The thoracic diaphragm.

Ephraim MANZI, MBChB IV

Ephraim MANZI, MBChB IV
 Fibromuscular sheet; separates thoracic from abdominal cavities; for inspiration.
 The muscular part takes origin from transversus group of body wall muscles.
 The origins of the muscle fibers are;
I. Costal origin; attaches along the inside of costal margin.
II. Medial and lateral arcuate ligaments. (what are they? How do they attach?)
III. The right and left crura.
 Fibers from the crura and arcuate ligaments arch up wards to form domes, then descend to attach
to the central tendon, which lies at the level of the xiphisternal joint, level with T8 vertebra.
(anterior view)
 The right dome ascends up to fourth intercostal space, the left up to fifth rib.
 Viewed from the side, inverted J (what forms the long and short limbs?)
 Viewed from up, kidney shaped i.e. body wall is oval in cross section, indented at the back by the
vertebral column to form the kidney shape.

Ephraim MANZI, MBChB IV

  The crura; strong tendons, attach from anterolateral surfaces of upper three (right crus) and
upper two (left crus) lumbar vertebrae.
 Muscle fibers from these tendons overlap, ascend vertically upwards and then descend to the
central tendon.
 Fibers from right crus ascend on the abdominal surface of the left crus, forming a sling around
the esophageal orifice.
 The medial- most fibers from both crura arch anteriorly and medially to meet in the midline to
form the median arcuate ligament in front of the aortic orifice at the level of T12 vertebra.
 The medial arcuate ligament; thickening in the psoas fascia; from side of L1 or L2 to a ridge
on the anterior surface of the transverse process of L1 vertebra.
 The lateral arcuate ligament; thickening in the anterior layer of lumbar fascia over quadratus
lumborum; from continuation of medial arcuate, arches over the middle of the lower margin of
the twelfth rib.
 Further laterally, attach to the inner aspects of the lower six ribs in continuity with
transversus abdominis.
 Anteriorly, fibers from the xiphisternum.
 Central tendon; trefoil shape; anterior middle leaf, lateral leaves, attach to the posterior wall.
Ephraim MANZI, MBChB IV
 Blood supply;
 Costal margin fibers; lower intercostal and subcostal arteries.
 Abdominal surface of main fibers; inferior phrenic, from abdominal aorta.
 Superior phrenic from thoracic aorta, pericardiacophrenic and musculophrenic arteries al
contribute.
 Nerve supply;
 Phrenic nerve (right and left), all motor, and proprioception to central tendon.
 Lower intercostals and subcostal; proprioception to periphery.
 55% slow twitch, why?

Ephraim MANZI, MBChB IV

 Openings (orifices) in the diaphragm.
 Aortic opening; at T12, midline, Azygos vein, thoracic duct, aorta (from right to left).
 Esophageal opening;
 Opposite T10 vertebra.
 2.5cm to the left of midline, behind seventh costal cartilage.
 Located in fibers of left crus but with sling of right crus on its abdominal surface.
 Esophagus, vagal trunks, esophageal branches of left gastric artery, vein, lymphatics; fascia
transversalis from abdominal surface to thoracic, blends with endothoracic fascia, and is
attached to the esophagus 2-3cm above gastroesophageal junction; phrenoesophageal
ligament; stretched in sliding hiatus hernia.
 Site for portal-systemic anastomosis.

Ephraim MANZI, MBChB IV

 Vena caval foramen;
 Opposite T8 vertebra, right of midline, behind sixth right costal cartilage.
 Between middle and right leaf of central tendon, with right phrenic nerve.
 Other foramina
 Hemiazygos vein; left crus
 Greater, lesser and least splanchnic nerves, pierce each crus.
 Sympathetic chain, behind medial arcuate ligament
 Subcostal nerve and vessels; posterior to lateral arcuate ligament.
 Neurovascular bundles of lower five intercostal spaces pass between digitations of diaphragm
and transversus abdominis to enter abdominal neurovascular plane.
 Superior epigastric vessels pass between xiphisternal and seventh costal fibers.
 Extraperitoneal lymph nodes.

Ephraim MANZI, MBChB IV

 Embryology
 Develops from four sources;
1. Septum transversum; most of central tendon.
2. Third, fourth and fifth cervical myotomes; join septum transversum before it descends from
cervical region to the adult position.
3. Pleuroperitoneal membranes; mesodermal folds which separate thoracic from abdominal part
of embryonic coelom. Failure of these to fuse, Bochdalek’s foramen; most common type of
congenital hiatal hernia posteriorly, commonest on the left.
Foramen of Morgagni; between xiphoid and costal fibers, smaller hernia.
4. Dorsal esophageal mesentery.

Ephraim MANZI, MBChB IV

  Clinical correlates.
I. Hiccups
II. Section of a phrenic nerve
III. Referred pain from diaphragm
IV. Rupture of the diaphragm and herniation of viscera. Sliding versus Rolling.
V. Congenital diaphragmatic hernia.

Ephraim MANZI, MBChB IV