part
of the diaphragm is from the phrenic nerves
and for the peripheral part; it is from the twigs
from the intercostals nerves.
 Innervation
• Pain from the central part of the diaphragm is
referred to the base of the neck and to the
shoulder.
• These are cutaneous areas supplied by the 3rd
to 5th cervical nerves.
• Pain from the periphery of the diaphragm is
referred to the costal area or the anterior
abdominal wall.
 Congenital diaphragmatic hernias
• Common sites for congenital hernias are at the
junction of the lumbar and costal parts of the
diaphragm at the 12th rib.
• If the lumbar and the costal elements fail to
fuse, there will be a gap here known as
Bochdalek’s foramen. It is common on the left.
• Another possible but smaller hernial sites is at
the junction of the costal and xiphoid origins
known as Morgagni’s foramen.
 acquired diaphragmatic hernias
• Acquired ones are the sliding type of hiatus
hernia through the oesophageal opening,
gliding or paraoesophageal type and mixed
type.