The pleura

Surface anatomy

St. : Sternoclavicular joint

Med. 1/3 S.A: Sternal angle
Med. 1/3 4th C.C.: 4th costal cartilage
St. St.
O.F.: Oblique fissure
H.F.: Horizontal fissure
S.A. Pleura 1.: 6th costal cartilage
O.F. 2: 6th rib mid clavicular
Lung 3.: 8th rib mid axillary
H.F. O.F 4.: 7th costal cartilage
4th C.C. . 5.: 8th rib mid clavicular
6: 10th rib mid axillary
1
1 4
4

2
2
3 3
5 5

6 6
 The pleura
Features and
parts
Cervical pleura

Hilum of the lung

Costal pleura
Parietal layer

Pleural cavity
Mediastinal pleura
Lung
Visceral layer
Lung

Diaphragmatic pleura

Lung invaginates the

pleural sac
 The pleura
Features and
parts
The pleura is a closed sac invaginated by the lungs
Formed of visceral and parietal layers continuous with
each other at hila of the lungs
The visceral layer adheres closely to the lungs
The parietal layer lines thoracic wall, diaphragm and
mediastinal structures
The pleural cavity is a potential space between the 2
layers, it contains a thin film of serous fluid which
prevents friction between the 2 layers.

The left pleural cavity is smaller than the right

because the heart extends further to the left.
 The pleura
Parts of pleura
Parietal pleura
1.Cervical pleura: Extends in the neck above the med. 1/3
of clavicle
2.Costal pleura (costovertebral pleura): Lines the sternum,
ribs and
sides of vertebral bodies
3. Diaphragmatic pleura: covers most of upper surface of
diaphragm
4. Mediastinal pleura: Covers the structures in the
mediastinum. At the hilum it forms a tube( pulmonary lig.)
to enclose the hilar structures and continues with the
visceral layer
Visceral pleura
Adherent to the lung lobes & fissures. Absent at hilum &
site of pulmonary ligament.
 The pleura
Pulmonary ligament

The parietal and visceral layers of pleura

are continuous with each other at the hilum
of the lung where a tube of pleura
encloses the hilar structures and is
prolonged downwards to the diaphragm as
the pulmonary ligament. It acts as a dead
space allowing distension of the pulmonary
veins.

Pulmonary
ligament
 The pleura
Pleural recesses

lung

Costmediastinal recess

Diaphragm Costodiaphragmatic recess

Are parts of pleural cavity not filled by lungs in

quiet inspiration, lungs fill them only in forced
inspiration
1. Costomediastinal recess: Along anterior borders of the
lungs
2. Costodiaphragmatic recess: Along inferior borders of
 The pleura
Nerve supply
Parietal pleura
-Lower 7 intercostals: Supply costal pleura and
peripheral parts of
diaphragmatic pleura
-Phrenic nerve: Supply central parts of diaphragmatic
pleura and
mediastinal pleura
Visceral pleura
supplied by sympathetic fibers that accompany bronchial
vessels. The visceral pleura is insensitive to
exteroception (pain, temperature and touch) but is very
sensitive to visceral sensations (tension and
ischaemia).
 The pleura
Arterial supply
-Intercostal -Internal mammary
arteries artery
-Musculophrenic -Bronchial arteries
( Visceral pleura )
Clinical
aspects
-Pleurisy : Inflammation of pleura, Friction leads to
severe pain
-Pleural effusion : Watery fluid accumulates in the
pleural cavity
-Pyothorax ( empyema ): Pus accumulates in thoracic cavity.
-Hemothorax : Blood accumulates in the pleural cavity
-Pneumothorax : Air accumulates in the pleural cavity

Drainage of any accumulated fluid by a needle

passing along
upper border of ribs (4-7 ribs) in midaxillaryline
The lungs
Surface anatomy
 The lungs
Surface anatomy of
fissures

3 --- 3
3 --- 3

M . AX .
4
c.c

3 --- 6 3 --- 6
 The lungs
General features
Apex Apex

Rounded
Sharp post . bord
Sharp ant . er
Rounded ant . border
post . bord border
er
Costal
surface
Costal
surface

Base Base
 The lungs
General features

Vertebra
l S.

Mediastinal Mediastinal
S. S.
Vertebra
l S.

Hilu
m
Hilu
m
 The lungs
Structures in the hilum

BE A

B B VU
VU

VL VL Hilum of left
lung and hilar
Hilum of right structures
lung and hilar
structures
A.: Pulmonary artery
B.: Bronchus (hypoarterial bronchus)
VL.: Lower pulmonary vein
VU.: Upper pulmonary vein
B.E.: Bronchus (epiarterial bronchus)
 The lungs
Differences between right and left
Right lung lungs
left lung

Larger, wider, shorter & heavier Smaller, taller and lighter

3 lobes 2 lobes

2 fissures One fissure

No cardiac notch cardiac notch

More concave diaphragmatic less concave diaphragmatic

surface surface
In order to know a given lung put In order to know a given lung put
it in the anatomical position it in the anatomical position
 Relations of mediastinal surface
of right lung
Above hilum (4)
1. Arch of azygos. 2 3
2. Trachea, right vagus nerve
3. Esophagus
4. Right brachiocephalic vein &S.V.C. 4 1
Behind hilum (2) 10
5. Vena azygos.
6. Esophagus, right vagus. 8
In front of hilum (4) 5
7. Right atrium.
8. Right phrenic nerve. 7
9. I.V.C. 6
10. Ascending aorta.

9
 Relations of mediastinal surface
of right lung
Above hilum (4)
1. Arch of azygos.
2. Trachea, right vagus nerve
3. Esophagus
4 2 3
4. Right brachiocephalic vein &S.V.C.
Behind hilum (2) 1
5. Vena azygos.
6. Esophagus, right vagus. 10
In front of hilum (4) 5
7. Right atrium. 8
8. Right phrenic nerve.
9. I.V.C.
6
10. Ascending aorta. 7
9
 Relations of mediastinal surface
of left lung
Above hilum (4)
1. Aortic arch.
2. Left common carotid artery. 4 3 2
3. Left subclavian artery.
4. Esophagus. 1
10
Behind hilum (3)
5. Descending aorta.
5 9 8
6. Left vagus.
6
7. Esophagus.
In front of hilum (3)
8. Left ventricle
9. Left phrenic. 7
10. Thymus gland
Relations of mediastinal surface
of left lung
Above hilum (4)
1. Aortic arch.
4 3 2
2. Left common carotid artery.
3. Left subclavian artery.
1
4. Esophagus. 10
Behind hilum (3)
5. Descending aorta.
5 9
6. Left vagus.
6 8
7. Esophagus.
In front of hilum (3)
8. Left ventricle 7
9. Left phrenic.
10. Thymus gland
 Bronchopulmonary segments of the
lungs
Each lung is divided into segments, each segment is

-Wedge-shaped, its apes lies at the hilum while its base

lies at the
surface of the lung.
-Each segment is covered with C.T. and is a functionally
separate unit
having its segmental bronchus, blood vessels and
lymphatics
-Removal of any segment does not affect other segments
Bronchopulmonary segments of the
right lung
Upper lobe
1. Apical
1 1 2. Posterior
2
3. Anterior
2 3 3 Middle lobe
6 4. Medial
6 5. Lateral
5 9 Lower lobe
4 4 10 6. Superior
7
7. Anterior basal.
8
7 8. Lateral basal
8 9. Posterior basal
10. Medial basal
Bronchopulmonary segments of the
left lung
Upper lobe
1. Apical
2. Posterior
1 1 3. Anterior
4. Superior lingular
2,3 2,3 5. Inferior lingular
6 6 Lower lobe
4 6. Superior
4 5 7. Anterior basal
9 7 , 10 8. Lateral basal
5 7,1 9. Posterior basal
0 8
10. Medial basal
8
7+10= Anteromedial
basal
 Arterial supply of the lungs
From bronchial arteries
A .2 left bronchial arteries 3 rd
posterior
from intercost
descending aorta al
B. One right bronchial
artery from 3rd right
posterior intercostal
artery
One right
bronchial
artery
2 left
bronchial
arteries
 Venous drainage of the lungs
Into hemiazygos and azygos veins

-Right bronchial vein into

azygos vein
-Left bronchial veins into
Accessory
hemiazygos vein

Right bronchial
vein Left bronchial
vein

Azygos vein
Accessory
hemiazygos
vein
 Nerve supply of the lungs
From pulmonary plexus
A .Sympathetic ( From 2,3,4 thoracic ganglia) produces
bronchial dilatation

B. Parasympathetic (From vagi) produces

i. Bronchial spasm
ii. Increases bronchial secretion
 Lymph drainage of the lungs
Thorac
ic
duct
Right lymph
trunk
Lymph vessels pass
from the periphery to B.M.
the intrapulmonary
nodes (I . P.) -----
broncho pulmonary
lymph nodes (B . P .) in
the hilum of the lungs
 to tracheobronchial
lymph nodes (T . B . )at T.B.
bifurcation of the
trachea  efferents
ascend upon the B.P.
trachea to form right
and left
bronchomediastinal I.P.
lymph trunks ( B . M .)
which drain in the
right lymph trunk and
thoracic duct
 Mediastinum
Thoracic inlet

T2 Manubrium Superior
T3 mediastinum
T4
T5
Anterior mediastinum
T6

T7 Middle mediastinum
Inferior mediastinum
T8

T9 Posterior
mediastinum
T10

T11

T12

Diaphragm
 Mediastinum
Is the partition lying
in the median plane
between the 2 pleural
sacs. S
It extends from the sternum
in
front to vertebral column
behind I
& from thoracic inlet above
to
It is divided
thoracic outletinto superior
(diaphragm )
mediastinum
below & inferior
mediastinum by an imaginary
line passing between the
sternal
angle and the lower border
of T4
vertebra
 Mediastinum
The inferior
mediastinum is
divided by the heart
into
A .Anterior mediastinum
in
front of the
heart mediastinum containing
B .Middle
the heart A.
B .Posterior mediastinum behind
the heart

M.
P.
 The superior
Mediastinum
Boundaries
:
Above: Thoracic
inlet
Below: Imaginary line
extending
from lower border of
manubrium
sterni to lower border of T4
vertebra
Anteriorly: Manubrium
sterni
Posteriorly: Upper 4 thoracic
vertebrae
laterally: Mediastinal
pleurae
 The superior
mediastinum
Contents :

A. Retro-manubrial compartment:
1.Lower parts of sternohyoid & sternothyroid
muscles
2. Remains of thymus gland.
3. Right and left brachiocephalic veins.
4. Upper half of S.V.C.
5. Left superior intercostal vein.

B. Intermediate compartment:
1. Arch of aorta.
2. The 3 arteries arising from aortic
arch (brachiocephalic, left common
carotid, and left subclavian arteries).
3. Right and left phrenic nerves.
4. Right and left vagus nerves.
 The superior
Contents :
mediastinum
C. Prevertebral structures:
1.Trachea
2. esophagus.
3. Left recurrent laryngeal nerve.
4. Thoracic duct.
5.Both sympathetic chains
6.Longus coli muscles.
7.Anterior longitudinal ligament.
 The anterior
mediastinum
Contents :

1 . Remains of thymus gland .

2 . Loose areolar tissue .
3 . Upper and lower
sternopericardial
ligaments
4 . Two to three lymph nodes .
 The middle mediastinum
Contents :

1 . Pericardium &
heart .
2 . Bifurcation of
trachea into
2 bronchi .
3 . Tracheobronchial
lymph N .
4 . Both phrenic
nerves
5 . Deep cardiac
plexus .
6 . Arteries
( ascending aorta
& pulmonary
trunk ).
7 . Veins ( lower ½ of
 The posterior
mediastinum
Contents :
1 . Esophagus .
2 . Thoracic duct .
3 . Descending aorta .
4 . Azygos and hemiazygos
veins .
5 . Nerves :
A . Esophageal plexuses
from both vagi .
B . Both sympathetic
chains and their
splanchnic nerves .
6 . Mediastinal lymph nodes .
 Variations of position
of the mediastinum

Body built: Tall, thin -------- Low diaphragm

( mediastinum is lower)
Short obese-------- High
diaphragmErect
Position: ( Higher mediastinum
posture-------- )Mediastinum is lower
Supine posture------- Mediastinum is
higher
State of abdominal viscera
Pregnancy, abdominal distension, ascites-------
Mediastinum is higher

respiration:
During inspiration ----- Diaphragm & mediastinum
descend
 Pericardium
The pericardium is formed of 2 sacs
A. Outer sac: Fibrous pericardium

Conical sac made of tough

connective tissue. It surrounds
the heart completely without
being attached to it.
Apex

Anterior
surface
Posterior
surface

Bas
e
 Pericardium
A. Outer sac: Fibrous pericardium:
Has
Base : Attached to central tendon of the diaphragm &
is pierced by
the I.V.C.
Apex : Surrounds S.V.C., ascending aorta & pulmonary
trunk &
continues above with the pre-tracheal
Anterior surface : Connected to back of
fascia
sternum by
sterno-
posterior
pericardial surface
ligaments . : pierced by the 4
pulmonary veins.
 Pericardium

Heart
Heart
V. Pericardium
Pericardium
P. Pericardium

B. Inner sac: Serous pericardium: Lines the fibrous

sac & covers the heart

The heart invaginatesthe serous sac from above and

behind and
almost obliterates its cavity, the space being a
potential space lying between the parietal and visceral
layers. It allows the free movements of the heart
within the fibrous pericardium.
 Pericardium
Serous pericardium : Lines the fibrous pericardium,
invagination of the heart to it divides it into
parietal and visceral layers
Parietal serous pericardium : Lines the inner
surface of the fibrous pericardium
Visceral serous pericardium ( Epicardium ): Covers
the heart and great vessels and is reflected from the
great vessels to form the parietal layer.

- The portion which covers the great vessels is arranged

in 2 tubes
First tube : Closes the aorta and pulmonary trunk
Second tube: Closes the S.V.C., I.V.C., the 4 pulmonary
veins. The
tube surrounding the veins has the shape of an
inverted J . Thus
2 recesses of serous pericardium are formed:
 Pericardium
Primary heart tube Transient dorsal
In pericardial sac mesocardium Heart

Pericardiu
A V m
Heart A. : Arterial end of heart tube
B. : Venous end of heart tube
A T T T. : Transverse sinus of
V pericardium
Heart
O. : Oblique sinus of
pericardium

S.V.C
Left T
pulmonary Right pulmonary
T veins veins
I.V.C
O.
 Pericardium

Transverse
sinus of
pericardium
Right
pulmonary Left
veins pulmonar
y veins

Oblique sinus
of pericardium
 Pericardium
Pericardial
sinuses :
Oblique sinus of pericardium : is the space
between the limbs of the inverted J , it has
the following relations :
Anteriorly : Back of left atrium
Posteriorly : Parietal serous pericardium, fibrous
pericardium
separating it from posterior
On mediastinum
each side : The corresponding pulmonary veins
Superiorly : The reflection of visceral pericardium on
back of left
atrium to become parietal
Inferiorly : Opening to oblique sinus, between I.V.C. and
lower left
pulmonary vein
 Pericardium
Pericardial
sinuses :
Transverse sinus of pericardium : is the passage
between the 2 tubes of pericardium , It has the
following boundaries :
Anteriorly : ascending aorta & pulmonary trunk
Posteriorly : Both atria mainly the left atrium
 Pericardium
Arterial supply of
pericardium :
1. Pericardial branches of internal mammary
artery
2. Pericardiophrenic artery
3. Musculophrenic
4. Pericardial branches from descending aorta

Nerve supply of
pericardium :
Vagi, phrenic nerves and sympathetic chains
 The heart
Surface anatomy of the
heart :
A . Surface anatomy of the
heart itself

4cm

3cm

5th space
3cm
 The heart
Surface anatomy of the
heart :
B . Surface anatomy of A / V and I / V
grooves
 The heart
Surface anatomy of the
heart :
C . Surface anatomy of cardiac
valves

Arrows: Indicate areas where auscultation of

heart sounds is done
 The heart
Position of the heart :
The heart is a hollow fibromuscular organ with conical or
pyramidal shape. It lies in middle mediastinum enclosed
in the pericardium. It is placed obliquely behind the body
of the sternum, costal cartilages and ribs. Approximately
1/3 of its mass lies to the right of the middle line.

Cardiac size and weight :

1 . Length of heart from base to
apex is 12 cm
2 . The broadest transverse
diameter is 9 cm
3 . The anteroposterior diameter is
6 cm .
4 . The weight of the heart is 250 gm in
females and 300 gm in males ( weight
achieved at 17 - 20 years
 General features of
the heart
A.A.: Ascending aorta
P.T. : Pulmonary trunk
S.V.C. R.A.: Right auricle
A.A. L.A. L.A.: Left auricle
P.T. 1.Atrioventricular groove
1b
R.A. 1a Anterior part

Left surface
1b Left part
Right atrium 1c Posterior part
Right
2. Interventricular groove
ventricle
2a Anterior part
1a 2a
Right border 2b Inferior part
1C

Left
2b ventricle
I.V.C. Apex

Inferior surface
1b
1a 1C

2b 2a
 General features of
Position of thethe heart
heart :

The heart lies obliquely in the middle mediastinum with its

axis directed downwards , forwards & to the left
The cavity of the heart is divided obliquely into right and left
halves by an oblique
longitudinal septum
Each half consists of receiving chamber (atria) behind and pumping
chamber
(ventricles ) in front.
The heart is similar to a cone having:

Apex: Lies anteriorly in the 5 th left intercostal space.

Base (Posterior surface): Lies posteriorly and to the right from 5-8 T vertebrae

Anterior surface: Sternocostal surface

 General features of
Position of thethe heart
heart :
Inferior diaphragmatic surface:

Left pulmonary surface:

Right pulmonary surface:

Four borders: Upper , lower, right and left

Atrioventricular groove. Has 3 parts: anterior, posterior (inferior) and left parts

Interventricular groove. Has 2 parts: anterior and inferior parts

Shallow interatrial groove

 General features of
Surfaces of thethe heart S.V.C.
heart :
1 . Sternocostal
surface : A.A.
P.T.
L.A.
- Formed by the 4 1b
R.A.
chambers

Left surface
mainly the right Right
- Theventricle
anterior part of ventricle
1a 2a
A / V groove 1C
crosses it obliquely
to the
- The right part I / V .
anterior Left
ventricle
2b
groove
divides its I.V.C. Apex
Inferior surface
ventricular part into
larger right ( 2 / 3 ) and
smaller left
( 1 / 3 ) parts
 General features of
Surfaces of thethe heart S.V.C.
heart :
2 . Inferior
surface : A.A.
P.T.
L.A.
- Formed by the 2 1b
R.A.
ventricles : 2 / 3

Left surface
left ventricle & 1 / 3 Right
right ventricle
- Separated from the base ventricle
1a 2a
of the 1C
heart by the posterior
A / V groove
- Rests on central tendon Left
ventricle
2b
of the
diaphragm I.V.C. Apex
Inferior surface
3 . Left surface :

- Formed by left ventricle &

left auricle
- Rests on mediastinal surface
of left lung
 General features of
Surfaces of thethe heart S.V.C.
heart :
4 . Base :
L.A.
- Formed by both atria A.A.
P.T.
1b
mainly the R.A.
left

Left surface
- The pulmonary veins , Right
S.V.C. & 1a
ventricle
2a
I . V . C . enter the base 1C
- Posteriorly lies the
Left
esophagus ventricle
5 . Apex : 2b

I.V.C. Apex
- Formed by the left Inferior surface
ventricle
Borders of the
heart :
1 . Right border : Formed by right atrium ,
S.V.C. & I.V.C
2 . Left border : formed by left
 General features of
the heart S.V.C.
Borders of the
heart :
3 . Upper border : Formed A.A. L.A.
P.T.
by both 1b
atria but concealed R.A.

Left surface
by ascending Right
aortaborder
4 . Lower & pulmonary
: formed ventricle
trunk
by both ventricles 1a 2a
1C

Left
2b ventricle

I.V.C. Apex
Inferior surface
 General features of
the heart
Grooves of the
heart :
1 . A . V . groove : Formed of
3 parts C
- A . Anterior part : passes
to right obliquely
from pulmonary trunk A B
to lower border
- B . posterior part :
separates the base of
the heart from the
diaphragmatic surface
- C . left part : passes
from in between the
pulmonary trunk and
left auricle to left
border
 General features of
the heart
Grooves of the
heart :
2 . I / V . groove : Formed of
2 parts
- A . Anterior part : crosses
the anterior surface
being parallel to left
border
A.
- B . Inferior part : crosses
the inferior surface
till it meets the B.
posterior part of A / V .
groove
 Interior of the heart
Interior of the
right atrium
right
auricle Pectinat
S.V.C e
. muscles

Crista
I. terminali
Atrial s
Annulusseptum Tricuspi
ovalis
Fossa d
ovalis
Coronary
orifice
I.V.C sinus
Valve of coronary
. sinus
Valve of
 Interior of right
atrium
S.V.C
.

Annulus
ovalis
Fossa
ovalis
Coronary
sinus
I.V.C
. Valve of coronary
sinus

Valve of
Tricuspid valve

S. A.
P.
Closing tricuspid
valve
Closed tricuspid
valve
 Interior of right
ventricle
Pulmonary
trunk

Infundibulum

Supraventricu
lar Septal pap .
muscle
Septomargin
crest al
Ant . cusp trabecula
Post . Pap .
muscle
Moderator band
Trabecula
e

carni Ant . Pap . muscle

 Tricuspid valve

Tricuspid
orifice
Sept . Ant . Post .
cusp cusp cusp

Post . pap .
Septal pap . Ant . pap . M .
M. M.
Septomarginal
Pulmonary valve
Closing pulmonary
valve
Closed pulmonary
valve
Left atrium

P. P.

Left P.
P.
atrium
 Interior of left
ventricle
Aort
a

Ant . Pap .
muscle
Trabeculae
carni
post . Pap .
muscle Anterior
cusp

Posterior
cusp
 Mitral valve

Mitral
orifice
Ant . Post .
cusp cusp

Ant . Pap . post . Pap . Ant . Pap .

M M M
Left ventricle

Vest
.
Aortic
orifice
Left ventricle
 Wall of ventricles

R. L.
 Differences between the
ventricles
Right ventriclee Left ventricle

Forms 1/3 inf. Surface, 2/3

 1. Forms whole left border, 2/3
ventricular part of ant. surface inf. Surface, 1/3 ventricular
 part of ant. Surface

2. Wall 3-5 mm 2. Wall 8-12 mm

Semilunar in cross section Circular in cross section

3. Trabeculae carni few & rough 3. Trabeculae carni multiple & fine

4. Tricuspid valve has 3 cusps 4. Mitral valve has 2 cusps

3 papillary muscles 2 papillary muscles
 Coronary
arteries
The arterial supply is
formed of :
Circle : The coronary arteries form
this circle,
they run in the A/V
grooves
Loop : The I/V branches of coronary
arteries
form this loop, they run
in the I.V.
grooves.
 Coronary
arteries
Aortic Left
cusps post .
sinus

Left
coronary
Ant . artery
sinu
s

Right coronary
artery
 Coronary
arteries
Origin of
Aortic left
Origin of sinuses
right coronary
Left
coronary post .
sinus

Anterior
sinus
 Coronary
arteries
R. L.
Coronary Coronary

Ant . I / V .
A

Post .
I/V. A
 Blood supply of the heart
Coronary
arteries
left coronary
artery

Circumflex
Right A.
coronary

artery Ant . I / V
artery

Marginal
artery
 Coronary
arteries

Right
coronary

artery
Post .( inf .) I / V
artery
Right coronary artery

Anterio
r
sinus
Right
coronar
y
artery Margin
al
artery
 Left coronary artery

Left
Left coronar
posteri y
or artery
sinus
Circumf
Ant . I / V . lex
artery
artery
 Coronary
arteries
Branches of right coronary
artery
1.Inferior I/V artery: Runs in the inferior I/V groove till the
apex.
3.Marginal artery: Runs along lower margin of anterior
surface.
3. Small unnamed branches.

Typically the right coronary artery supplies:

•The right atrium.
•Most of right ventricle.
•The diaphragmatic surface of left ventricle.
•The posterior third of A/V septum.
• S .A . node (in about 60% of peoples).
• A .V. node (in about 80% of people).
 Coronary
arteries
Branches of left coronary
artery
1 . Anterior I / V artery . It descends in the
anterior I / V groove till apex .
2 . Circumflex artery .
3 . Small unnamed branches .
Typically the left coronary artery supplies :
- The left atrium .
- Most of the left ventricle .
- Part of the right ventricle .
- Most of the I / V septum ( anterior 2 / 3 including
the A / V bundle ).
- S . A . Node in about 40 % of people .
 Venous drainage of
the heart G. : Great cardiac vein
M. : Middle cardiac vein
S.V.C. S.: Small cardiac vein
Ascending aorta
Pulmonary trunk
G
Right
auricle G
Right
atrium
Coronary
sinus
G

M.
I.V.C.
S
 Venous drainage of
Mainlythe heart
: into coronary sinus
Coronary sinus : 2 - 3 cm in length lying in
the posterior part of A / V groove , its right
end opens in right atrium between I . V . C . and
tricuspid orifice and is guarded by a valve
while its left end is joined by the great
cardiac vein .
Tributaries of coronary sinus:
1. Great cardiac vein. 2. middle cardiac vein.

3. Small cardiac vein.

4. Oblique vein of left atrium (vein of Marshal).

5. posterior vein of left ventricle

 Venous drainage of
the heart
The veins which do not drain into the coronary sinus are:

1 . Anterior cardiac veins ( 2 - 3 in

number ), They ascend on the sternocostal surface
of the heart to end in the right atrium .
They drain the anterior part of the right
ventricle .
2 . Venae cordis minimi : Drain in the
different chambers
( mainly the right atrium ). These veins are
found within the
myocardium
 Lymph drainage of
the heart
Into
:
1 . Posterior mediastinal lymph
nodes
2 . Brachiocephalic lymph nodes
 Arteries in the
mediastinum
S . A . of ascending aorta and
aortic arch

AA
2 2 A.: Ascending aorta
AA.: Aortic arch
3 A 3
 Ascending
aorta

Ascending
aorta
Pulmonary
S.V.C. trunk

Right
auricle

Right
atrium

I.V.C.
 Ascending
aorta
A .: Ascending
aorta
P . T . Pulmonary
R.B. trunk
R . P .: Right Pulm .
R.P. A.
S.V.C R . B .: Right
. A. A. bronchus
P.T. S.V.C
.
P.T.
 Aortic arch
S . A . of
aortic arch

AA
2 2

3
3
 A Aortic arch
C Sternum

1 2

Lung
1

Lun g
3 B
5 4 A
C
B A
Vertebr
a
 Aortic arch
Anteriorly:
1. Left phrenic.
2. Left vagus.
3. Cardiac branch from left vagus.
4. Cardiac branch from left sympathetic chain
5. Left superior intercostal vein.
Posteriorly:
A. Left recurrent laryngeal nerve.
B. Bifurcation of trachea.
C. Esophagus.
Below:
A. Left recurrent laryngeal nerve.
 Branches of
aortic arch

Left
subclavian
Left C .
carotid
Brachioceph
alic
 Descending
thoracic aorta

A.
Descendin
g aorta

Esophagus

Thoracic
duct
 Relations of descending
thoracic aorta

Hilum of left
lung
Descending
aorta
Esophagus
Azygos vein
 Descending
thoracic aorta
Anteriorly: From above downwards:
- Hilum of left lung.
- Pericardium and left atrium.
- Esophagus (crossing it at level of T8 vertebra).
- Diaphragm.

Posteriorly:
- Vertebral column.
- Hemiazygos and accessory hemiazygos veins
crossing behind it opposite T8

To the right: To the left:

1. Vena azygos. 1. Left lung and pleura.
2. Thoracic duct. 2. Esophagus (lower
3. Esophagus (high up). down).
 Branches of descending
thoracic aorta
1. Nine pairs of posterior intercostal arteries
2. Pair of subcostal arteries
3. Two left bronchial arteries
4. Four to five esophageal arteries
5. pericardial, mediastinal and diaphragmaticarteries
 Pulmonary trunk
S . A . of
pulmonary trunk

2 2

3 P.T.
3
 Pulmonary trunk
Anteriorly: Left lung,left pleura, pericardium

Posteriorly:
Ascending aorta
left coronary artery
Left atrium
P.T. Transverse sinus of pericardium

To the right:
Right auricle, ascending aorta
To the left:
left auricle
Above: Aortic arch, lig. Arteriosum superf.cardiac plexus
 Relations of right
pulmonary artery

Relations : That of
right hilum
Anteriorly :
- Ascending
aorta (1). 2
- S.V.C.(2) 1 4
- Right phrenic 5
nerve(3). 3
Posteriorly:
- Right bronchus R.P.A
(4). .
- Esophagus (5).
 Relations of left
pulmonary artery

Relations : That of left

hilum
Anteriorly :
- Left phrenic nerve (1). L.P.A
Posteriorly : 1 .
2
- Left bronchus (2). 3
- Descending aorta (3).
Inferiorly:
Upper border of left
atrium.
 Pulmonary
arteries
Right pulmonary artery Left pulmonary artery
- Longer (2 inches), wider, more - Shorter (1 inch) narrower, runs
vertical horizontally above the left
atrium

Relations: That of right hilum Relations: That of left hilum

Anteriorly : Anteriorly :
- Ascending aorta. - Left phrenic nerve.
- S.V.C. and right Posteriorly :
phrenic nerve.
- Upper right pulmonary - Left bronchus .
vein. - Descending aorta.
Posteriorly : Inferiorly :
- Right bronchus. Upper border of left
- Esophagus . atrium.
 Brachiocephalic
veins
Beginning and end:

Right brachio- 1 1
cephalic vein Left brachiocephalic vein
2 2
S.V.C.

3
3
 Brachiocephalic
veins
Right brachiocephalic vein Left brachiocephalic vein
- 2.5 cm - 6 cm
- Vertically downwards - Obliquely to the right
- Begins at right sternoclavicular joint - Begins at left sternoclavicular joint
by union of right internal jugular & by union of left internal jugular &
right subclavian veins left subclavian veins

Both veins end at first right Both veins end at first right
costal cartilage by uniting costal cartilage by uniting
together to form the S . V . C . together to form the S . V . C .

Relations : Relations
To the right : Right phrenic Behind : The 3 big arteries of
nerve . the aortic
To the left and posteriorly : arch , The 4 nerves between
Brachiocephalic artery & left
right vagus common carotid and left
subclavian
arteries .
 Left brachio-
Brachiocephalic cephalic vein
Relations of veins
right
brachiocephalic vein :
To the right : Right phrenic Right phrenic
nerve . Right
To the left and posteriorly vagus
: Right brachio-
Brachiocephalic artery & cephalic vein
right vagus
S.V.C.

Relations of left
brachiocephalic vein:
Behind : The 3 big arteries of the
aortic
arch , The 4 nerves between
left
common carotid and left
subclavian
arteries .
Below : Aortic arch .
 Brachiocephalic
tributaries: veins
Right internal mammary vein Left internal mammary vein.
Right vertebral vein. Left vertebral vein.

Right inferior thyroid vein. Left inferior thyroid vein.

Right lymph trunk. Thoracic duct.

Right 1st posterior intercostal Left 1st posterior intercostal

vein. vein.
6. Left superior intercostal vein.
Beginning and end:
S.V.C.

Right brachio- 1 1
cephalic vein Left brachiocephalic vein
2 2
S.V.C.

3
3
 S.V.C.
cm in length , it has no valves .
ns at 1st right sternocostal junction by union of the two
ocephalic veins .

at 3rd right sternocostal junction by entering the right atriu

- Its upper half lies in the superior mediastinum ,

while its lower half lies
in the middle mediastinum within the fibrous
pericardium
- At the .level of the second costal cartilage , it
receives the arch of the
azygos vein which enters its right side .
- The azygos vein is the only tributary .
 S.V.C.
Anteriorly: Anterior
border
of right lung , right
pleura
and pericardium.
Right phrenic

Posteriorly: Hilum
of right
lung
To the right:
Right phrenic nerve.
Right pleura and lung.

To the left:
Ascending aorta (Anteriorly)
Trachea and right vagus
(Posteriorly )
 Thoracic
duct
1 - It is the common trunk of all lymph
vessels of the
body except :
- Right side of head and
neck .
- Right side of the thorax .
- Right upper limb .
- Upper surface of right lobe
2of liver
- It begins
. in the abdomen at L2
vertebra from the
tapering upper end of cisterna
3chyli
- It .enters thorax by passing through
aortic opening of
diaphragm between aorta and azygos
4vein
- It. ascends in posterior mediastinum
between
descending aorta and azygos vein and
behind the right
border of the esophagus till the
level of T5 vertebra . Thoracic duct
Azygos vein
 Thoracic
duct
5 - At level of T5 vertebra it crosses
from right to left Thoracic duct
behind the aorta and esophagus
to ascend in the
superior mediastinum along the
left border of the
6 - It esophagus
enters thebehind
root of
thethe neck , arch .
aortic
arches laterally
behind left subclavian artery
then descends
downwards in front of 1st part
of subclavian
artery to end in left
brachiocephalic vein at its
beginning .
Azygos vein

Thoracic duct

7 - The thoracic duct is about 18

inches long ( 45 cm ),
it has a beaded appearance , and
it has several
valves especially at it
 Thoracic
Tributar
duct
ies :
1.Right & left lumbar lymph trunks(they pierce the
corresponding crus of the diaphragm). They drain
upper lateral aortic lymph nodes.
2. Left bronchomediastinal trunk ( Drains left half of
the thorax)
3. Left jugular lymph trunk ( Drains left half of head and
neck)

4. Left subclavian lymph trunk ( Drains left upper limb)

5. Bilateral descending thoracic lymph trunks from

intercostal lymph nodes of lower 6-7 intercostal
spaces
 Right
lymph trunk
- One cm in length
- It opens in the right brachiocephalic vein at its beginning

Tributar
ies :
1. right bronchomediastinal trunk ( Drains right half of
the thorax)
2. Right jugular lymph trunk ( Drains right half of head
and neck)

3. Right subclavian lymph trunk ( Drains right upper

limb)
 Lymph drainage of
the thorax
Lymph drainage of anterior thoracic
wall : Into
Pectoral :
( Anterior) group of axillary lymph nodes.

Lymph drainage of posterior thoracic

wall : Into :
Subscapular (Posterior) group of axillary lymph nodes.

Lymph drainage of deeper

structures : Into
Internal thoracic, :
intercostal and diaphragmatic nodes.
 Right Phrenic
nerve C3
1 st part of
C4 subclavian
Right artery
phrenic C5
Scalenus
anterior
Right
brachiocephalic
vein S.V.C
.

Right
atrium
Right
phrenic
I.V.
C.

Abdominal surface of the

diaphragm
 Left phrenic
nerveC3
C4
Left
C5 phrenic
Scalenus
anterior
Left C . C . & left
subclavian
Aortic
arch

Left
ventricle

Abdominal
surface
 About phrenic
Both
nerves
enter the thorax by crossing first part of
subclavian artery .
The right phrenic ( shorter and vertical ) is
related to venous side of
the heart
The left phrenic is related to arterial side of
the heart
The phrenic nerves arises in the neck and supply
abdominal structure
( diaphragm ) ---- why?
The diaphragm develops in the neck from the
septum transversum and migrates caudally taking
its nerve with it .
The phrenic nerve supplies the abdominal surface
of the diaphragm
due
The to folding
phrenic of the
nerve is a embryo
mixed nerve ( motor to the
diaphragm and
sensory to pleura and pericardium ).
 The right
vagus nerve
Right
vagus
Subclavian
artery

Trache
a

Right
posterior
pulmonary
plexus
Posterior
esophageal
plexus
Posterior
gastric
nerve
 The left vagus
nerve
Left C . C . & Left
subclavian

Left
vagus
Aortic
arch
Left pulmonary
plexus
Anterior esophageal
plexus

Anterior
gastric nerve
 Branches of vagus
in the thorax
- Anterior pulmonary branches to join anterior
pulmonary plexus
- posterior pulmonary branches to join
posterior pulmonary plexus
- Esophageal branches to join esophageal plexus
- Cardiac branches to join superficial and
Left cardiac
-deep recurrent laryngeal nerve ( from left
plexuses
vagus ). It arises on the
left side of the aortic arch , curves below it
immediately behind
the ligamentum arteriosum to reach the
concavity of the aortic
arch . It ascends to the left between the trachea
and esophagus .
 Autonomic plexuses in
theSuperficial
thorax cardiac
plexus
Site: In concavity of aortic arch
Mode of formation
•Sympathetic : Cardiac branch from left superior cervical ganglion.
•Parasympathetic: Lower cervical cardiac branch of left vagus.

Communications: With ac
rd i l ef t o n
- Deep cardiac plexus l ca us. rom gli
- Right coronary plexus i c a ag h f
gan
ce rv ft
e
v P . ranc cal
i
S
- Left ant. Pulm. plexus r of l b erv
e
w ch ac
i rc
o r d
•L ran C a erio
b p
su
Superficial
cardiac plexus
 Autonomic plexuses in
the thorax
Deep cardiac
plexus
Site: In front of bifurcation of trachea
Communication : with :
Superficial cardiac V 1
plexus . V 4
Left anterior pulmonary
plexus .
Left coronary
Sup . G . plexus
M. G. . M. G.

V 1 Inf . G . V 3
Inf . G .
V 2

V 3

2,3,4 Deep cardiac

plexus
2,3,4
Symp . Symp .
 Autonomic plexuses in
the thorax
Pulmonary
plexuses
Anterior and posterior pulmonary plexuses: In front of
and behind corresponding hilum of the lung
Symp. : 2,3,4 thoracic ganglia
Parasymp. : Corresponding vagus

Anterior esophageal plexuses: In front of esophagus

Symp. : Greater splanchnic nerve.
Parasymp. : Left vagus

posterior esophageal plexuses: Behind the esophagus

Symp. : Greater splanchnic nerve.
Parasymp. : Right vagus
Thoracic part of
sympathetic chain
Neck of 1 st 1
rib
2
Necks of 3
ribs 4
5
6
Sides of 7
bodies of 8
vertebrae 9
1
01
11
Med . arcuate lig .
2
 Thoracic part of
sympathetic chain
Branches :
1. Each ganglion receives white ramus and gives grey ramus
communicans to corresponding spinal nerve.
2. From 1-5 ganglia to aortic plexus
3. From 2,3,4 ganglia to pulmonary & cardiac plexuses plexus
4. From 5-9 ganglia --- Greater splanchnic n. (preganglionic),
it pierces the corresponding crus of diaphragm to reach celiac plexus
in the abdomen
5. From 9,10 ganglia --- lesser splanchnic n. (preganglionic),
it pierces the corresponding crus of diaphragm to reach sup.
mesenteric plexus in the abdomen
6. From 11,12 ganglia --- least splanchnic n. (preganglionic),
it pierces the diaphragm to reach renal plexus in the
abdomen
 Thoracic part
of trachea
Cricoid
cartilage
Trach 16 - 20 C -
ea shaped
cartilages

Sternal
angle Left
Right bronchus
bronchus
 Thoracic part
of trachea R

Relation E
Anteriorly:
s 2
1. Manubrium sterni
2. Left brachiocephalic
3
3. Arch of aorta
4. Deep cardiac plexus, lymph ns
Posteriorly:
E. Esophagus
R. Left recurrent laryngeal nerve
 Thoracic part
of trachea
Relation
To the right :
s
1. Right mediastinal pleura 6
2. Right vagus 7
2 5
3. Azygos vein 3
To the left:
4. Left mediastinal pleura
5. Arch of aorta
6. Left common carotid
7. Left subclavian
 Thoracic part
of trachea
Arterial supply
in thorax :
Bronchial arteries

Venous drainage :
Into azygos & hemiazygos veins
B

B
 Bronchi
Right bronchus
Wider
Shorter (One inch)
More vertical
Gives its epiarterial bronchus
before entering the hilum.
Relations: That of the hilum
Anteriorly: Pulmonary artery
Posteriorly: Pulmonary plexus
Above: Arch of azygos
Below: Tracheobronchial L.Ns.
Left bronchus
Narrower
Longer (2 inches)
Oblique
 Gives its sup. Division within
the lung

Relations: That of the hilum
Anteriorly: Pulmonary artery
Posteriorly: Pulmonary plexus
Above: Arch of aorta
Below: Tracheobronchial L.Ns.

 Azygos Bronchi Aortic
arch arch

BE
A
A
A
VU B
B VU
VL

Right VL
bronchus Left
Anteriorly: Pulmonary bronchus
artery
Posteriorly: Pulmonary Anteriorly : Pulmonary
plexus artery
Above : Arch of azygos Posteriorly : Pulmonary
Below : Tracheobronchial plexus
L.Ns. Above : Arch of aorta
Below : Tracheobronchial
 The
Course : esophagus
muscular tube about 25 cm in length .
- It begins at the lower border of
cricoid cartilage
( C6 ) as the continuation of the
pharynx . Its
beginning
- It descendslies in the
in the neckmiddle
in
line
front . of vertebral
column , then in the superior
mediastinum
andpasses
- It finally in thethe
through posterior
mediastinum
esophageal .opening of
the diaphragm . The right crus
forms a
sphincter around it at lower
border of T10
- It ends atone
vertebra theinch
cardiac
to theendleft
of
themiddle
of stomach
linea.
the lower border of T11 one
inch to the left
of the middle line .
 The
esophagus
Curves of the
esophagus :
Anteroposterior curve : Follows the vertebral column

Left curves : A. Slight curve at the root of the neck

B. Returns to the middle line at T5
C. Curves to the left at T7
D. Remains left till it passes through
the diaphragm.

Sites of constrictions : (sites of impaction of foreign

bodies):
- At its beginning (6 inches from lower incisor teeth).
- Opposite 4th thoracic vertebra As it is crossed by the arch of
aorta.
(9 inches from lower incisor teeth).
-Opposite the 5th thoracic vertebra where it is crossed by left
bronchus (11 inches from lower incisor teeth).
- As it traverses the diaphragm (16 inches from lower incisor
teeth).
 The
esophagus
Relations in the
thorax :
Anteriorly : From above
downwards
1 - Trachea . 2 - Right pulmonary
artery
3 - Left 4- 1
bronchus Pericardium
5 - Base of the 6 . Diaphragm
heart 3
Posteriorly :
- Thoracic duct - Descending
aorta
- Hemiazygos
veins 6
- Vertebral
column
 The
esophagus
To the right : From above Thoracic duct
downwards :
- Right vagus .

- Azygos vein .
- Thoracic duct .
To the left : From above
downwards :
Thoracic duct . Azygos vein

ch of aorta , left subclavian .

Left pleura . Thoracic duct

Descending aorta .
 The
esophagus
Arterial
supply :
ophageal arteries from descending aorta .

Venous
drainage
Azygos vein
:
 Events at T4
vertebra
1 . Sternal angle . S.V.C.
4
Bifurcation of trachea . 7 5 Pulmonary
3 6 trunk
End of ascending aorta .
Beginning and end of aortic arch .
Beginning of descending aorta .
. End of pulmonary trunk .
7 . Arch of azygos joins
S.V.C..
8 . Plane between superior &
inferior
mediastinum 2
1