Thoracic surgery Manual

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Robert Nicolae

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Surgical Sieve

General Embryology
 Anatomy of the Thoracic cage

Thoracic wall tumors

Thoracic Incisions

Diaphragm

Early complications

Late complications

Anatomy of the lung

Thoracic wall malformations

Imaging of the Lung

Congenital Anomalies of the Lung

Lung Cancer

Interstitial Lung Disease

Infections of the Lung

Pleural Anatomy

Pleural Diagnostic Procedures

Pleural Drainage systems

Pleural Disease

Anatomy of the Larynx

Anestehsia for Airway Surgery

Endoscopy

Congenital Anomalies of the Upper Airway

Post Intubation Injury

Idiopathic Stenosis

Tracheomalacia

Inflammatory Conditions of the Upper Airway

 Laryngeal Nerve Palsy

Tracheoesophageal Fistulas

Tumors of the Upper Airways

Surgical Techniques of the Upper Airway

Mediastinum

Esophageal Anatomy

Diagnostic Studies of the Esophagus

Surgery of the Esophagus

Benign Esophageal Disease

Cancer of the Esophagus

Breast

Studies I've Encountered

Surgery of the Neck

Pericardium

Thoracic Duct

Congenital Heart Disease

Surgical techniques of lung resections

SYNDROMES ENCOUNTERED

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Anatomy of the lung
SETTINGS

CONTENT PAGE
 -First pneumonectomies were performed by mass ligation of the pulmonary hilum.

-Identification of individual structures of the hilum ensured a successful pneumonectomy.

Embryology
The lung begins in the foregut at around week 3.

Branching is seen at week 4.

Development is asymmetric because of the absorption of the left eparterial bud.
Terminal branching ensues and is 70% formed by week 17.
Alveoli appear between week 20-24.
Vascular and venous plexus is derived from splanchnic plexus.
Pulmonary arteries arise fromm the 6th Aortic arch bilaterally to connect with the pulmonary
plexus.
On the right: there is absorption of the dorsal 6th aortic arch which separates pulmonary from
systemic vasculature.

4 Histological phases of Lung Development

Pseudoglandular (5-17 weeks after fertilization)

Canalicular (16-25wks)
Terminal sac(24-40wks)
Alveolar (late fetal-8years)

THE AORTIC ARCHES



On the Left: the dorsal part of the 6th aortic arch will connect with its ventral part (left
pulmonary artery) to form the ductus arteriosus (fetal communication between the pulmonary
and systemic vascular circuits)
The Bronchopulmonary Segment
Segments are subdivisions of the lung that function as individual units because of their
own arterial supply, venous drainage, bronchus.

The bronchial anatomy is most constant.

The pulmonary artery accompanies the bronchus but is more variable.
The pulmonary venous drainage do not accompany the artery and bronchus but run in the
intersegmental planes.
 Lobes and segments
Right Lung - 3 lobes (upper, middle, lower)/10 segments
Oblique fissure - major fissure separates the lower from the upper+middle lobes - free
in 80%

Horizontal fissure - minor fissure separates the upper from the middle lobes - blocked in 70%

 Carina - bifurcation of trachea - T4 level
Intrapericardial Anatomy
Allison 1946 then Healey and Gibon 1950 - control of pulmonary vessels within the
pericardium.

Is crucial for Lung transplantation, central tumor resection, distal vascular problems.
Right PA arises from the main PA to pass posterior to Aorta and SVC. 3/4 is within the
pericardial sac, covered by serous pericardium 2/4 of its surface.
Behind the Aorta and SVC the right PA constitutes as the superior border of the transverse
sinus.
Exiting the pericardial sac behind the SVC forms the superior border of postcaval recess of
Allison.
Postcaval recess of Allison 95%
- medial - SVC
- lateral - pericardial sac
- inferior - superior pulmonary vein
Right Superior Pulmonary Vein enters pericardium covered by serous pericardium 2/3 of
circumference and drains into LEFT Atrium.
Right Inferior Pulmonary Vein covered by serous pericardium 1/3 of circomfarance or not
covered 50% is very short so mobilization from pericardial attachments and division of
the frenulum of pericardium that runs to the IVC provide additional mobility (in release of
tracheal tension). Drains into LEFT Atrium. Additional mobilization by dissection into intra-atrial
groove.

As it leaves the pericardial sac the left PA is covered by serous pericardium 1/2 of
circumference.

Left pulmonary recess:

superiorly - left PA
inferiorly - left superior pulmonary vein
laterally - fibrous pericardium
medially - fold of Marshall ( contains the remnant of the left SVC).

Left superior pulmonary vein - enters the pericardium to be covered by serous pericardium 2/3
of circumference
 Left inferior pulmonary vein - the most distinct and free of all vessles - 90% of circumference
covered by serous pericardium.

Anomalies of pulmonary arteries

PA anomalies - accompanied by anomalies of Heart + Great Vessels

Agenesis
Hypoplasia
Abnormal origin
Vascular rings causing compression
Accessory arteries from the Aorta or its branches (causes sequestration of lung, atresia with
VSD)

Anomalies of pulmonary veins

Pulmonary vein anomalies are more common

- common left pulmonary vein

- separate right pulmonary veins for upper middle lower lobes
- Anomalous drainage: into SVC, Right Atrium, Coronary Sinus, IVC, persistent left vena cava
(Marshall), systemic veins.

Right - Hillar Anatomy

The right mainstem bronchus

- takes off from the trachea at a shallow angle (20-30degrees) from the midline - continues in
line with the trachea in some cases.
- 1.5-2cm
- 15mm diameter
- Angles:
a. tracheo-bronchial angle - right margin of the trachea and superior margin of the right main
bronchus - 137 degrees
b. subcarinal angle - inferior margins of both mainstem bronchi - 71degrees
c. right subcarinal angle - inferior margin of the mainstem bronchi with middle plane - 30%
- is the most superior and posterior of the right hillar structures
- exits the mediastinum bellow the azygos vein
- terminate into RUL bronchus and bronchus intermedius
Esophagus and Vagus lie posterior to the right Hilum

Bronchial artery (systemic arteries)

- single artery arising from 3rd intercostal artery posteriorly (directly from the aorta)
- 2nd bronchial arteries (sometimes directly from the aorta or even the left superior bronchial
artery) 20%
- form a peribronchial plexus which follow the bronchus into the parenchyma supplying also
the visceral pleura and the walls of the pulmonary arteries and veins as vasa vasorum.
- also form anastomoses to pulmonary alveolar arterioles and thus drain through the pulmonary
venous system.
- supplies the esophagus, pericardium, lymphatic nodules
- sometimes we find a small bronchial artery on the anterior side of the bronchus

Venous drainage to azygous and hemiazygous but also through the pulmonary venous system.
Nervous system: sympathetic and parasympathetic (there is no plexus - Bauman)
Lymphatic system: Rouviere 1929
- mediastinal groups:
a. 7
b. 2R,4R 4-6ggl (between SVC, azygos, trachea, asc. aorta, brachiocephalic arterial trunk)
c. 9
d. anterior mediastinal (anterior to the phrenic nerve and SVC)

Relations to PA:
- Right PA passes posterior to Aorta, SVC (aorto-caval window), exits lateral to atria (Allison
retrocaval/postcaval recess), anterior and inferior to right mainstem bronchus.
- gives off RUL branches where it is anterior to the right upper lobe bronchus (eparterial
bronchus)
- interlobar portion of PA is lateral to bronchial tree

Right Pulmonary Artery (PA) has 2 parts:

- intrapericardial
- extrapericardial
 Intrapericardial Anatomy:
Right PA arises from the main PA to pass posterior to Aorta and SVC. 3/4 is within the
pericardial sac, covered by serous pericardium 2/4 of its surface.
Behind the Aorta and SVC the right PA constitutes as the superior border of the transverse
sinus.
Division of posterior fibrous pericardium - access to trachea and bronchi
Exiting the pericardial sac behind the SVC forms the superior border of postcaval recess of
Allison.

The superior pulmonary vein passes from the parenchyma to lie anterior to the PA (a little
bellow the truncus anterior branch of the right PA) overlaping the pars interlobares of the PA.
- it receives 4 branches (3 branches drain the upper lobe and 1 branch the middle lobe)
1. apical anterior vein
2. inferior anterior vein (drains the inferior surface of the anterior segment)
3. posterior deep vein - enters the vein deep from its posterior aspect

4. middle lobe vein

The inferior pulmonary vein - lies posterior and inferior to superior pulmonary vein
- it recieves 2 tributaries:
1. superior basal branches
2. common basal branches

RUL - 3 segments:
B1. apical B2. posterior B3. anterior
Perisegmental venous planes:

1. inter apico-ventral plane

2. inter apico-dorsal plane
3. inter dorso-ventral plane

Bronchi
The RUL bronchus (eparterial bronchus - the artery is anterior so the bronchus is posterior to
the artery, unlike on the left):
-arises at right angles from the main bronchus from the lateral wall
- initially bifurcates before subdividing into the 3 segmental bronchi (50%)
-Roux 1962 - anomalies of the RUL bronchus in 3% of pts. :
a. "tracheal bronchus" - most common anomaly (1.4%) - origin of the apical bronchus from
the trachea or from the main bronchus.
b. entire right upper lobe bronchus originates from the trachea (0.5%).
c. absence of a true right upper lobe bronchus (immediate division into segmental
bronchi- tree - 1.1%).
d. Azygos lobe <1% of pts. It is not a supranumerary lobe but instead is a segregation of a
portion of the RUL by an anomalous bronchobascular supply. The azygos vein has a long
mesentery.

Arteries: 2 main branches: -Milloy 1963 -

variations
a. truncus anterior (from the hilum - that's why it is sometimes called "mediastinal artery")-
first and largest branch of the right pulmonary artery supplies the apical the anterior and
sometimes the posterior segments (10%). Don't confuse this with the pulmonary artery as it can
be fairly large
Variations
-1 bifurcates after travelling 1cm 80% into a . apico-dorsal; b. ventral trunk
-2 separate branches arising from the right pulmonary artery (3.6%) : a. ventral mediastinal,
b. anterior mediastinal
-3 separate branches
b. ascending branches (from the parenchyma - interlobar portion of PA- which is anterior to
bronchus intermedius) - in only 10% may be absent
Variations:
-one ascending branch (60%) (Hovlaque's dorsal scizural artery or retrobronchial artery),
a posterior ascending branch supplying the posterior segment (88% of pts with ascending
arteries) arising from the posterior aspect of the PA opposite the middle lobe branch and lies
anterior to the junction of the inferior margin of the upper lobe bronchus and the intermedius
bronchus *may originate from a common trunk with the superior segmental artery
(Fowler) (12%).
-two ascending branches (29%)
a. posterior ascending (dorsal scizural) branch 88% of pts
b. anterior ascending (ventral scizural) branch supplying the anterior segment of the RUL
(25%) arising from the lateral aspect of the PA opposite the middle lobe branch.
1% arise from a common trunk of the middle lobe artery
 -three ascending branches (1%)

Veins:
Superior pulmonary vein drains the right upper and middle lobes. It is important to preserve this
vein when doing right upper lobectomy.
Superior pulmonary vein has two roots:
- superior root - which drains the RUL
- inferior root - which drains the ML

The superior root has 3 venous tributaries:

Two are anterior

a. apical-anterior veins - usually visible in its subpleural location on the mediastinal surface
(also called the "mediastinal venous trunk").
b. inferior veins - inferior to the anterior segmental bronchus (anterior interlobar)

One is Posterior
c. posterior veins - the largest vein formed from a large central vein that drains the upper half
of the right upper lobe and from a superficial vein located subpleurally on the interlobar aspect
of the lobe.(superior scizural)

Right Superior root vein

Right upper lobe veins
Tr. Mediastinal (anterior)

1.v. Apicala mediastinala

2. V.Inter ventro-apical
3. V.Ventrala mediastinala

Tr. Interlobar (anterior)

1. V. Interlobara marginala anterioara
2. V. Interlobara anterioara

Tr. Scizural sup

1. Tr. Central (great deep)

-v. Crestei de oprire
-v. Intersubsegmentara
- v. Interapicodorsala
2. Tr. Interlobar posterior
- mediastinala posterioara
-mediastinala interlobara
-marginala interlobara

Variante ( de constituire, de origine):

-lipsa v. Apicale mediastinale
-lipsa vv. Interlobare anterioare cu varsarea ambelor interlobare in tr scizural superior
-tr central care dreneaza in tr mediastinal
-tr interlobar dreneaza in rad inf
-absenta unui tr
-terminatii atipice ( tr interlobar post nu se uneste cu tr central ci in VPI.
Dupa Appleton avem tip preponderent mediastinal sau preponderent central





Bronchus Intermedius
2-3cm

Artery of the bronchus intermedius (80%) but it may be absent in these situations:
- when posterior ascending (dorsal scizural) has a common trunk with superior segmental
(apical inferior) artery (Fowler a).
- when anterior ascending (ventral scizural) has a common trunk with medial lobar artery.

ML - 2 segments:
B4. lateral B5. medial
Perisegmental venous planes:

1. inter medio-lateral

Bronchi

The intermedius bronchus is the portion between the origin of the RUL bronchus and the ML
bronchus or the RLL bronchus. It is 2-4cm long
The middle lobe bronchus is 1.8cm. It usually bifurcates (2 segmental bronchi)

Arteries
-Wragg 1968 - anomalies:
-one artery (46.5%) - first branch of the pars intralobares originating from the PA at the level of
the ascending branch of the upper lobe
 -two arteries is more common (51.5%) - the second artery arises from:
a. the ascending branch of the right upper lobe (0.5%)
b. common trunk with a basal segmental artery (2.5%) (this may be the recurential paracardiac
artery)

-three arteries are seen only rarely (2%).

Veins
the middle lobe vein joins the upper lobe vein to form the superior pulmonary vein.???
Lindskrog (1949)
-there are 2 segmental veins join to form the middle lobe vein (64%)
-sometimes the 2 segmental veins terminate separately at the superior pulmonary vein (36%)

Right inferior root vein -middle lobe veins

1. V.mediastinala mediala

2. Tr. Scizural inf. ( voluminos) -cheia planului de clivaj cand marea scizura este blocata)
-v laterala interlobara inf
-v interlatero mediala


Variante:

-absenta v. Mediale mediastinale

-terminatii atipice ale ramurilor rad inf
-vars rad inf in AS
- varsare separata in VPS fara formarea rad inf
-tr scizural inferior se varsa in VPI
-absenta tr scizural inf

RLL - 5 segments:
6. superior 7. medial basal 8. anterior basal 9. lateral basal 10 posterior basal
Perisegmental venous planes:

1. inter apico-basal
2. inter bazo-paracardiac
3. inter ventro-lateral
4. inter latero-terminal

Bronchi

B6 - superior segmental broncus (apical inferior bronchus of Nelson-Fowler) originates from

the posterior-lateral aspect of the bronchus intermedius (usually above the middle lobe
bronchus and has 3 subsegments:
a. superior
b. posterior
c. lateral
Boyden 1951 variation: 2 separate superior segmental bronchi 6-10mm appart (6%)
Sauvage disposition:
- Cordier - existance of a short inferior lobar bronchi 0.5cm (contested)
- cross dispozition in which apical inferior bronchi arises at the same level with medial lobar
bronchi
- ladder dispozition in which the apical inferior bronchi arises higher than the medial lobar
bronchi thus shortening the bronchus intermedius
Aeby names a supranumerary bronchus "dorsal colateral" bronchi later named by Neil et al
"subapical" bronchus. - may arise 1-2cm under inferior apical bronchus 38% in pts according to
Cordier.

common inferior lobar bronchus (pyramidal trunk): 4 segments

a. medial bazal - paracardic B7
b. anterior bazal - ventro-bazal B8
c. lateral bazal - latero-bazal B9
d. posterior bazal - termino-bazal B10

Arteries
Wragg 1968
80% 2 arteries:
a. superior segment (Fowler) supplied by a single artery (78%)/2 arteries (21%)/3 arteries
(1%). Origins of these arteries are dispersed arising as common trunks (from ascending branch
of the upper lobe (12%), from basal segmental arteries (6%)).
b. Common basal segmental artery (pyramidal trunk)
Variations:
- common trunk of Fowler with the posterior ascending (Fowler-Hovlaque connection)
- common trunk of the paracardiac with the inferior medial lobar artery

Veins
The inferior pulmonary vein has 2 segmental tributaries:
a. superior segmental vein
b. common basal veins (arising from
- superior basal vein (drains segment 8,9)
-inferior basal (drains 9+10 or 7+10 - segment 7 sometimes has its own vein leading to the
common basal vein)

Rarely venous drainage is received from the posterior segment of the RUL or from the ML.
 VPI-lata (1.8cm)si scurta(o.5) Abbey -"ca un arbust ce porneste de la sol"-risc de
derapare-se foloseste ligaturi obligatorie si pe radacini!

Rad sup a VPI

1.Tr. Inter apico-bazal (cheia planurilor de clivaj)

(-Vv. Inter apicobazale ant, post, apicale)

2.Tr intersubsegmentar apical


Rad inf a VPI

Tr. Interbazal anterior (v inter ventrolaterala + v interbazo paracardiaca)

Tr. Interbazal mijlociu (v interlateroterminala + v interbazo paracardiaca)

Tr. Interbazal posterior (v interterminosubterminala + v interbazo paracardiaca)


Variante

- confluent retroparacardiac intre tr interbazal anterior si cel mijlociu

-teritorii suplimentare subapicale, axilare
-ramuri ale rad. Sup se varsa in rad inf
-rad vpi se varsa separat in AS
- 4 vene pulmonare ( arbust)
-vp unica rar pe dreapta

Left - Hillar Anatomy

The left main bronchus (4-6cm) passes under aortic arch and bifurcates into upper and
lower lobe bronchi.

Arises at a sharper angle from the trachea (40-50degrees) from midline.

- 4-5cm (more vascularized than on the right bc of it's length-2 bronchial arteries directly frim
the aorta)
- 11mm diameter

Bronchial arteries
- 1-2 arteries from anteromedial surface of the descending aorta (one is typically dominant)
- superior branch is at level with carina
- inferior branch is at a level inferior to left mainstem bronchus.
-arcada subcarenala- anastomoze cu ram bronsic drept din tr bronhocostal
- form a peribronchial plexus which follow the bronchus into the parenchyma supplying also
the visceral pleura and the walls of the pulmonary arteries and veins as vasa vasorum.
- also form anastomoses to pulmonary alveolar arterioles and thus drain through the pulmonary
venous system.
1. A. Bronsica stg superioara
- traiect pe marg sup a bronsiei
- in contact cu fata inf a crosei si deci cu recurentul
-da incostant si ram prebronsic drept
2. A. Bronsica stg inferioara
- merge pe fata post a bronsiei impreuna cu pneumogastricul

Venous drainage to azygous and hemiazygous but also through the pulmonary venous system.
-tr venos intercostal superior= v lui braine

Ganglioni limfatici parapediculari stg

-Ggl interlobari Rouviere - marg inf a bifurcatiei BPS

-Ggl interlobari arteriali Rouviere- marg sup fata post a BPS in contact cu APS
-Ggl pe fata post a BLI

Ggl mediastinali 4 grupuri

-ggl bifurcatiei ce dreneaza in ggl laterotraheali pe partea dreapta!
-ggl mediastinali anteriori -deasupa AP inaintea BPS si sub crosa Ao.(cel mai mare se numeste
ggllui Engel al canalului arterial)
-ggl posteriori Hein si Leval-Piquet chef sunt sub crosa langa recurent pe marg sup a BPS la
originea lantului ganglionar laterotraheal stg numit lant recurential pana la crosa a. Tiroifiene inf
-ggl lig triunghiular ce primesc limfa din lob inf stg dar si din ggl mediastinali post si subdiafragm
si celiaci (dupa Vial)
Ggl paratraheal drept ( biopsie prescalenica dreapta daniels)

Relations to PA
- origin of left PA is anterior to left mainstem bronchus
- distally the PA is located laterally to bronchus
- between the bifurcation into lingular and pyramidal branches
The left PA is the most anterior in the Hilum.
Ligamentus arteriosum (remanant of ductus arteriosus) connects the Aorta and the Left PA as it
exits the pericardium.
Left recurrent laryngeal nerve loops around the aorta at the lateral margin of lig. arteriosum
 The Left Superior Pulmonary Vein
- lies anterior and inferior to the PA
- has 3 draining veins:
1. apical posterior
2. anterior
3. lingular

The Left Inferior Pulmonary Vein

- at the apex of the pulmonary ligament.
- is inferior and more posterior to the superior pulmonary vein.

Posterior Left Hilum

superiorly - pulmonary arter
middle - left main bronchus
inferiorly - left inferior pulmonary vein.
esophagus and vagus lie posteriorly behind the posterior hilum
Descending Aorta is posterior to the esophagus.

Left PA intrapericardial anatomy

APS continua conul AP (APD se detaseaza in unghi drept fiind ascunsa in spatele APS
si o lig aici poate jena circulsyia contralaterala)

Pliul vestigial Marshall leaga VPS de AP -cheia planului de clivaj in abordul intrapericardic al
APS

Left PA extrapericardial anatomy

La iesirea din pericard poate fi intalnit canalil arterial persistent botal
Canalul arterial persistent
-Lig arterial leaga crosa de APS sub nivelul recurentului in aminte de orig
a.subclaviculare stg

-Orificiul canalului pulmonar este extrapericardic, fiind chiar la iesirea APS din pericard
 Regiunea canalului arterial : trigonul Gross
Ant-n.frenic

Post-n. Vag
Inf APS=elementul cel mai superior al pedicului pulmonar, luand contact cu BPS, trece
deasupra, ocoleste B LSS si patrunde in scizura


LUL - 5 segments
1 +3. apical + posterior 2. anterior 4. superior lingular 5. inferior lingular
The lingula is the equivalent of the middle lobe and is part of the upper lobe

5 perisegmental planes:

1. inter culmino-lingular
2. inter apico-ventral
3. inter apico-dorsal
4. inter ventro-dorsal
5. inter lingular dintre segmentele lingulei

Left Upper Bronchial system

Left upper lobe bronchus bifurates after 1cm (stem) into tr. lingular and the common bronchus
of the anterior and apico-posterior segments ( tr.culminal)

Bifurcates in 75%
a. Tr culminal- left upper lobe proper subdividing into apico-posterior and anterior segmental
b. Tr lingular - inferior branch subdivides into superior and inferior lingular segments
Variants:

Trifurcates in 25%
- superior and anterior branches (apico-posterior and anterior segments)
- inferior branch subdivides into superior and inferior lingular segments

Atipical bifurcation
Tr apico-dorsal
Tr ventro-lingular
Teritorii suplimentare tip axilar ca in dr.
Sciziunea lingularei pe segmentara ventrala
Sciziuni ale trunchiului pt culmen si lingula separat din BPS dar APS patrunde printre ele si nu o
mai gasim in scizura

Left upper lobe arterial system

Clasificare: prevronsica, suprabronsica, retrobronsica
Clasificare: ramuri mediastinale si ramuri scizurale
Maxim 7 artere minim2 pt lob sup

1 mediastinala=prebronsica
-ventrala mediastinala
-apicodorsala mediastinala
2 Mediastinala suprabronsica=posterioara
3 mediastinala retrobronsica=dorsala scizurala
4 lingulare

Conventional Variants:
1. the existance of a lingular mediastinal (the artery arises from the mediastinal and supplies the
lingular lobe)
2. the existance of an apical superior artery (the zenith of the left pulmonary artery)
3. ventral scizural artery
4. two separate lingular arteries
5. inferior lingular artery arising from common trunk with paracardiac artery
6. superior lingular artery arising from common trunk with ventral scizural artery

Milloy 1968 - The most variable of all lobes (varies from 1-8 branches).
3 branches (46%);4 branches (36%) arising as two groups:

a. truncus anterior (Mediastinal) 1.5cm distal to ligamentum arteriosum

- large, short, covered by superior pulmonary vein.
- may give a hidden deep branch to anterior or lingular segments (25%) - mobilization of the
truncus anterior hazardous : "artery of sorrow"

- may be the only source 1%

- usually two branches 70%
- apical posterior segments + anterior segments supplied by truncus anterior 62%
- anterior and lingular segments supplied by truncus anterior 8%
- 3 branches by truncus anterior supply all segments of the uppper lobe 15.6%.

b. posterior segmental branches (originate in the fissure from the PA).

- 0-5 branches
- no common branches seen 65%.
- common trunks 35%
- only one posterior branch found in 5%
- 2 posterior segmental branches 46%
- 3 posterior segmental branches 36%
- 4 posterior segmental branches 12%
- 5 posterior segmental branches 1%

Veins
Superior pulmonary vein receive 2 major branches; 3 major branches; radiating veins (tree).
Veins lie anterior to PA except its deep branches.
VPS este legata de AP prin pliul Marshall, fata sa posterioara fiind in apropiere de fundul de sac
Haller
VPI are un traiect intrepericardic scurt si nu atinge marginea superioara a vasului care este
separat de VPS de un pliu "mezou"
VPS e cea mai lunga vena pulmonara avand 1cm extrapericardic
VPS are un traiect perpendicular cu AP
Se imparte in 2 radacini( rad sup si rad inf)
3/4s of pts have 3 veins draining the left upper lobe:

A. Superior root of the superior left pulmonary trunk tributaries: ( din culmen dar si din planul
de clivaj interculmino-lingular)

1. Tr. Pre-hilar
A - mediastinal
- apical -mediastinala
- inter apico-ventrala
B - central trunk
- inter apico-dorsal anterior
- inter apico-dorsal posterior
- inter ventro-apico-dorsal ("de oprire")

2. Tr Inter culmino-lingular
- ant.
 - mid.
- inf. Tr pastrat in rezectiile de culmen

B. Inferior root of the superior pulmonary vein

- lingular vein
Variante:
1. Formarea VPS din 3 trunchiuri( mediastinal, interculmino-lingular, lingular)
2.rad inf dreneaza in VPI

a. apical-posterior vein - a branch of this apical-posterior vein is called the superior hilar
vein
b. anterior vein (mediastinal) joins the apical posterior in 35% of pts or the lingular in 5% of pts
or enters the superior pulmonary vein individually in 35%. In the remaining 25% there are two
anterior veins.
c. lingular vein drains

Variations:
- single vein (25% Gibbon)

LLL - 5 segments
6. superior 7-8. medial basal + anterior basal 9. lateral basal 10 posterior basal

Perisegmental venous planes:

1. inter apico-basal nu este orizontal ci oblic in stg

2. inter bazo-paracardiac
3. inter ventro-lateral
4. inter latero-terminal

Left lower lobe Bronchi

In stg exista intotdeauna o lobara inferioara scurta de 1cm Apoi tipic se bifurca:
a. Tr apical inf =superior segmental bronchus (B6) nelson fowler bifurcates in less than 1%
so it's a single branch in nearly all pts.
- apical
- posterior
- lateral
b. common basal trunk (pyramidal trunk)
- divide in
-Tr ventro-paracardiac which alsi bifurcates into
- tr ventro -paracardiac B7 ( 2 subsegm ant si post)
-Tr ventrobazal B8 ( 2 subsegm lat si axiala)
Tr. -lateral bazal B9 (subsegm lat si ant)
Tr.-terminal bazal B10 (2 subsegm lat si axiale)

Arteries (soley from arteries arising in the

fissure)
Variations by Wragg 1968:
a. superior segmental artery may be single 72%, double in 26%, triple in 2% directly from PA
or
- in less than 3% as a common trunk with posterior artery of the LUL less common than on the
right side.
- in 12% as a common trunk with basal segmental arteries (paracardiac artery common trunk
with inferior lingular - "recurential artery")
b. basal segmental arteries bifurcates but varies from 2-4 branches

Veins
The inferior pulmonary vein receives 2 major branches:
a. The superior root of the Inferior left pulmonary vein (the superior segmental veins)
- inter apico-bazal - superior, middle, inferior veins
- inter subsegmentary apical vein
-uneori poate primi o vena mediastinala superficiala

b. The inferior root of the Inferior Left Pulmonary Vein ( common basal veins)
- interbazal anterior
-inter bazo - paracardiac anterior
-inter ventro-lateral
- interbazal middle
 -inter bazo - paracardiac middle
-inter latero-terminal
- interbazal inferior
- interbazo-paracardiac inferior
- inter termino-subterminal

Variante:
1. Vena unica gibbon si healy in traiectul extrapericardic 25%
2. Rad inf a VPS drenata in rad sup a VPI
3. Intrapericardic VPS si VPI sunt legate de un mezou deci practic este o singura vena

 Anomalies of lobation
Incomplete development of the fissures cause fusion of lobes

Accessory fissures account for accessory lobes

The cardiac lobe is the medial basal segment.
Agenesis and aplasia of the lung

Accessory lobes
If no bronchial communication exists => extralobar sequestrations

If rarely there is bronchial connection (such as in a tracheal lobe - apical segment on the right
with a segmental bronchus coming from the trachea).

Fissure Control of bronchovascular structures

Right Major Fissure

Confluence of fissure - what is in the way of the artery:

1. posterior branch of the superior pulmonary vein runs in the interlobar plane overlying the
pulmonary artery.
2. interlobar lymph node R11 (sump node)
- posterior interlobar lymph node R11 - overyling the pulmonary artery at the notch between
posterior ascending and superior segmental arterial branches (between the inferior margin of
the RUL bronchus and the bronchus intermedius)
- anterior interlobular lymph node R11 - between the ML bronchus and basal segmental bronchi
(

Pars interlobares of the PA

- anteriorly - superior branch of the ML
- postero-superiorly - posterior ascending branch of the RUL (Holvaque)
 - postero-inferiorly - superior segmental of RLL (Fowler)
- inferiorly - common basal trunk

1. Posterior interlobular lymph node (posterior superior portion of the major fissure)
A. Confluence dissection between Holvaque-Fowler artery (posterior interlobular node R11)
(anterior inferior portion of the right major fissure): interlobar plane

B. Posterior hillar dissection between the RUL bronchus and Bronchus intermedius in the
posterior hilum (posterior aspect of the posterior interlobular node R11) - in the posterior
superior portion of the fissure.

2. Anterior interlobular lymph node (anterior inferior portion of the major fissure)

C. Returning the the confluence of fissures - dissection between the inferior arterial branch
of ML and the basal segmental artery reveals the bronchial notch between the middle lobe and
the basal segmental bronchi where the anterior interlobar node R11 is found. - anterior
inferior portion of the major fissure.

D. Anterior hillar dissection between superior and inferior pulmonary veins allows
identification of the middle lobe and basal segmental bronchi and the anterior surface of
the anterior interlobar lymph node.

Right minor fissure

Interlobular PA identified

- superior arterial branch of ML and anterior ascending branches

Anterior approach
- space between the middle lobe vein and inferior segmental vein of the upper lobe (don't
dammage the posterior deep vein)

LYMPHATIC
PERIPHERAL CHANNELS
Network of lymph vessels in loose connective tissue beneath visceral pleura/interlobular
septa/peribronchial vascular sheaths

Parenchymal plexuses within the connective tissue sheaths around airways/vessels arising from
the terminal/respiratory bronchioles (do NOT extend into interalveolar septa by Okada et al,
Leak, Jamuar) but begin as blind end tubes/sacules.

JUXTA-ALVEOLAR LYMPHATICS (Laweryns & Leak)

Network that drains into larger collecting vessels/monocuspid valves directing flow to hilar area

INTERLOBULAR SEPTA CHANNELS

Kerley's B lines - radiographically noted by Steiner perpendicular to the pleural surface - extra-
alveolar interstitial edema (lymphatic channels also drain the lobular septa along pulmonary
veins)
Subpleural network drains to interlobular septa to hilar area (direct connection to mediastinum
recorded (Rouviere, Borrie, Riquet) -multiple connections with peribroncho-vascular sheaths
(connecting channels btw perivenous and bronchoarterial lymphatics deep in the parenchyma)
Kerley's A lines = connecting channels (<4cm L, oblique lines less than 1mm thick that course
toward the hila midway btw hilus and periphery)


Lymphatic nodes
Pumonary lymph nodes

-intrapulmonary-rare
-broncho-pulmonary (lobar, hilar)
Mediastinal nodes

Intrapulmonary nodes
if present - beneath visceral pleura within 1cm

-solitary peripheral lymph node identified radiographically (Greenberg, Houk & Osborne,
Ehrenstein)
Trapnell - injected subpleural lymphatics-radiographic postmortem 18% (5/28) intrapulmonary,
1/92 peripheral (Trapnel) but 10% (Dail - other method - resected nodes)
-all such nodes were anthracotic/nonencapsulated (Kradin): solitary 65%22% 2 nodes, 12 % 3
nodes (60% bilaterally)
-most are 0.5-1 cm
-ddx - Ohbuchi reported ecision by VATS of 10 intrapulmonary nodes most in the lower lobes
-Nagahiro - 13 intrapulmonary lymph nodes identified on CXR/HRCT (sharp border, ovoid
shape, lower lungs, subpleural location, high density, homogenous, short spicules could be
present, calcification/cavitation possible).

Bronchopulmonary nodes (N1= 10,11,12,13,14)

 subsegmental/ segmental (Nagaishi- 5th-6th order segmental bronchi in the bifurcation of

segmental bronchi/bifurcation of associated arteries)
lobar
hilar

1965 Borrie - 200 op lung cancer specimens

- 13 locations on the right

-15 locations on the left
RIGHT lung:

Borrie's right bronchial sump nodes

Superior interlobar node of Rouviere
1-btw upper lobe bronchus and middle lob bronchus (100%)
Inferior interlobar node of Rouviere
2-below middle lobe bronchus (65%)

3-medial to middle lobe bronchus (42%)

4-above upper lobe bronchus (40%)
5-On the right PA (junction of oblique and transverse fissure-Boyden's crest)( 29%)

6-medial to upper lobe bronchus

7-behind upper lobe bronchus
8-medial to superior segmental bronchus
9-above superior segmental bronchus
10-btw superior segmental and lower lobe bronchus
11-medial to lower lobe bronchus
12-lateral to lower lobe bronchus
13-btw ant and medial basal bronchi

LEFT lung
Left lymphatic sump of Borrie:
1.-btw upper and lower lobe bronchi (97%)

2-above upper lobe bronchus (49%)

3-medial to left main bronchus (33%)
4-medial to superior segmental bronchus (29%)

5-medial to upper lobe bronchus

6-above superior segmental bronchus
7-anterior to left main bronchus
8-behind upper lobe bronchus
9-behind left main bronchus
10-medial to lower lobe bronchus
11-lateral to left main bronchus
12-lateral to lower lobe bronchus
13-lateral to upper lobe bronchus
14-btw segmental bronchi of upper lobe
15-btw superior segmental bronchus and basal bronchi

RIGHT SUMP NODES

Superior interlobar node of Rouviere
1-btw upper lobe bronchus and middle lob bronchus (100%)
Inferior interlobar node of Rouviere
2-below middle lobe bronchus (65%)

Nohl Oser's bronchus intermedius node (upper posterior end of the major fissure btw right
upper lob bronchus and bronchus intermedius) - a bronchial artery leads to it - courses over the
posterior aspect of right main bronchus

interlobar PA node - where posterior ascending segmental branch (holvaque)/superior

segmental (fowler) arise

interlobar PA node is contiguous inferiorly with a constant node lying above the superior
segmental bronchus of lower lobe (fowler)

Base of the major fissure node - bifurcation of interlobar PA

more anterior nodes- upper lobe branchs of superior pulmonary vein (VPS node)

NonSump nodes
upper nodes
-above the upper lobe bronchus - merge with hiller nodes of right main
-medial to upper lobe bronchus
-behind upper lobe bronchus

middle nodes (besides inferior interlobar node of Rouvier)

-lateral to middle lobe bronchus near its confluence with lower lobe bronchus
-medial to middle lobe bronchus
 lower nodes
-medial to superior segmental (fowler)
-btw fowler and basal bronchi
-basal stem of the lower lobe (medial, lateral btw anterior and medial basal bronchi)

LEFT SUMP NODES

Nohl and Nohl Oser node sump: btw upper and lower lobes in the main fissure:
-bifurcation of upper and lower lobe bronchi (in close relation to inferior branch of the lingular
bronchus (bronchial artery branch passes across the membranous portion of the left main to it)
-interlobar PA nodes - in the fissure/in the angle of its branches
-left interlobar bronchus node- above and posterior to it - contiguous with :
-a node in the angle btw interlobar bronchus and fowler bronchus.

Non sump nodes

-medial, posterior, lateral to upper lobe bronchus
-medial, above, inferior to fowler bronchus
-medial, lateral to pyramidal stem

Hilar nodes are contiguous with lobar nodes distally and with mediastinal nodes proximally
-inferior border of azygos (concept questioned by Tisi)
on the left, anatomic separaton btw mediastinal an dhilar are on an imaginary place connecting
lateral surfaces of ascending and descending portons of thoracic aorta- medial, anterior,
posterior, lateral to left main bronchus in order of decreasing frequency :
- anteriorly are found in relation with PA and are contiguous with subaortc nodes including
Bartello's node (lig. arteriosum node)
-medial - contiguous with subcarinal nodes.

Mediastinal nodes (N2)

Anterior (prevascular) mediastinal

RIGHT
-nodes lie parallel and anterior to right phrenic n.
-extend upward and along SVC to beneath the right brachiocefalic v

LEFT
 -orig. of PA/lig. arteriosum
-extend upward near left phrenic n. to beneath the left brachiocephalic v
-is joined by left superior intercostal vein

Tracheobronchial
three groups around bifurcation of trachea
1. superior tracheobronchial nodes (outside the pretracheal fascia)
-right superior tracheobronchial nodes are medial and beneath the azygos v/above right PA and
contiguous with right superior hilar distally/right paratracheal proximally.
-left superor tracheobronchial nodes are in the aortic arch related to the left recurrent laryngeal n/lig
arteriosum (more anteriorly)/root of PA = link btw visceral compartment and anterior mediastinal
groups (paraaortic).

2. inferior tracheobronchial nodes=subcarinal nodes = within the pretracheal fascial envelope

by definition (but outside the bronchopericardial membrane which is also dense), contiguous with
hilar nodes
-more posteriorly- are on the anterior surface of esophagus connecting with posterior group
-Brock & Whytehead described a low anterior tracheal group in front of the lower trachea = bridge
between right superior tracheobronchial nodes and subcarinal, inferior tracheobronchial

Paratracheal
RIGHT
-superior
-inferior
LEFT
-superior
-inferior

Posterior mediastinal
Paraesophageal nodes - (more frequently on the left, more of them inferiorly)
Pulmonary lig nodes - connections with paraaortic nodes beneath the diaphragm (one node
here is called the sentinal node of pulm lig)

Mountain and Dressler/Naruke Map/Tisi map/German map

Naruke map + AJC maps conflicted with ATS (Tisi map) esp in the existance of hilar
node station 10

Riquet -survival data of N1 vs N2 nodes - solitary node metastasis in 7,10,11 behave as N1.
 Unified AJC and ATS map by Mountain and Dresler - station 3 nodes (anterior midline
paratracheal superior to carina up to station 1) -believed by Naruke, Asamura, Watanabe to be
an important individual station has been placed in station 4 nodes - this is the disagreement btw
American vs Japanese classification.
Station 3a - anterior mediastinal on the ant surface of SVC level of anterior wall of ascending
Ao.
Station 3p- central retrotracheal nodes behind the trachea

a German map involves the Japanese station 3 nodes

Size of nodes in different stations

Beck & Beattie - first report of 5 autospsies

-3 nodes in anterior mediastinum

-50 nodes in tracheobronchial tree
11 subcarinal
23 paratracheal
16 peribronchial
nonspecific anatomy but recorded their size
Genereux, Howie, Baron, Osborne, Ekholm Moak recorded sizes of normal mediastinal nodes
by CT 96% were less than 11mm
Glazer - used ATS map to measure size - 56CT scans of pts without primary inflammatory
disease/or primary lung cancer
-subcarinal nodes -largest 11mm
-lower paratracheal - large 10mm

CT can't identify all nodes: subaortic, subcarinal, inferior lig, inferior paraesophageal -can't be
seen

Kiyono 40 cadavers - similar results

station 2,5,6,8,9, 10L - 8mm
station 4 and 10R - 10mm
station 7 - 12mm

Kondo - TEUS (Transesophageal US) - pts studied had carcinoma of the lung - normal =
<10mm 95% in short axis.
 Lymphatic drainage of the lobes to N1 nodes

injection of substances in the lymphatic channels of the lungs of autopsy specimens of stillborn
infants/adults without lung dz. (Rouvier, Cordier, Riquet, caplan)
Borrie & Nohl - disected specimens from lungs of cancer pts (also Naruke, Martini, Libshitz,
Watanabe, Ishida, Asamura)
Nohl Oser, Greschuchna and Massen - evaluated superior mediastinum via mediastinoscopy of
lung cancer pts.
Hata used Dynamic Lymphoscintigraphy - living pts without pulmonary dz - injecting Tc99-
antimony sulfide colloid or rhenium colloid labeled into various segments via fiberoptic
bronchoscope

Right lobar drainage

RUL
-deduced from the study of Borrie - to superior interlobar nodes (the sump nodes) on lateral
bronchus intermedius to nodes above right upper lobe bronchus/medial right upper lobe
bronchus to azygos/subcarinal nodes
-distal drainage has not been described

ML
-superior sump region
-inferior sump region
-direct drainage to subcarinal (Okada)
-direct drainage confirmed by (Watanabe, Asamura, Naruke) to subcarinal (Okada) and also to
pretracheal mediastinal nodes!

RLL
-to inferior interlobar
-to superior sump nodes (primarily to medial surface of bronchus intermedius)
-direct drainage to subcarinal (Okada, Watanabe, Asamura, Naruke)
-to inferior pulmonary ligament node (12% by Borrie)

Left lobar drainage

LUL
-from all segments to the left sump nodes/upper lobe bronchus, left main bronchus
 -Culminal LUL -direct drainage to subaortic nodes
-Lingular LUL - direct drainage to subcarinal nodes (Asamura)

LLL
-subjacent peribronchial nodes, interlobar sump nodes to hilar
-to inferior pulmonary ligament (47% by Borrie)

Lymphatic drainage of lungs to N2 nodes (Hata et al)



RIGHT Lung Drainage to N2:

RUL
B1,B2 -apico-posterior segments - to hilar nodes (10R) into superior tracheobronchial nodes
and further into paratracheal nodes (4R/2R) and right scalene (R1).
B3 1/2-anterior segment: 1/2 flows through a similar route
B3 1/2-anterior segment the other half into
a. -most flow into subcarinal (7)/ right superior tracheobronchial to right superior
paratracheal OR some flow into subcarinal/ anterior paratracheal to left paratracheal nodes
b. R. ant mediastinal nodes along the L. brachiocephalic vein into L. ant. mediastinal into
L1scalene.

ML (B4,5)/Fowler (B6)
-most flow into subcarinal (7)/ right superior tracheobronchial to 2R
-some flow into subcarinal (7)/anterior paratracheal to 4L/2L
-some flow into R. ant mediastinal nodes via L. brachioceph. v. into L ant. mediastinal nodes
toward L1 scalene ( like for the anterior segment of RUL)

RLL (B7,B8,B9,B10)
-dominant flow from basal segments to subcarinal (7) nodes via bronchopulmonary nodes
(R14,R13,R12,R11,R10) to ipsilateral lower and upper paratracheal (4R/2R) into right scalene
(R1).


LEFT Lung Drainage to N2 4 major Routes by Hata: highly variable

apico-posterior segment of upper lobe- first route

1. through subaortic nodes (5)
1a-runs along the vagus n to left scalene (L1)
1b-rungs along left recurrent laryngeal nerve to highest mediastinal nodes
anterior and lingular segments of upper lobe-second route/or other routes
2. through para-aortic nodes upward along the lef frenic nerve through the anterior mediastinal
nodes to left scalene nodes
3. along the left main bronchus to left superior tracheobronchial nodes and paratracheal nodes
3a to the right side of mediastinum through right upper pretracheal node
3b upward along the left side of the trachea to highest left mediastinal node
basal segments - fourth route
4. under the left main bronchus to subcarinal nodes
4a- to right superor tracheobronchial nodes
4b-lower pretracheal node to right upper paratracheal nodes
4c-upward along left side of trachea to highest left mediastinal nodes
Major routes:
apico-posterior segment of upper lobe- first route
anterior and lingular segments of upper lobe-second route/or other routes
fowler segments - first, third, fourth routes
basal segments - fourth route

Direct lymphatic drainage of Lobes to N2 nodes ( Rouviere,

Borrie, Cordier, Riquet)
8 drainage lymphatic chains into superior mediastinum by postmortem subpleural
lymphatic injection (Riquet 343 segments of right lung 344 segments of left lung)

Superior Mediastinum
2 major chains on the right
 -RPT (right paratracheal) from anterior carina to ipsilateral supraclavicular fossa (station 3, 4L,
4R)
-TE (tracheoesophageal) from behind the trachea
2 minor chains on the right
-RP (right phrenic) chain
-AZM (azygos vein)- directly into thoracic duct (no nodes usually)
2 major chains on the left
-AO (preaortic-carotid) chain -large node at lig arteriosum (5) passes behind the phrenic nerve
in front of the vagus to the neck
-LSB (left superior bronchial)/LRN (left recurrent laryngeal) - corresponds to TE
(tracheoesophageal chain on the right)
2 minor chains on the right
-LP (left phrenic)
-Azao (aortic arch)

Inferior Mediasinum
1 Major - ITB (intertracheobronchial) arranged in 3 clusters: (7) in the midline flanked by left and
right nodes below respective bronchus
2 minor (inferior lig and juxtaesophageal)
-PL (pulmonary lig) 40
-JE (juxtaesophageal) drains little of the lungs

conclusion:
RIGHT DRAINS MOSTLY IPSILATERALLY

Drainage from right lung is unilateral and crossover to contralateral mediastinum is infrequent
(Hata noted drainage from right upper lobe into left paratracheal and sequentiallly from right
prevascular into left prevascular (anterior).
Lower right lobes rarely drain contralaterally but Riquet recorded direct drainage channel from
right basal to left pulmonary lig.
Nohl Oser and Maassen mediastinoscopy study reported incidence of N3 spread
5%-9% from RUL to N3 if N2 present
5-7% from RLL to N3 if N2 present
2-3% from right lung (50% N2) spread to N3

LEFT DRANS ALSO CONTRALATERALLY

N3 drainage from lef lung is common (Rouviere)-confirmed by all the studies.
via lower pretracheal nodes from LLL (direct channel by Riquet)
Nohl Oser and Maassen mediastinoscopy study:
22-21% LUL to N3 if N2 is present
40-33% LLL to N3 if N2 is present
6-11% incidence of crossover if N2 not present (Hata found 7-11% incidence of crossover)

RUL to inferior mediastinum via subcarinal nodes DOES occur (first ovserved by Rouvier)
discounted by Nohl but reconfirmed by Borrie, Hata, Riquet, Watanabe, Asamura.
Watanabe and Asamura - 13% incidence of subcarinal involvement in 45 pts w/ RUL tumors/
Libshitz 14%.

Skip metastasis (Martini and Flehinger/Libshitz /Ishida/Riquet/Asamura)

RLL skips to subcarinal and to pulm lig
LUL skips to subcarinal and Aortic window