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HISTORY
The anatomic and surgical history of the respiratory system is summarized in Table 6-1.
Table 6-1. Anatomic and Surgical History of the Respiratory System
AssyroBabylonia

3000 to
1000
B.C.

Described the sibilanta rhonci of lung tuberculosis: "His breathing sounds like a flute"

China

1100
B.C.

The Nei Ching classified the lungs as one of the five solid formative organs. The lungs also were said to contain the emotion of sorrow.

Egyptians

663 to
The Sema Amulet represented the trachea and lungs. When depicted in color, the lung was clear, bright red, or "lung color."
520 B.C.

Galen (ca. 130200 A.D.)
Rolandus

Described the lungs, heart, and thorax as necessary for breathing. Recorded a blood supply to the lungs coming from the aorta, but
failed to name it. Called the trachea "aspera arteria" and identified the divisions of the lung. He also noted the presence of the pleura.
1499

Leonardo da
Vinci (14521519)

Resected part of a lung visible from a hernia of the chest wall
Dissected the bronchial vessels. One drawing shows increase in bronchial circulation in response to inflammation.

Andreas
Vesalius

16th
century

Used endotracheal intubation for anesthesia in animal surgery

De Pozze

1673

First description of pulmonary agenesis

Ruysch

1696

Claimed discovery of bronchial circulation: "I unhesitatingly avow that this vessel has not been seen before"

von Sömmering 1808
and
Reisseissen

Described the bronchial circulation as the "vasa nutritia" of the lung

Antony

1823

Removed a portion of a lung attached to a large mass of pus in his patient's chest

Virchow

1847

Stated that bronchial circulation preserves pulmonary function in areas of arterial obstruction

Macewen

1878

Initiated the use of tracheal intubation for oral surgery and edema of the glottis

Block

1881

Partially removed the lungs of rabbits. He tested his methods on a cousin suffering from tuberculosis, taking out the apex of each lung.
When the operation failed, Block committed suicide.

Weinlechner

1882

Unsuccessfully removed a myxochondroma of the chest wall and middle lobe. He also resected part of the upper lobe, eliminating several
metastatic deposits.

Kroenlein

1883

Performed a two-staged lower left lung resection after the recurrence and extension of previously removed osteogenic sarcoma. The
patient recovered from the operation but died of pneumonia later.

Tuffier

1891

Performed the first successful lung resection to treat pulmonary tuberculosis by removing the apex of the right lung

1896

Developed an intratracheal tube with an inflatable cuff

Matas

1899

Developed artificial respiration via intralaryngeal insufflation

Garré and
Quincke

1901

Advocated adding intrapleural or extrapleural pneumolysis to thoracoplasty

Sauerbruch

1904

Attempted the use of positive pressure respiration, using a tight-fitting face mask, while employing his negative pressure chamber or
"pneumatic chamber"

Meltzer and
Auer

1909

Proposed the use of peroral intubation to facilitate positive pressure anesthesia

Elsberg and
Lilienthal

1910

Performed the first thoracotomy under intratracheal anesthesia

Kummel

1910

Performed an unsuccessful pneumonectomy by clamping the pedicle and leaving the clamps in situ. The patient died six days later.

Stuerz

1911

Cut the phrenic nerve to obtain relaxation of the lower lobe with tubercular adhesions

Davies

1913

Performed a dissection lobectomy using individual dissection ligature and suture of the hilar structures

Lilienthal

1914

Performed a one-stage lobectomy

Bull

1920

Reported to have performed apicolysis down to the fourth rib in 116 patients

Brun

1929

Published "Surgical Principles Underlying One-Stage Lobectomy," which gave a detailed description of one-stage lobectomy. His first case
in the study dated back to 1918.

Shenstone and
Janes

1929

Used a hilus tourniquet for lobectomy. Reported its usage in 1932.

Sauerbach and
Brunner

1930s

Developed selective apical thoracoplasty

Churchill

1931

Performed dissection lobectomy, reestablishing its efficacy after Davies' 1913 procedure

Nissen

1931

Succeeded in performing a two-stage total pneumonectomy to treat diffuse bronchiectasis of the left lung. This procedure involved tying

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Nissen

1931

Succeeded in performing a two-stage total pneumonectomy to treat diffuse bronchiectasis of the left lung. This procedure involved tying
off the hilum with rubber tubing and several silk ligatures, then waiting for the necrotic lung to slough off two weeks later.

Kramer and
Glass

1932

Originated the term "bronchopulmonary segments" to describe lung anatomy

Haight

1932

Performed a successful total pneumonectomy using a procedure similar to Nissen's

Bigger

1932

Performed a bronchotomy in order to remove a tumor of the left bronchus

Graham and
Singer

1933

Performed a one-stage total pneumonectomy when unexpectedly forced to resect the entire lung while treating a bronchogenic
carcinoma too close to the lobar bifurcation point

Rienhoff

1933

Introduced the modern technique of bronchial suture by cutting the cartilage at various points and using interrupted silk sutures to
suture the bronchus

Freedlander

1935

Reported an unsuccessful case of pulmonary lobectomy

Belsey and
Churchill

1939

Performed a lingulectomy, which is often thought of as the first segmental resection. They wrote, "It is suggested that the
bronchopulmonary segment may replace the lobe as the surgical unit of the lung."

Eloesser

1939

Removed an adenoma originating in the lower left lobe bronchus

Kent and
Blades

1942

Published a paper long considered the basis of the techniques of individual hilar ligation

Belsey

1944

Repaired a bronchus using fascia after removing a bronchial adenoma

Allison

1946

Reported on a procedure involving intrapericardial pneumonectomy with dissection of mediastinal tissue and lymph nodes (radical
pneumonectomy)

Thomas

1947

Performed a bronchial sleeve lobectomy

Sellors

1947

Performed a pulmonic valvotomy

Juvenelle

1947

Published report of investigation of pulmonary denervation which concluded that animals could survive lung autotransplantation

Gebauer

1948

Performed the first bronchial excision-reconstruction procedure, using a wire-supported dermal graft

Overholt and
Langer

1949

Systematized operative methods for segmental resection

Metras

1951

Described canine lung transplantation, with dogs surviving up to 29 days

Overholt

1952

Performed a simultaneous bilateral resection for bronchiectasis

Neptune

1953

Published report of attempts of en-bloc heart-lung transplantation in dogs

Björk and
Bagger

1954

Performed a pulmonary resection with pulmonary valvulotomy on a patient with pulmonary stenosis and pulmonary tuberculosis

Price-Thomas

1955

Performed a sleeve resection of the bronchus, removing a right main bronchus adenoma

Gaensler

1956

Advocated parietal pleurectomy to treat recurrent pneumothoraces

Brantigan

1959

First postulated that force needed to keep airways open is missing in emphysema; partial lung resection would improve patient's
condition by restoring this force

Hardy and
Webb

1963

Transplanted a human lung. The patient survived 17 days.

Jensik

1966

Advocated irradiation before bronchopulmonary sleeve resection for lung cancer

Lower and
Shumway

1980

Explained en-bloc heart-lung transplantation in primates

Reitz

1981

Reported successful human heart-lung transplant

Perelman

1983

Developed and performed limited (less than segmental) pulmonary resection

Swanson et al.

1997

First report of minimally invasive technique for lung volume reduction surgery (LVRS) without cutting visceral pleura, thereby reducing
morbidity/mortality due to air leaks, improving mechanics of breathing, and reducing trauma to patient

Cooper

1997

Described improvement on partial lung resection for severe emphysema first developed by Brantigan in 1959. Both lungs partially
resected at the same time with median sternotomy.

History table compiled by David A. McClusky III and John E. Skandalakis.
References
Brantigan O, Mueller E, Kress MB. A surgical approach to pulmonary emphysema. Ann Rev Respir Dis 1959;80:194-202.
Cooper JD. The history of surgical procedures for emphysema. Ann Thorac Surg 1997;63:312-319.
Deffebach ME, Charan NB, Lakshminarayan S, Butler J. The bronchial circulation: small, but a vital attribute of the lung. Am Rev Respir Dis 1987;135:463-481.
Fell SC, Kirby TJ. Segmental resection. In: Pearson FG, Deslauriers J, Hiebert CA, McKneally MF, Ginsberg RJ, Urschel HC (eds). Thoracic Surgery. New York: Churchill
Livingstone, 1995, pp. 854-855.
Grover FL, Fullerton DA, Zamora MR, Mills C, Ackerman B, Badesch D, Brown JM, Campbell DN, Chetham P, Dhaliwal A, Diercks M, Kinnard T, Niejadlik K, Ochs M. The
past, present, and future of lung transplantation. Am J Surg 1997;173:523-533.
Martini N, Ginsberg RJ. Lobectomy. In: Pearson FG, Deslauriers J, Hiebert CA, McKneally MF, Ginsberg RJ, Urschel HC (eds). Thoracic Surgery. New York: Churchill
Livingstone, 1995, pp. 848-849.
Naruke T. Mediastinal lymph node dissection. In: Pearson FG, Deslauriers J, Hiebert CA, McKneally MF, Ginsberg RJ, Urschel HC (eds). Thoracic Surgery. New York:
Churchill Livingstone, 1995, p. 909.
Naef AP. The Story of Thoracic Surgery: Milestones and Pioneers. Toronto: Hogrete and Huber Publishers, 1990.
Naef AP. Early history of thoracic surgery. In: Shields TW (ed). General Thoracic Surgery. Baltimore: Williams and Wilkins, 1972, pp. 1-9.
Naef AP. Pioneers on the road to thoracic surgery. J Thorac Cardiovasc Surg 1991;101:377-384.
Swanson SJ, Mentzer SJ, DeCamp MM Jr, Bueno R, Richards WG, Ingenito EP, Reilly JJ, Sugarbaker DJ. No-cut thorascopic lung plication: a new technique for lung
volume reduction surgery. JACS 1997;185:25-32.

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Tsuchiya R. Bronchoplastic bronchovascular techniques. In: Pearson FG, Deslauriers J, Hiebert CA, McKneally MF, Ginsberg RJ, Urschel HC (eds). Thoracic Surgery. New
York: Churchill Livingstone, 1995, p. 870.
Warren R. Surgery. Philadelphia: W.B. Saunders Company, 1963, pp. 598-599.
Waters PF. Pneumonectomy. In: Pearson FG, Deslauriers J, Hiebert CA, McKneally MF, Ginsberg RJ, Urschel HC (eds). Thoracic Surgery. New York: Churchill
Livingstone, 1995, p. 844.

EMBRYOGENESIS

Normal Development
During the fourth week of development, the primordium of the lower respiratory system appears to start with an opening at the ventral pharyngeal wall of
the foregut. This opening is the laryngotracheal groove. The laryngotracheal groove will later produce an outgrowth, the respiratory diverticulum, which will
in turn produce the respiratory epithelium.
The respiratory diverticulum grows, carrying with it the mesenchyme. It finally separates from the pharynx (which represents the cranial part of the
foregut) by the two esophagotracheal ridges. These ridges unite and form the esophagotracheal septum. The esophagotracheal septum divides the foregut
into an anterior (ventral) part (the laryngotracheal tube) and a posterior (dorsal) part (the esophagus) (Fig. 6-1). The mesenchyme produces connective
tissue, muscle, and cartilage for the larynx, trachea, and lungs.
Fig. 6-1.

Division of the foregut into trachea and esophagus. Stippled area shows the future tracheal portion. Arrows indicate the local morphogenetic movements. (Modified
from Skandalakis JE, Gray SW. Embryology for Surgeons, 2nd ed. Baltimore: Williams & Wilkins, 1994; with permission.)

Remember

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The respiratory primordium continues to communicate with the pharynx through its opening, which will become the laryngeal orifice or the inlet of the larynx.
Therefore, the proximal end of the diverticulum will produce the larynx.
The epithelium and glands of the trachea and lungs are of endodermal origin. Cartilages and muscles of the trachea are of splanchnic mesenchymal origin.

Prenatal Lung
During the fourth and fifth weeks, two asymmetrical phenomena occur. First, 26 days after fertilization,2 the tracheal end of the diverticulum, which is still
the respiratory diverticulum, produces the two lung buds (Fig. 6-2). The bronchial buds enlarge to form the primordia of the right and left bronchi. The
former has a caudal pathway and the latter an oblique one.
Fig. 6-2.

Development of trachea and bronchi. A, Four anterior views and lateral view of lung buds at the end of the fifth week (horizon XIII). B, Lateral view at the middle
of the sixth week (horizon XV). C, Lateral view near the end of the sixth week (horizon XVI). (Modified from Streeter GL. Developmental horizons in human
embryos: description of age group XIII, embryos about 4 or 5 mm long, and age group XIV, period of indentation of the lens vesicle. Contrib Embryol Carnegie Inst
Wash 1945;31:27-63; Streeter GL. Developmental horizons in human embryos: description of age groups XV, XVI, XVII, and XVIII. Contrib Embryol Carnegie Inst
Wash 1948;32:133-204; with permission.)

The second asymmetrical phenomenon is the production during the 5th week of two lateral buds on the right bronchus and only one on the left. The
bronchial tree subdivides within the lung bud to form several blind ends (the so-called infundibula).
GENESIS OF THE LOBES
The genesis of the lobes takes place as follows:
On the right

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The pulmonary formation ceases around the end of the 5th week. The trachea and esophagus have elongated. with permission. Respiratory System – the upper lateral bud produces the lateral bronchus and upper lobe – the lower lateral bronchus produces the middle lobe – the stem (lowest) bronchus produces the lower bronchus and lower lobe On the left – the (single) lateral bronchus produces the upper left bronchus and lobe – the original left stem bronchus produces the left lower bronchus and lobe Lobe segmentation (bronchopulmonary segments) continues until there are 10 segments on the right and 8 on the left (Fig. 6-3. These are: glandular or pseudoglandular. Contrib Embryol Carnegie Inst Wash 1948.htm 5/46 .bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. Development of trachea and bronchi. XVI.32:133-204. three antenatal periods or phases of ramification of the pulmonary systems commence sequentially.uni-plovdiv.) At this time. GLANDULAR OR PSEUDOGLANDULAR PHASE This phase starts at the end of the 5th week and perhaps ends around the 16th week. Anterior and lateral views at the beginning of the seventh week (horizon XVII). canalicular. and five orders of bronchial branching are visible. This phase was named glandular or pseudoglandular because http://web. and alveolar or terminal sac. (Modified from Streeter GL. XVII. 6-3).5/24/2014 On the right Print: Chapter 6.3 Fig. and XVIII. Developmental horizons in human embryos: description of age groups XV.

bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. The embryonic right primary bronchus develops two primary buds. asplenia and anomalous pulmonary veins Bronchgenic cysts Week 6-7 Infancy. Postnatal Lung During the first week. From the sixth through the eighth week. http://web. if at all ? Uncommon Compression of trachea may be fatal Pulmonary cysts Week 24 Infancy and childhood Male Uncommon Eventually fatal if untreated Congenital cysts of the respiratory tract: Source: Skandalakis JE. The pulmonary alveoli of the newborn are said to be 20 million. therefore. 2nd Ed. They will later become secretory epithelial cells (type II pneumocytes) and produce surfactant. The left primary bronchus produces only one primary bud which forms the left upper lobe. Respiratory System clusters of solid epithelial cuboidal cells surrounding each infundibulum of the bronchial tree give the pulmonary parenchyma the histologic appearance of an exocrine gland. Blood and lymphatic capillaries absorb the fluid occupying 50% of the lung. Embryology for Surgeons. Typically 10 segmental bronchi form on the right lung and 8 form on the left. This phase is associated with a rich vascular proliferation of blood capillaries and lymph capillaries. a foreign body within the trachea will most often travel downward into the right bronchus. ALVEOLAR OR TERMINAL SAC PHASE This period extends from the 24th to 26th week until birth. Gray SW. Gas exchange is not possible. 6-4. Thus. the number in adults is approximately 300 million. Cormack4 stated that 95% of alveoli develop after birth. CANALICULAR PHASE This period starts around the 16th week and ends around the 25th week. NOTE: More alveoli are formed during the first postnatal years. The development of terminal sacs multiplies during the terminal sac phase. At its commencement. and the multiple bronchioles have enlarged laminae. 1994. Three Embryoanatomic Pulmonary Asymmetric Curiosities It has been said that: The right primary bronchus has a caudal pathway and the left bronchus an oblique one. terminal sac (alveolar) formation overlaps the end of the previous period.uni-plovdiv. 6-4. Respiration at the 24th to 25th week is possible and the born fetus may be able to survive. The left lower lobe is produced by the blind end of the primary left bronchus. Congenital Anomalies Congenital anomalies of the trachea and lungs are shown in Table 6-2 and Fig. The pulmonary tissues become very vascular. These are the alveolar epithelial cells (type I pneumocytes). The premature infant will survive only if adequate pulmonary vasculature and surfactant are present. Surfactant lines the terminal sacs in a coatlike formation. air inflates all the alveoli. The epithelium of the sacs becomes thin and flat. there is rapid development of alveoli.5/24/2014 Print: Chapter 6. the fetus born at this phase cannot survive. and the surfactant promotes maturity of the antenatal lungs. lowering surface tension and preventing collapse during expiration of the alveoli. Fig. the lungs have some secretory function. The respiratory apparatus of the lungs is formed during this period by ramification of blood vessels around the infundibula as well as around the primordia of pulmonary alveoli. A premature seven-month fetus may survive because the respiratory system at this time has good function. The blind end of the primary bronchus then forms the right lower lobe. the upper for the upper lobe and the lower for the middle lobe. Congenital Anomalies of the Trachea and Lungs Anomaly Prenatal Age at Onset First Appearance (or Other Diagnostic Clues) Sex Chiefly Affected Relative Frequency Remarks Tracheal atresia Week 3-4 At birth ? Very rare Fatal at birth Congenital tracheal stenosis Week 3-4 At birth ? Rare Usually fatal soon after birth Tracheobronchomegaly Mo 5 Late childhood or later ? Rare Bilateral agenesis of the lungs Week 4 At birth ? Very rare Fatal at birth Unilateral agenesis and hypoplasia of the lungs Late week 4 Infancy and childhood Female Uncommon 50% die in first 5 yrs Anomalies of lobulation Week 10 None Male ? Common Asymptomatic Pulmonary isomerism Unknown None ? Uncommon Associated with heterotaxy. Table 6-2. Baltimore: Williams & Wilkins.htm 6/46 .

) Accessory Lobes According to Shields.5 the common accessory lobes are the posterior accessory. 2nd ed. Respiratory System Congenital anomalies of the trachea and lungs. middle lobe of the left lung.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. Embryology for Surgeons. with permission. Fig. http://web. (Modified from Skandalakis JE. 1994. 6-5.5/24/2014 Print: Chapter 6. 6-6). Baltimore: Williams & Wilkins.htm 7/46 . inferior accessory. and "azygos lobe" of the upper right lobe (Figs.uni-plovdiv. Gray SW. 6-5.

S.v. Upper portion of the right lung. Contents of the right pleural cavity.uni-plovdiv. the associated great vessels..c. d to f.v. superior vena http://web.4 percent (8 cases in 2. 6-6. Posterior thoracic structures. anterior jugular vein. and (at *) the transverse connection between the azygos and hemiazygos veins...bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System..5/24/2014 Print: Chapter 6.v. right innominate vein (NA. showing the pulmonary relations of the anomalous azygos vein and its connections. S. in the author's 65 laboratory.j.i. a.j. showing the azygos vein. left innominate vein. L. three aspects.. Inset: The anomalous azygos vein with part of its reflection of the parietal pleura. Fig. b.. upper pulmonary lobe is retracted to expose the accessory lobe and the anomalous azygos vein. brachiocephalic). subclavian vein.000 specimens). A. Azygos lobe. Transverse section through the right lung and related structures at the level of the loop of the anomalous azygos vein. I. internal jugular vein.i. seen in anterolateral view. c.htm 8/46 . Incidence of anomalous lobe.v. R. Respiratory System Accessory lobes of the lungs. 0.v.v.

Analysis of the ramification of veins revealed that V(6) (superior vein) tributaries were often double. 6-7. I. called "agenesis of the lung" in earlier classifications Class II bronchopneumonic dysplasia (Fig. Pulmonary aplasia. 2nd Ed. F) Displacement of part or all of a lung has occurred. with permission.v.) There is confusion in the literature about the terminology for these "accessory lobes. Normal lungs. 6-7C. Some bronchial elements are present. Analysis of the ramification of bronchi revealed that B(7) (medial basal bronchus) tended to form a common trunk with B* (subsuperior bronchus) or B(8) (anterior basal bronchus). Schechter8 classified congenital deficiency of lung tissue as follows: Class I bronchopneumonic aplasia (Fig. Enlargement of the sound lung and the resulting displacement of the heart and mediastinum are not shown. Philadelphia: WB Saunders.j. The incidence of PPL was 13% on the right side and 3% on the left side. 6-8D. the azygos lobe is not an accessory lobe.Nineteen PPL cases (15 right and 4 left) were found in 273 (116 right and 157 left) human lung specimens. anterior jugular vein.. left innominate vein. (Modified from Anson BJ. S. inferior and middle lobe of the left lung are true accessory lobes.i. Aplasia.v.s. It is formed by a deep indentation from an aberrant tributary of the azygos vein and its mesoazygos component in the region of the apical and posterior segments of the right upper lobe. Pulmonary dysplasia. mediastinal surface. The azygos lobe varies in size and extent.. but there are no alveoli. vertebrocostal surface.c..j. An Atlas of Human Anatomy. L.6:286-313. parenchyma... with bronchoesophageal fistula present Fig.. subclavian vein. A. (Modified from Schechter DC. These results show that the PPL does not always correspond to S(6) and frequently has an anomalous vessel from other segments. 1963. and Hypoplasia of the Lung Raffensperger7 provided pragmatic definitions of pulmonary unilateral agenesis (complete absence of bronchus.. The PPL frequently (right 87%. B.c. 6-7B) Unilateral or bilateral absence of the entire lung and bronchial tree.) Fig. http://web. We quote from their excellent work: The posterior pulmonary lobe (PPL) is defined by an aberrant fissure running horizontally on the costal surface of the lower lobe.. called "aplasia of the lung" in earlier classifications Class III bronchopneumonic hypoplasia (Fig. superior vena cava.5/24/2014 Print: Chapter 6. C) Entire lung is reduced in size or one lobe of lung is absent Class IV bronchopneumonic ectoplasia (Fig.v. it is a partial separation of a portion of the apical segment of the right upper lobe by the azygos venous arch.v. and V(6) tended to disperse widely." The posterior. Respiratory System innominate vein (NA. M. E. with complete absence of both bronchial and alveolar tissue.6 studied the segmental and vascular anatomy of the posterior pulmonary lobe. V. with permission. Ann Thorac Surg 1968. Unilateral Agenesis. 6 right and 1 left) in PPL. brachiocephalic). and vessels) and pulmonary hypoplasia (various degrees of underdevelopment). internal jugular vein.htm 9/46 . In reality. 6-8A. S. Congenital absence or deficiency of lung tissue: the congenital subtractive bronchopneumonic malformations. Matawari et al. A.s. D) Interrupted formation of the bronchial tree with absence of alveoli..v. B.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. 6-8. left 50%) corresponded to S(6) (superior segment).uni-plovdiv. Anomalies in which the segmental artery and vein communicated with other segments were found in seven cases (37%) (4 arteries and 3 veins. C and D.

Hypoplasia resulting from lobar dysplasia. the trachea is located between C6 and T6 (Fig. Three conditions of different embryogenesis that all result in a smaller than normal lung. including the tracheal bifurcation. 6-9). according to Endo et al. This anatomic variant is reported in approximately 1 of 250 patients at bronchoscopy. Congenital absence or deficiency of lung tissue: the congenital subtractive bronchopneumonic malformations. D to F. There was cervical ascent of the liver and right hemidiaphragm. because of the risk of pulmonary compression. Ann Thorac Surg 1968. infection. (Modified from Schecter DC. Bronchoesophageal fistula.5/24/2014 Print: Chapter 6. Sequestration of lower lobe and dysplasia of upper lobe. the interested student is encouraged to read Embryology for Surgeons.) Peragallo and Swenson9 studied congenital tracheal bronchus: Tracheal bronchus is a congenital anomaly in which the right upper lobe bronchus originates from the lateral tracheal wall. 6-9. the trachea can be divided into two parts: upper (or cervical) and lower (or thoracic). Although it is usually of little clinical significance.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. E. . For details of congenital anomalies of the respiratory system. In the few cases of a fetal intrathoracic mass.10 presented a case of unilateral right pulmonary agenesis without mediastinal displacement. In upright posture.uni-plovdiv.6: 286-313. http://web..13 SURGICAL ANATOMY Trachea From a surgicoanatomic viewpoint. Respiratory System A to C. The accompanying mediastinal shift is not shown. A. Alveolar tissue not functional. this atypical origin of the right upper lobe bronchus may complicate one-lung ventilation during thoracic surgery. with permission.14 the tracheal length may increase by approximately 1. According to Kubik and Healey. Pulmonary ectoplasia. D. Sequestration of right lower lobe.5-2. . Congenital pulmonary venous obstruction causes pulmonary hypertension which. Part or all of one lung is attached to the esophagus and usually is supplied by a systemic artery.11 about congenital parenchymatous malformations: [A]ny thoracic cystic lesion expanding on chest radiography should be an indication for surgical resection. We quote from Evrard et al. even if asymptomatic. The length of the trachea in the supine position is 10 to 13 cm from the laryngotracheal junction at C6 (cricoid cartilage) to T4 where the bifurcation is located. or malignant degeneration.5 cm during the processes of swallowing or respiration. Fig. B. C. prenatal diagnosis and intrauterine intervention may be indicated. Roque et al.12 seems to be reversible and amenable to operation. Pulmonary hypoplasia.htm 10/46 . Reduced size of one lung. F.

The position of the trachea is not fixed. Respiratory System Origin of the trachea at the level of the sixth cervical vertebra.5-2 cm below the skin. 1963.htm 11/46 . Fig.14 the cervical trachea at its origin is located 1. The rings are united by a thin elastic membrane. and at the bifurcation the depth is at approximately 7 cm.5/24/2014 Print: Chapter 6. the cartilages are united by the thin tracheal smooth muscle (the trachealis). Clinical Anatomy.5-5. 6-10). it can deviate to the right or left because it is ensheathed within a stroma of loose connective tissue that also is related to the esophagus. because the cricoid cartilage drops to the level of the thoracic inlet. The sternal notch is 4. New York: McGraw-Hill.) Mulliken and Grillo15 stated that the trachea can be located totally within the mediastinum when the neck is flexed.0 cm beneath the skin.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. The following is a summary of the topographic relations of the cervical trachea (Fig. http://web. (Modified from Brantigan OC. The trachea has 15 to 20 U-shaped rings of hyaline cartilage that are responsible for the lateral rigidity of the organ. 6-10. Topography and Relations CERVICAL TRACHEA According to Kubik and Healey. with permission. Posteriorly.uni-plovdiv.

New York: Parthenon. 3rd. manubrium of sternum Thymus and thymic fat. with permission. RV. and vagus nerve Omohyoid. Lateral Skin. Anterior Skin. Skandalakis JE.uni-plovdiv. these vessels and the isthmus are covered with a thin connective tissue stroma. 6-11) Left brachiocephalic vein Brachiocephalic artery and left common carotid artery. and 4th tracheal cartilages. Clinical Gross Anatomy. (Modified from Colborn GL. sternohyoid. superficial fascia. thymic vessels (Fig.) Anterior Skin Subcutaneous fascia with platysma Investing layer of deep cervical fascia Sternohyoid and sternothyroid muscles Pretracheal fascia Inferior thyroid and thyroid ima veins. sternothyroid muscles Middle thyroid vein Thyroid lobe Inferior thyroid artery and recurrent laryngeal nerve Paratracheal lymph nodes Posterior Thin areolar tissue Esophagus Prevertebral ("danger") space of the neck Vertebral column and musculature THORACIC TRACHEA The thoracic trachea is the deepest anatomic entity of the superior mediastinum. and platysma Sternocleidomastoid muscle and cervical investing fascia Carotid sheath with common carotid artery. superficial fascia. Occasionally the thyroid ima artery is located just below the isthmus. 6-12) Fig. D. aortic arch Cardiac plexus (Fig. retrovisceral or retropharyngeal space between the prevertebral fascia and the pretracheal (visceral) facial layers. 1993.htm 12/46 . The topographic relations of the thoracic part of the trachea follow. 6-11.5/24/2014 Print: Chapter 6. The thyroid isthmus is in front of the 2nd. http://web. the "danger space" within the prevertebral fascia. internal jugular vein. Respiratory System Cross section of the neck showing fascial layers.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System.

Lateral On the right: right vagus nerve.uni-plovdiv. mediastinal pleura. showing the deep cardiac plexus. http://web. 6-12. The lower end of the trachea. azygos venous arch (Figs. left common carotid artery Fig. left recurrent laryngeal nerve. 6-12. 6-13) On the left: paratracheal nodes. paratracheal lymph nodes. Fig. Respiratory System The thymic vessels.5/24/2014 Print: Chapter 6.htm 13/46 .bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. 6-13.

Vascular Supply http://web. an alternative radiographic marker is needed for correct placement of central venous catheters. Respiratory System Right vagus nerve. bronchial arteries The carina is an inside ridge at the bifurcation of the trachea at the level of the last tracheal cartilage.uni-plovdiv.5/24/2014 Print: Chapter 6. The carina is a reliable.1) cm above the pericardial sac as it transverses the superior vena cava. Posterior Esophagus TRACHEAL BIFURCATION At the level of the sternal angle anteriorly and the fifth thoracic vertebra posteriorly.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. the carina is radiologically visible even in poor quality.4 (0. right pulmonary artery Posterior Pulmonary plexus. In almost all cases.. Schuster et al. Because the pericardium cannot be seen on chest x-ray. portable chest x-rays. The topography and relations of tracheal bifurcation are: Anterior Superior and inferior tracheobronchial lymph nodes.htm 14/46 .The carina was a mean distance of 0. just above the left atrium.16 proposed the carina as a landmark for central venous catheter placement: Location of the tip of a central venous catheter within the pericardium has been associated with potentially lethal cardiac tamponade. Central venous catheter tips should be located in the superior vena cava above the level of the carina in order to avoid cardiac tamponade. the trachea bifurcates into the right and left primary bronchi. simple anatomical landmark for the correct placement of central venous catheters.. In no case was the carina located below the pericardial sac.

Respiratory System ARTERIES The arterial supply of the trachea is from the inferior thyroid arteries and from branches originating from the superior thyroid arteries. bronchial arteries. tracheal. LYMPHATICS The tracheal lymphatic vessels drain into the cervical. The length of the left primary bronchus. and internal thoracic arteries.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. and tracheobronchial lymph nodes. VEINS The inferior thyroid veins drain the trachea. 6-14. The shorter and larger (2.htm 15/46 . almost double that of the right primary bronchus. The primary bronchi (A) and some of their anterior vascular relations (B and C). The left bronchus crosses anterior to the esophagus to reach the left hilum behind the left third costal cartilage. disappearing at the level of the bronchioles. although the irregularity of the cartilaginous plates increases distally. Many small clusters of ganglionic cells are present in the autonomic plexuses of the walls of the trachea and bronchi. The reflection of the pericardial sac upon the great vessels is shown in C. Bronchi (Fig. These fibers are bronchoconstrictive. Parasympathetic fibers arise from the vagus nerves and the recurrent laryngeal nerves and pass to the mucosa and tracheal muscle.uni-plovdiv. The plates of cartilage decrease in prominence within the lungs. Both bronchi have mobility and elasticity comparable to that of the trachea.5 cm) right bronchus turns only slightly from the vertical orientation of the trachea through the mediastinum. Fig. http://web. 6-14) Each primary bronchus extends from the tracheal bifurcation to the hilum of the related lung. passes more obliquely laterally to the left.5/24/2014 Vascular Supply Print: Chapter 6. Innervation Sympathetic fibers from the cardiac branches of the cervical sympathetic trunk and thoracic visceral nerves convey postganglionic fibers to the tracheal muscle for bronchodilatation. emptying into one or both brachiocephalic veins.

when compared to the right bronchus. giving origin to its pulmonary branch to the right lung LEFT PRIMARY BRONCHUS Anterior The aortic arch. superior vena cava (SVC) Posterior The azygos arch curves over the bronchus and drains into the SVC The right vagus nerve passes between the azygos arch and the proximal part of the bronchus.the left lung.17: [The] left lung is more vulnerable to bronchiectasis than the right. Saja KF. Al-Fraye AR. World J Surg 1999. Anatomy of the left main bronchus as it passes through the subaortic tunnel. RIGHT PRIMARY BRONCHUS Anterior Right pulmonary artery. left pulmonary artery and vein NOTE: The pulmonary artery is located between the left upper lobe bronchus and the left primary bronchus. is more vulnerable to the bronchiectatic process both in frequency and severity. main pulmonary artery. and pulmonary plexus http://web.) According to Trotter et al.uni-plovdiv.18 torsion of the lung in toto or torsion of a lobe may be spontaneous or occur after trauma.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. Current surgical therapy for bronchiectasis. a narrower diameter. Posterior Descending aorta. . a clinical observation that could be explained on the basis of the anatomic peculiarities of the left main bronchus. .5/24/2014 Print: Chapter 6. The latter. when compared to the right. 6-15. 6-15) . (Modified from Ashour M. with permission. Al-Kattan K. Rafay MA.23: 1096-1104. Hajjar W. Respiratory System We agree with the anatomic observations of Ashour et al. and limited peribronchial space as it passes through the subaortic tunnel (Fig.. Anatomic features of the left main bronchus make it more prone to obstruction than the right. ascending aorta. Felson19 stated that the following anatomic conditions may be responsible for this rare and peculiar pathological occurrence: Abnormal length of the primary or lobar bronchus with free pedicle A complete fissure Absence of the inferior pulmonary ligament Topographic Relations The topographic relations of the bronchi follow.htm 16/46 . Fig. has a longer mediastinal course. esophagus.

Origins and Number of Bronchial Arteries in 150 Dissected Autopsy Specimens Anatomic Variation Number of Right Bronchial Arteries Number of Left Bronchial Arteries Percent Incidence I 1 2 40. Table 6-3.20 Miller and Nelems.6 VIII 1 4 0.86:395-412..bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System.23 and several other investigators. In most cases the single right bronchial artery arises from the aorta or the third right posterior intercostal artery. The bronchial arteries: an anatomic study of 150 human cadavers. ARTERIES (Fig. The left lung is nourished by two bronchial arteries that arise directly from the beginning of the descending thoracic aorta. 6-17A & B.0 VII 3 2 0. but capable of giving vital help when needed. http://web. subclavian artery. Source: Caudwell EW. Variations in origin of bronchial arteries are shown in Figs. The origins of the bronchial arteries and the pattern of bronchial venous drainage are both highly variable. with permission.htm 17/46 . Respiratory System The left vagus nerve crosses behind the left bronchus.6 *A branch from the left bronchial artery anterior to the esophagus passing to the right bronchus plus two right bronchial arteries from the aorta and one right bronchial artery from the subclavian artery. Anson BJ. They may arise from the internal thoracic artery.5/24/2014 Print: Chapter 6. 6-16..3 III 2 2 20.22 Deffebach et al.21 Olson and Athanasoulis.7 V 1 3 4. Siekert RG. Fig. providing a pulmonary branch that passes to the left lung Vascular Supply The bronchial circulation is like Mother or the Red Cross: normally accepted and unsung.8 IV 2 1 9. or inferior thyroid arteries. Table 6-3) The origin of the right and left bronchial arteries is very variable.20 The bronchial blood supply has been studied in detail by Cauldwell et al. 6-16. Lininger RE.uni-plovdiv.0 VI 2 3 2. Surg Gynecol Obstet 1948.6 IX 4* 1 0.8 II 1 1 21.—Deffebach et al.

htm 18/46 . http://web. Lininger RE. See Table 6-3 for percentage of occurrence of each. Surg Gynecol Obstet 1948. The bronchial arteries: an anatomic study of 150 human cadavers. Respiratory System The four most common sites of origin and numbers of bronchial arteries to the right and left lungs. 6-17. with permission.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System.86:395-412.5/24/2014 Print: Chapter 6. Siekert RG.) Fig. (Modified from Cauldwell EW. Anson BJ.uni-plovdiv.

left view. According to Deffebach et al. VEINS The right bronchial veins (usually two) drain to the terminal part of the azygos vein. whereas intrapulmonary flow becomes anastomotic with the pulmonary circulation and returns to the left heart. The bronchial circulation: small. right view. http://web. Their findings on the feasibility of bronchial artery revascularization may be applicable to pulmonary transplantation. (Modified from Deffebach ME.24 dissected 40 fresh cadavers.uni-plovdiv. 6-19.htm 19/46 . 6-18. A.) After Carles et al.135:463-481. 6-18). Fig. since its abolition is possible during lung transplantation (Fig.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. Butler J. Am Rev Respir Dis 1987. Fig. Their excellent article explores the "small.. Lakshminarayan S. 6-19. Schematic of the systemic blood supply to the lung.20 the systemic bronchial arterial blood network "appears to be quite unimportant" at first. but a vital attribute of the lung. Charan NB. with permission. 6-20). B. they reported that the bronchial blood supply is dominated by the intercostobronchial trunk and anastomotic networks of different territories of the bronchial tree. Note that the flow from the extrapulmonary airways and supporting structures returns to the right heart. and the left bronchial veins end in the left superior intercostal vein or the accessory hemiazygos vein (Figs. but vital" role of bronchial circulation in health and disease.5/24/2014 Print: Chapter 6. Respiratory System Variations in origin of bronchial and esophageal arteries.

Respiratory System Right bronchial veins.uni-plovdiv. 6-20.5/24/2014 Print: Chapter 6.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. Fig. http://web.htm 20/46 .

with permission. (Modified from O'Rahilly RO. 1932. The bronchi are relatively insensitive to pain.uni-plovdiv. three borders. Both lungs exhibit the following characteristics: apex. A dashed line indicates the course of a left superior vena cava (a rare anomaly) on its way to the coronary sinus. and fissures (Figs. 6-22A & B).) LYMPHATICS Lymphatic vessels from the bronchi pass to the bronchopulmonary and tracheobronchial lymph nodes (Fig. Lungs Topography and Relations The lungs are movable organs within the thoracic cavity.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. The right lung is shorter because of the right hepatic lobe. Gardner-Gray-O'Rahilly Anatomy: A Regional Study of Human Structure. and stimulation of their mucosal lining produces coughing. Philadelphia: WB Saunders. Each lung accepts the bronchi as well as the pulmonary vessels. 6-22. Fig. http://web. 6-21. Respiratory System The main veins of the thorax. Anatomie des Lymphatiques de l'Homme. Pulmonary lymphatics: overall view of regional drainage. The right lung is composed of three lobes and the left lung of two lobes.htm 21/46 . three surfaces. 6-21). with permission. both are anchored to the heart and trachea. however.5/24/2014 Print: Chapter 6. 1986. base. (Modified from Rouvière H. Both the liver and heart modify the external contour of each lung. Fig. the left lung is narrower because of the leftward location of the heart and pericardium. Paris: Masson. 5th Ed.) Innervation Sympathetic and parasympathetic innervation occurs through the pulmonary and cardiac plexuses.

htm 22/46 .5/24/2014 Print: Chapter 6. Respiratory System http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System.

5/24/2014 Print: Chapter 6.htm 23/46 .bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System.uni-plovdiv. Respiratory System http://web.

htm 24/46 . diaphragm. A. peritoneum. The medial or mediastinal surface of the lung is in contact with the organs of the mediastinum (Fig. and the angle of view. B. 1st thoracic nerve. vessels. diaphragm. The posterior part of the medial surface is related to the spine. (Modified from Frick H. The apex of the left lung is a little longer than that of the right. The right lower lobe is related to the pleura. right brachiocephalic vein. Fig. posture. and inferior pulmonary borders. and right lobe of the liver. gastric fundus. and spleen. 6-23. superior intercostal artery Medial: brachiocephalic trunk. Wolf-Heidegger's Atlas of Human Anatomy (4th ed). body build. Kummer B.uni-plovdiv. vagus nerve Posterior: sympathetic trunk. anterior view of male. middle. anterior scalene muscle. THREE PULMONARY SURFACES The costal surface of each lung is related to the thoracic wall. posterior. The hilum (pulmonary porta) is the most important anatomic area for the entrance and exit of bronchi. The left lower lobe is related to the pleura. Putz R. The relations of the apex are as follows: Anterior: subclavian artery. 1990. phrenic nerve. with permission. It projects above the clavicle into the base (root) of the neck. trachea on the right. posterior view of male. and posterior mediastinum. http://web. Respiratory System Projections of thoracic viscera. The extent of the lung above the clavicle varies with respiration. left lobe of the liver. first rib BASE The base is related to the superior surface of the diaphragm and several subdiaphragmatic organs. subclavian vein. It ends at the anterior. and nerves.) APEX The apex is covered by pleura.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. left subclavian artery and left brachiocephalic vein on the left Lateral: scalenus medius muscle. 6-23).5/24/2014 Print: Chapter 6. peritoneum. Basel: Karger. Its medial mediastinal part is related to the superior.

Philadelphia: BC Decker.uni-plovdiv. v.5 cm. Its most inferior part was at the level of L1 or L2. 6-25). The left anterior ILM was visible in 64% of cases and more often oblique inward and upward (58%). THREE PULMONARY BORDERS The three pulmonary borders (anterior. Its most inferior part faced L1 or L2 in 92% of cases.) The right diaphragmatic surface is related to the right hemidiaphragm and right lobe of the liver.htm 25/46 .7 ± 1. Inf. Its height was 6. the spleen. Hodge J. The posterior ILMs were very similar in shape and inferior level and differed in depth only by the difference of height of the diaphragmatic cupolas..6 cm. It was continuous medially inside with the azygo-esophageal recess in 96% of cases. The anterior ILMs were more variable than the posterior. and occasionally to the splenic flexure of the colon and the left lobe of the liver. Frija et al. Its height was 8. 6-24.9 ± 1. Fig. Sup. The right anterior ILM was visible in 76% of cases.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. It was most often concave upward (82% of cases). inferior pulmonary vein. It was continuous medially with the left inferior precardiac recess. 1990. The left posterior ILM was not visible laterally in 34% of cases and medially in 60% of cases. posterior) correspond to the lines of pleural reflection (Figs. It was continuous medially with either the left paraspinal line or the paraaortic line. Surgical Anatomy (2nd ed).25 reported the radiologic anatomy of the inferior lung margin using computed radiography: The right posterior inferior lung margin (ILM) was always visible and usually concave upward (94%). (From Healey JE Jr.5/24/2014 Print: Chapter 6. The left diaphragmatic surface is related to the gastric fundus. superior pulmonary vein..v. with permission. Respiratory System Relationships between the lungs and organs of the mediastinum. http://web. inferior. 6-24. It was most often oblique upward and medially (46%) or concave upward (33%) and often notched (38%).

FISSURES (Fig. 6-25.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. 6-26) The left oblique fissure begins posteriorly at the 4th rib or occasionally at the 3rd or 5th. 1984.) Both right and left borders are atypical and not always constant. with permission. Deep or shallow respiration changes the topography. Philadelphia: WB Saunders. http://web. (Modified from McVay CB. The surgeon should always remember the upward cervical projection of the lung and its downward projection and relations (costodiaphragmatic recess) to organs within the peritoneal cavity. with permission.uni-plovdiv. Anson & McVay Surgical Anatomy (6th ed). Philadelphia: WB Saunders.) Fig. (Modified from McVay CB. It ends at the area of the 6th or 7th rib with a downward and forward pathway. Anson & McVay Surgical Anatomy (6th ed). such as the liver on the right and the spleen on the left. Fig. almost reaching the hilum. Respiratory System Borders of the pleurae and lungs in anterior and posterior views.5/24/2014 Print: Chapter 6. Borders of the pleurae and lungs in lateral views.htm 26/46 . 1984. 6-26.

6-27). Segmentation of the Lungs The three lobes of the right lung and the two lobes of the left lung are composed of bronchopulmonary segments. Table 6-4. Respiratory System External fissures of the lungs. Absence of a fissure does not imply alteration in the underlying bronchial pattern. The less common fissures create dorsal and cardiac lobes. it ends at the 6th costochondral junction. By definition. With a downward and forward pathway. Embryology for Surgeons (2nd ed). Baltimore: Williams & Wilkins. 1989. However. (Modified from Skandalakis JE. Fig.5/24/2014 Print: Chapter 6. thereby giving the left lung also 10 bronchopulmonary segments.) The right oblique fissure begins posteriorly approximately at the level of the 5th rib. The medial end of the horizontal fissure is located at the 4th costal cartilage or 4th intercostal space. The right lung has 10 segments and the left lung has 8 segments (Table 6-4.htm 27/46 . Gray SW.uni-plovdiv. and consider the anteromedial basal segment of the lower lobe as medial basal and anterior basal. with permission.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. The horizontal fissure begins at the level of the 6th rib near the midaxillary line where the pathway of the oblique fissure is located. however. adjacent to the sternum. some writers count the two terminal branches of the apicoposterior segment separately. The left and right oblique fissures cross the midaxillary line on their respective sides at the level of the 5th or 6th rib. a bronchopulmonary segment is that portion of pulmonary tissue served by a tertiary bronchus. http://web. Bronchopulmonary Segmental Nomenclature and Numerical Designations Right Lung Left Lung Upper lobe Apical 1 [1] Superior division Anterior 2 [3] Apicoposterior 1 + 3 [1 + 2] Posterior 3 [2] Anterior 2 [3] Inferior division—lingula Superior lingular 4 [4] Inferior lingular 5 [5] Middle lobe Lateral 4 [4] Medial 5 [5] Lower lobe Superior 6 [6] Superior 6 [6] Medial basal [cardiac] 7 [7] Anteromedial [Medial basal-cardiac] [7 + 8] Anterior basal 8 [8] Lateral basal 9 [9] Lateral basal 9 [9] Posterior basal 10 [10] Posterior basal 10 [10] [Anterior basal] [8] Note: Terms and numerals in brackets are those of the Nomina Anatomica. 1994. and the frequency of their occurrences.

1961. Philadelphia: Lippincott Williams & Wilkins.htm 28/46 . posterior segment (of the upper lobe). SL. 5th ed. General Thoracic Surgery. 2000. MM.) The segments are characterized by the central location of a bronchus and a branch of the pulmonary artery. medial segment of the middle lobe. 6-27. IL. New York: Hoeber-Harper. anterior segment (of the upper lobe). Fig. Source: Shields TW. apical-posterior. superior segment of the lower lobe.uni-plovdiv. PB. In: Shields TW. inferior lingular. The pulmonary venous tributaries run between http://web. An. LB. Respiratory System Note: Terms and numerals in brackets are those of the Nomina Anatomica. MB. AMB. Ponn RB (eds). pp. anterior basal.5/24/2014 Print: Chapter 6. with permission. The bronchopulmonary segments. ApP. medial basal. (Modified from Hollinshead WH. Anatomy for Surgeons. LoCicero J III. AB. Surgical anatomy of the lungs. with permission.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. S. LM. 1989. 63-75. superior lingular. P. apical. posterior basal. lateral segment of the middle lobe. anteromedial basal. Ap. lateral basal.

The lower lobe has a superior segment and 4 basal segments: anterior basal. middle. RIGHT LUNG The 3 lobes of the right lung (upper. Posterior to the pulmonary artery is the bronchus. The distribution of bronchopulmonary segments differs from that of the right lung. and by a horizontal minor fissure separating the upper lobe from the middle lobe. and anterior. The pulmonary venous tributaries run between segments. Characteristically. 6-28.26 despite the fact that supernumerary segments are common. The most anterior anatomic entity in the hilum is the superior pulmonary vein. posterior. and lateral basal. and lower) are defined by an oblique major fissure separating the lower lobe from the middle lobe. the supernumerary bronchi almost never arise from the trachea. Knowledge of these differences is essential for the surgeon when approaching the right and left lung hila. The upper lobe of the right lung has three bronchopulmonary segments: apical. The lung root consists of a group of structures that enter and exit the hilum. According to Woźniak. 6-28. Respiratory System The segments are characterized by the central location of a bronchus and a branch of the pulmonary artery. The two lungs differ not only in number of lobes and arrangements of segments. Lung Roots and Hila The hilum is the area of the mediastinal surface that transmits the bronchi and pulmonary vessels. The inferior part of the left upper lobe is called the lingula. The bronchopulmonary segments of both lungs have specific topographic locations. It is the homologue of the right middle lobe. the apical and posterior segments of the upper left lobe form the "apicoposterior segment" of the upper lobe.htm 29/46 .bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. the lingula is related to the left 6th rib and left ventricle. Their names indicate their positions relative to the thoracic wall and mediastinum. medial and lateral. RIGHT LUNG HILUM Anterior Approach (Fig.1). because of its thin prolongation in front of the left side of the heart.uni-plovdiv.5/24/2014 Print: Chapter 6. but also in topographic relations with surrounding structures. The azygos vein and the vagus and phrenic nerves are nearby. The medial basal and anterior basal segments have a common origin from the anteromedial segment of the lower lobe. medial basal. The lingula contains superior and inferior bronchopulmonary segments which correspond to the anteroinferior position of the lingula. posterior basal. The middle lobe is characterized by two segments. http://web. It partially covers the right pulmonary artery. LEFT LUNG The 2 lobes of the left lung (upper and lower) are separated by the oblique fissure. Fig. Topographically.

and the left recurrent nerve.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. Respiratory System Approaches to the right lung hilum. Hodge J. Close to the vein and a little posterior. Philadelphia: BC Decker.3). 6-29. The superior pulmonary vein with its three tributaries corresponds to the bronchopulmonary segment of the left upper lobe and the left pulmonary artery side by side.htm 30/46 . RML. the lower lobe bronchus can be seen.) Interlobar Approach (Fig.1.2). The inferior pulmonary vein and/or its branches are side by side with the intermediate bronchus. with permission. and azygos vein are visible. Posterior Approach (Fig. 1. LEFT LUNG HILUM Anterior Approach (Figs. 6-28. vagus nerve. 1990. right middle lobe. With lateral and posterior lung retraction. (From Healey JE Jr. One can also observe the aortic arch. the ligamentum arteriosum. 6-28. 3. http://web.uni-plovdiv. 2. right lower lobe. Interlobar approach. Surgical Anatomy (2nd ed). 6-29. RLL. RUL. The esophagus. The pulmonary artery and its branches are the most superficial structures. The interlobar approach to the right lung hilum is through the oblique fissure. Fig.5/24/2014 Print: Chapter 6. the vagus and phrenic nerves are visible. Anterior approach. right upper lobe. 6-29.2). Posterior approach.

but on the right the pulmonary artery passes laterally to the bronchus. Respiratory System Approaches to the left lung hilum. LUL. 3. (From Healey JE Jr. 2. Anterior approach. the pulmonary artery crosses the bronchus anteriorly on the left. left upper lobe. Posterior approach.3). Hodge J. Remember The root of the lung is enveloped by the mediastinal pleura.2). left lower lobe. and both atria.htm 31/46 . The esophagus is related more medially to the left lung hilum. The left atrium and main pulmonary artery are related anteriorly to the left lung hilum.) Interlobar Approach (Fig. The most superficial structures are the inferior pulmonary vein and the left pulmonary artery side by side.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. 6-29. the descending aorta lies posteriorly and laterally. The right lung root is located under the azygos venous arch. which inferiorly forms the pulmonary ligament. Philadelphia: BC Decker. The left pulmonary artery is the dominant anatomic entity in the interlobar approach to the left lung hilum. The left main bronchus lies anterior to and between the vein and artery.5/24/2014 Print: Chapter 6. The phrenic nerve lies posteriorly. On the left mediastinal surface (the hilum of the left lung) the pulmonary artery lies above the bronchus. with permission. The left vagus nerve and its branch and the left recurrent laryngeal nerve are also associated with the left lung root. Posterior Approach (Fig. The left lung root is located under the aortic arch. On the right mediastinal surface (the hilum of the right lung) the eparterial bronchus is located above the pulmonary artery. To be more anatomically correct. LLL. with the ligamentum arteriosum fixed to the right. Surgical Anatomy (2nd ed).uni-plovdiv. 6-29. http://web. 1990. 1. Interlobar approach. SVC. and the esophagus and right vagus nerve lie anteriorly.

Philadelphia: Lippincott Williams & Wilkins. Fig. tissue-paperlike sheath. In: Shields TW (ed). pp. 6-31. Right bronchial tree. 2000.5 cm. and anterior). and gives off 3 segmental bronchi (apical. (Modified from Shields TW.htm 32/46 . It originates from the lateral wall of the right main bronchus below the carina. lateral view. The genesis of the segmental bronchi is quite variable. posterior. It is probable that they form by trifurcation of the right upper lobe bronchus. The veins are surrounded by a thin. 6-30. 63-75. Surgical anatomy of the lungs. 6-32) The upper right lobe bronchus has a length of 1-1.uni-plovdiv. General Thoracic Surgery (5th ed). B. anterior view. Boyden's modification of numerical nomenclature used.5/24/2014 Print: Chapter 6.) Fig. 6-30.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. with permission. Respiratory System The bronchi do not have a connective tissue sheath. Bronchial Trees RIGHT BRONCHIAL TREE (Figs. http://web. The arteries have a well formed sheath. A. 6-31.

it is the caudal end of the right primary bronchus. A. with permission. anterior basal. It provides origin for five segmental bronchi (superior. (Modified from Shields TW. 6-32. General Thoracic Surgery (5th ed).bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System.) The right middle lobe bronchus arises perhaps 1 cm below the orifice of the upper lobe. Philadelphia: Lippincott Williams & Wilkins.uni-plovdiv. pp. Anterior view. Lateral view. Schema of the segmental bronchi of the right lung. For all practical purposes. Surgical anatomy of the lungs. The right lower lobe bronchus is located inferiorly and posteriorly. 2000. New York: HoeberHarper. Lateral view. Respiratory System Tracheal bronchus supplying the apical segment of the right upper lobe. medial basal. A. (Modified from Hollinshead WH. and posterior basal). In: Shields TW (ed). Anatomy for Surgeons. 1961. with permission. LEFT BRONCHIAL TREE http://web.5/24/2014 Print: Chapter 6. B.) Fig.htm 33/46 . lateral basal. B. 63-75. The lateral and medial segments are formed by bifurcation. Anterior view.

the well known lingula (Fig. 6-34) The left upper lobe bronchus originates anterolaterally from the main bronchus. (Modified from Shields TW. 6-35). approximately 5 cm distal from the carina. Surgical anatomy of the lungs.5/24/2014 Print: Chapter 6.) Fig. In: Shields TW (ed). Boyden's modification of numerical nomenclature used.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. General Thoracic Surgery (5th ed). which divides into superior and inferior lingular bronchi. Fig.htm 34/46 . 6-34. Left bronchial tree. 63-75. and (2) the inferior. 2000. It divides into 2 branches: the ascending superior and the descending inferior. Philadelphia: Lippincott Williams & Wilkins. The superior division bifurcates into: (1) the apicoposterior and the anterior bronchi. A. 6-33. Anterior view. Respiratory System (Figs. B. 6-33. pp. Lateral view. with permission. http://web.uni-plovdiv.

uni-plovdiv. with permission. New York: Hoeber-Harper. At approximately 0. 1961. Respiratory System Schema of the segmental bronchi of the left lung. Anatomy for Surgeons. 6-36.5/24/2014 Print: Chapter 6. The four remaining basal bronchi are formed by bifurcation and trifurcation. (Modified from Hollinshead WH. Anterior view. http://web. the most common being the presence of a combined anteromedial basal segment. see Fig. For identification of segmental bronchi. Lateral view. Typical branchings of the chief bronchi of the left lung. A.) The left lower lobe bronchus is the caudal end of the main left bronchus. Vascular Supply The lungs have a dual blood supply: one for the interchange of gases (pulmonary arteries and veins) and the other for nutritional supply of the pulmonary parenchyma (bronchial arteries and veins [see section on bronchi]).5 cm below the orifice of the upper bronchus. New York: HoeberHarper. 6-37. with permission. 6-36) Fig. (Modified from Hollinshead WH. Anatomy for Surgeons.htm 35/46 . There are multiple variations. 1961. ARTERIES (Fig. 6-35.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System.) Fig. anterior view. it gives origin to the superior segmental bronchus. B.

The pulmonary trunk bifurcates in the concavity of the aortic arch below the trachea and in front of the left main bronchus. Fig.htm 36/46 .bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. SVC. pp. Healey JE.25 cm long). with permission. B. which in turn arises from the right ventricle. Its anterior relations are as follows: ascending aorta. Pulmonary trunk. 1970. There are usually two pulmonary veins in each side.75 cm long) and extrapericardial (1. At the root. 6-37. Philadelphia: WB Saunders. segmental arteries. 5.) Left Pulmonary Artery. the right bronchus is above and the pulmonary veins below. Surgical Anatomy of the Thorax.) Pulmonary Trunk The right and left pulmonary arteries arise from the pulmonary trunk. Middle lobe artery. 2. Fig. 6-37A). Right pulmonary artery (mediastinal portion). Interlobar portion of the pulmonary artery. 63-75. 1. the superior and inferior. Right Pulmonary Artery. It is located below the carina and anterior to the right main bronchus. The left pulmonary artery is attached to the concavity of the aortic arch by the ligamentum arteriosum (Fig. Lingular artery.uni-plovdiv. with permission. with the superior lobar and apical veins in front. In: Shields TW (ed). (Modified from Shields TW. 4. 6-38. Respiratory System Pulmonary arteries. phrenic nerve.5/24/2014 Print: Chapter 6. The right pulmonary artery is longer and larger than the left pulmonary artery (Fig. The artery crosses over the left primary bronchus behind the upper lobe bronchus and it is situated at the dorsolateral area of the bronchial stem. and do not follow the bronchi very closely. 3. The veins are formed by intersegmental tributaries. A. 6-38) The pulmonary veins are highly variable and do not contain valves. Left pulmonary artery (mediastinal portion). Right pulmonary artery. VEINS (Fig. 6. The pulmonary trunk may be considered in two parts: intrapericardial (3. 6-37B). Philadelphia: Lippincott Williams & Wilkins. (Modified from Kubik S. The extrapericardial portion lies to the left of the ascending aorta. 2000. Surgical anatomy of the lungs. Common pattern of branching. http://web. This bifurcation forms the right pulmonary artery (associated very closely with the ascending aorta) and a short left pulmonary artery (located above the left bronchus). General Thoracic Surgery (5th ed). Left pulmonary artery.

The right inferior pulmonary vein is located inferior and posterior to the right superior vein. with permission. Left Pulmonary Veins The left superior pulmonary vein is formed by 3 or 4 branches.htm 37/46 . Table 6-5. as well as their special groups of lymph nodes which also communicate with each other. and Table 6-5) For all practical purposes.) Right Pulmonary Veins The right superior pulmonary vein is located anterior and occasionally inferior to the right pulmonary artery. confusing not only to the student but also to the practicing surgeon. 7. 14. Source: Borrie J. The left inferior pulmonary vein is formed by two branches and is located inferior and posterior to the superior vein. the lymphatics of the lung belong to the greater group of the lymphatics of the thorax.5/24/2014 Print: Chapter 6. Middle lobe vein. which drain the upper lobe in toto. 1. Apical basal vein. Its location is roughly anterior to the left pulmonary artery. There are several classifications. Distribution of Bronchopulmonary Lymph Nodes Right Lung Left Lung Between upper and middle lobe bronchi Angle between left upper and lower lobe bronchi Below middle lobe bronchus Above upper lobe bronchus Medial to upper lobe bronchus Medial to left main bronchus Above upper lobe bronchus Medial to superior segmental bronchus Junction of oblique and transverse fissure lying on right pulmonary artery Medial to upper lobe bronchus Medial to superior segmental bronchus Above superior segmental bronchus Behind upper lobe bronchus Anterior to left main bronchus Medial to middle lobe bronchus Behind left main bronchus Between superior segmental bronchus and lower lobe bronchus Medial to lower lobe bronchus Medial to lower lobe bronchi Behind upper lobe bronchus Above superior segmental bronchus Lateral to left main bronchus Between anterior and medial basal bronchi Lateral to lower lobe bronchus Lateral to lower lobe bronchus Lateral to upper lobe bronchus Between segmental bronchi of left upper lobe Between superior segmental bronchus and basal bronchi Note: Listed in order of decreasing frequency of the number of times lymph nodes identified in each location. Surgery and Survival. 15. 13. 6-21. http://web. New York: Appleton-Century-Crofts. 4. Lung Cancer. Anterior vein. 10. Superior basal vein. Left inferior pulmonary vein. Posterior vein. Left superior pulmonary vein. 1965. 12. Right superior pulmonary vein. Healey JE. 6-39. Lingular vein. Posterior basal vein.uni-plovdiv. Apical vein. three from the upper and one from the middle. Anterior basal vein. 6-39. 3. Superficial intersegmental vein between segment 7 and segment 10. segmental veins. 8. 6. Lateral basal vein. This is due to their rich intercommunication with each other. Fig. 11. 1970. 5. Philadelphia: WB Saunders. 16. It is formed by four tributaries which drain the upper and middle lobes of the right lung. (Modified from Kubik S. Respiratory System Pulmonary veins.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. Right inferior pulmonary vein. 2. with permission. 9. Inferior basal vein. Surgical Anatomy of the Thorax. LYMPHATICS (Figs.

uni-plovdiv. 3 and 4 = Deep groups of lymphatics. The deep group is formed by lymphatics located around vessels and bronchi. Remember Intrapulmonary lymph nodes are rare. close to the reflection of the visceral pleura. The pulmonary lymphatic network can be divided into two groups: superficial and deep. close to the pulmonary vessels. The lobar lymph nodes are situated at the origin of the lobar bronchi. and bronchopulmonary areas.htm 38/46 . The superficial group is formed by the lymphatics under the visceral pleura and by those of the interlobar septa. Respiratory System Highly schematic diagram of the respiratory lymphatic system. The lungs have an extensive formation of lymphatic plexuses with intercommunication. Rich communication between the two networks takes place in the hilar area. The pathway of the pulmonary lymphatics from the periphery (visceral pleura) to the hilum and beyond is as follows: – subvisceral pleura – interlobar septa – bronchial vessels – bronchopulmonary lymph nodes – tracheobronchial lymph nodes http://web. lobar. Bronchopulmonary lymph nodes are common. The hilar lymph nodes are located along the inferior area of the main bronchi or in the vicinity of the right or left pulmonary vessels. 1 and 2 = Superficial groups of lymphatics.5/24/2014 Print: Chapter 6. including hilar.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. Rich communications exist between superficial and deep groups. and multiple nodes that communicate with each other.

air (containing oxygen) enters the lungs. The formation of air flow depends upon the synergistic action of atmospheric. The same authors questioned whether such fibers terminate on bronchiolar muscles even though it is well established that sympathomimetic drugs produce bronchial dilation. When atmospheric pressure is lower than the alveolar pressure. – Intrapleural (thoracic cavity) By its own intrapleural pressure. Glands and the smooth muscle of the bronchi may or may not be innervated by an antiinhibitory action. According to Rosse and Gaddum-Rosse. alveolar. Rosse and Gaddum-Rosse27 also stated that the vagus nerve is motor to bronchial and bronchiolar smooth muscle.htm 39/46 . and smooth muscles of the bronchi. sensory fibers carried by the vagus nerve affect the pulmonary vessels. and produces bronchoconstriction.uni-plovdiv. together with respiratory physiology. air (containing carbon dioxide) exits the lungs. PARASYMPATHETIC (VAGUS NERVE) The contribution of the vagus nerve to the plexuses is by fibers which synapse upon intrapulmonary ganglion cells and their axons. These mediate touch and pain modalities.27 the sympathetic visceral efferents are motor to the bronchial glands and also produce vasoconstriction of pulmonary blood vessels. Submucosa with mixed seromucous glands 3. Adventitia The physiology of the respiratory system concerns the transport and exchange of oxygen and carbon dioxide. In some cases when the mediastinal and medial diaphragmatic areas of parietal pleura are irritated. Regarding innervation of the pleura. or pulmonary blood flow. pain is referred to the root of the neck and over the shoulder region due to the overlap of spinal cord segments serving the phrenic nerve (C3. Characteristically. HISTOLOGY AND PHYSIOLOGY The histologic features of the trachea and bronchi are practically the same.5/24/2014 Print: Chapter 6. These vagal sensory fibers also innervate the bronchial mucosa and are involved in the cough reflex. Most likely the vagus nerve does not innervate smooth muscle in the wall of the pulmonary vessels. C5) and supraclavicular nerves (C3. Both divisions contribute to form the pulmonary plexuses. The four layers from the inside to the outside are: 1a. Their purpose is uncertain. C4). Most likely. anterior and posterior. Lamina propria 2. SYMPATHETIC The sympathetic nervous system participates in the formation of the plexuses by postganglionic fibers. 4. Respiratory System – paratracheal lymph nodes – mediastinal lymph nodes – bronchomediastinal lymph trunks – thoracic duct – right lymphatic duct Innervation The lung is innervated by the sympathetic and parasympathetic systems. united by smooth muscle and some fibrous elements. These arise from the first 5 thoracic sympathetic ganglia. The visceral pleura's innervation via vagal fibers mediates no pain sensations. The following anatomic entities are related to the pressures – Atmospheric (nose and mouth) – Alveolar (alveolar ducts and alveoli) When atmospheric pressure is higher than the alveolar pressure. follows. Cartilaginous smooth layer. and intrapleural pressures. ventilation with transport and exchange. Mucous membrane with ciliated pseudostratified columnar epithelium 1b. but it has been reported to contribute in complex ways to the function of respiration. which are located at the root of the lung. the thoracic cavity negotiates both atmospheric and alveolar pressure. But a very brief description of the physiology of the trachea and bronchi. and supply blood vessels. This may cause severe hypotension. The inspiratory muscles are the http://web. glands. the parietal pleura is a somatic structure and thus receives generous general somatic sensory innervation via the intercostal and phrenic nerves. C4. and the heart rate changes. It is not within the scope of this book to discuss respiratory mechanisms. perhaps they inhibit the action of the smooth muscles.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. this layer is formed by hyaline cartilage of incomplete rings.

The sternocleidomastoid muscles and scalenes (the upper airway muscles) are innervated by the cervical nerves. More importantly. It separates the proximal ends of both bronchi and is a bronchoscopic landmark. The inner surface of the tracheal bifurcation is a sharp ridge (membranous or cartilaginous) called the tracheal keel or carina. The respiratory centers of the pontomedullary area of the brain are responsible for breathing. low-resistance pulmonary circulation causes the gas exchange. and the visceral compartment under the pretracheal fascia. The low-pressure. investing layer of deep cervical fascia. The platysma lies in the superficial fascia. Deviation of the trachea to the right or left results from pressure in the neck and mediastinum. The structures encountered are the skin and superficial fascia. The anterior jugular veins may lie close to the midline. Blunt chest trauma can produce severe injuries of the trachea or bronchi. 6-40). thereafter it is above the left main bronchus. the arch of the aorta is located anterior to the trachea. but is absent in the midline. http://web. The expiratory muscles are the – Three flat muscles (external oblique. SURGICAL APPLICATIONS Trachea Some of the most common surgical procedures of the trachea are tracheostomy. and treatment of tracheoesophageal fistulas. The brachiocephalic artery is in front of the trachea and then to its right.htm 40/46 . The sternohyoid and sternothyroid muscles lie between the investing layer of fascia and the pretracheal fascia on either side of the midline. The usual site of a tracheostomy is between the second and fourth tracheal rings. Penetrating wounds of the neck and chest can involve the cervical or thoracic trachea or even one or both bronchi. transversus abdominis) – Rectus abdominis – Internal intercostals The entire right ventricular output enters the lungs. Fig. respectively. treatment of tracheal stenosis. 6-40. Left and right descending veins enter the respective brachiocephalic veins (Fig.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System.uni-plovdiv.5/24/2014 Print: Chapter 6. At its beginning. The inferior thyroid veins arise as a venous plexus on the anterior surface of the isthmus of the thyroid gland. Respiratory System – Diaphragm (the most effective muscle of inspiration) – External intercostals – Sternocleidomastoid muscles – Scalenes – Serratus posterior muscles (superior and inferior) The diaphragm and external intercostal muscles are innervated by the phrenic and intercostal nerves. due to the various forces generated during the impact. internal oblique. they may be united by a jugular venous arch at the level of the seventh to eighth tracheal rings. The two veins may form a common trunk entering the superior vena cava or the left brachiocephalic vein. The last is considered in the chapter on the esophagus. tracheal resection. The left common carotid artery is at first anterior to the trachea and then passes to its left.

htm 41/46 . and transplantation are done according to the underlying pathology. muscles. the anterior thoracotomy is through the 3rd intercostal space. Pulmonary segmental veins are located between the segments.37 If necessary. Close the main bronchus near the carina. it can be ligated and incised. either open the pericardial defect widely or repair it with bovine pericardium or prostheses. Thoracoscopy McFadden and Robbins33 stated that video-assisted thoracoscopy may be used in selected patients. or primarily. The apicoposterior segments of the upper lobes and superior segments of the lower lobes are common sites for tuberculosis. this avoids air leaks and bronchopleural fistula. Segments Each bronchopulmonary segment is an independent and separate unit from a surgical standpoint. total pneumonectomy. the two lobes of the thyroid are not connected by an isthmus. Fernando et al. especially the horizontal one. thereby reducing the need for lung resections. Respiratory System The venous drainage of the thyroid gland. The possibility of a thyroid ima artery (10 percent of individuals)29 should not be forgotten.30 considered the risks resulting from tracheostomy and intubation acceptable for comatose children in need of prolonged ventilatory support. Liu et al. are described below in the discussion of the lungs. A suspensory ligament of the thyroid and a levator thyroid muscle may also be present in or close to the midline. Thoracotomy The lung can be approached by a posterior or anterior thoracotomy or a median sternotomy.) The isthmus of the thyroid gland commonly lies at the level of the second and third tracheal rings. Remember Tracheostomy in children remains controversial because of the possibility of complications. segmentectomy. http://web. shunting of the blood takes place and pulmonary distention does not occur. Am Surg 1976. with permission. less often more caudal. biopsy. Successful video-assisted thoracoscopic lung resection for infants and children was reported by Rothenberg. lobectomy. if necessary. Gray SW. Vascular patterns of the thyroid gland.32 advise bronchial artery embolization for treatment of hemoptysis. remember that the fissures may be absent or not well developed. Akin JT Jr.5/24/2014 Print: Chapter 6. Lungs Bronchoscopy. Remember that the recurrent laryngeal nerve on the left side passes under the aortic arch.uni-plovdiv. Bronchi To aid the healing of the bronchus. In about 10 percent of individuals. Skandalakis JE. Yim et al. Harlaftis N. partial lobectomy. enter the pericardium in order to have enough room for a good pulmonary vein ligation.38 Two patients with metastatic disease requiring extensive resections were converted to standard thoracotomy. The inferior thyroid veins are quite variable. Surgery of the bronchi. they are good landmarks for intersegmental separation and segmental resection.28 The isthmus can be retracted upward or downward to reach the trachea. (Modified from Tzinas S. it is often more cranial. To prevent cardiac herniation. Asaph et al. It can be excised in toto since there is minimal anastomosis between the adjacent segments. The posterior thoracotomy is through the 5th intercostal space. During ligation of the pulmonary veins. as well as their surgical complications. or omentum). Droulias C. In an editorial comment on Rocha. Tepas31 questioned the necessity of early tracheostomy. Rocha et al. Total Pulmonary Resection (Pneumonectomy) The thin-walled pulmonary artery should be dissected with extreme care by sharp and blunt dissection and finger mobilization.34 found it to be safe and effective both as a therapeutic and a diagnostic modality for pulmonary tuberculosis in the absence of chronic inflammatory response and distorted anatomy.35 recommended thoroscopy as the treatment of choice for patients with pneumothorax requiring surgical treatment. This prevents a blind pocket with subsequent breakdown of the bronchial stump or hemoptysis. citing completeness of lymph node staging and favorable wound infection and mortality rates. However. it is prudent for the bronchial stump to be covered by tissue (such as pleurae. Fissures Congenital anomalies and variations as well as pathological processes can distort the pathway of the fissures.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System.36 advocate median sternotomy instead of thoracotomy in treatment of primary pulmonary carcinoma.42:639-644.

Tube with correct curvature correctly placed. A thyroid ima artery is present occasionally. 1983.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. Respiratory System requiring extensive resections were converted to standard thoracotomy. Tube placed too low: subclavian vessel can be occluded. Overly aggressive sharp dissection can injure the brachiocephalic artery. Therefore. The brachiocephalic vein can be injured if sharp dissection is carried too far downward.. Tube too curved: the tracheal wall can be eroded and the subclavian artery occluded. The subclavian vein can also be compromised by a tracheostomy tube that is incorrectly curved or placed too low. especially the cricothyroid branches. The inferior thyroid vein is often asymmetric. and must be ligated if found. Its careless use and manipulation may cause a tracheoesophageal fistula. Segmental and Lobar Resection The surgicoanatomic features of segmental and lobar resection are the same as those of pneumonectomy. but from errors in the use of the tracheostomy tube. Gray SW. with permission. B. (Modified from Skandalakis JE. urged further study of long term sequela. In approximately 20 per cent of individuals. Erosion caused by tracheostomy tube placement can result in a tracheoarterial or tracheoesophageal fistula. The left brachiocephalic (innominate) vein crosses high on the trachea.39 reported that percutaneous and translaryngeal tracheostomy have fewer complications than open tracheostomy. The vein may be found just above the suprasternal notch. Vascular Injury ARTERIES The branches of the superior and inferior thyroid arteries may anastomose across the midline. A. ANATOMIC COMPLICATIONS Tracheostomy Tracheostomy may be accomplished using open. it is particularly vulnerable during tracheostomy. VEINS The thyroid venous plexus over the thyroid gland drains into the thyroid veins.40 while mentioning the convenience of percutaneous single-step dilatational tracheostomy. Rowe JS Jr. The subclavian artery can be compromised by a tracheostomy tube that is incorrectly curved or is placed too low (Figs. Organ Injury ESOPHAGUS Injury to the esophagus usually occurs not from an error of perception of the anatomy.41 http://web. Anatomical Complications in General Surgery. This artery will pass ventrally to the lower trachea above the sternum. 6-41. percutaneous. C. Its location puts it at risk for devastating injury. and therefore more liable to injury.htm 42/46 . Escarment et al. the left common carotid artery arises from the brachiocephalic artery rather than from the aortic arch. 6-41A & B).uni-plovdiv. New York: McGraw-Hill.5/24/2014 Print: Chapter 6. air leaks should be treated by careful ligation of the small bronchi. However. Fig. the common carotid artery can be injured or mistaken for the trachea.) In newborns. Tracheostomy tubes. The anterior jugular veins may be encountered when incising the investing fascia. MacCallum et al. or translaryngeal technique.

42 When blebs under the visceral pleura rupture. Bonanno concluded that the dysfunction was produced by inhibition of elevation and anterior rotation of the larynx and failure of the hypopharyngeal sphincter to open completely. finally. Jougon et al. 1. Mechanical stress is stronger in the apices. Placement of the tube through the thyrohyoid membrane can also produce vocal cord injury. 2. POSTTRACHEOSTOMY SWALLOWING DYSFUNCTION The adverse effect of a cuffed tracheostomy tube on the swallowing mechanism was reported by Bonanno. These authors observed 113 episodes of bleeding: 30% after pneumonectomy." Lung Resection VASCULAR INJURY Massive bleeding from the major pulmonary vessels is possible. http://web.51 stated. 4% after segmentectomy.5% was reported by Shama and Odell.48 reported correction of a left upper lobe bronchus separation secondary to nonpenetrating thoracic trauma. pneumothorax is produced. except after lung resection. Conservative treatment must often be considered. esophageal repair is essential to avoid fatal mediastinitis. which creates interstitial emphysema.41 PNEUMOMEDIASTINUM AND PNEUMOTHORAX The following observations may provide some explanation about the pathway of formation of spontaneous pneumomediastinum and pneumothorax. In comparing bronchial closure by manual suturing to closure by conventional staplers and endostaplers. recurrent.08% as reported by Vogt-Moykopf. Peterffy and Henze52 reported 0. and external laryngeal nerves revealed that nerve injury was not a factor. Air dissects within peribronchial or perivascular planes into the hilum and. with the newly developed endostaplers. Incidence is 0. Pneumothorax and Chylothorax The development of contralateral pneumothorax is 0.53 If injury is recognized in the operating room. Wood and Vallières49 reported that of 50 patients who underwent tracheobronchial resection and reconstruction.45 Roe46 recommended a 60° curvature (Fig. Tracheobronchial rupture may occur following intubation. VOCAL CORDS Too high a tracheostomy can result in direct injury to the vocal cords. 3.47 advised wedge carinal resection with rotational approximation for securing the challenging bronchial stump closure.05% according to Simpson55 and 0.54 This is most likely secondary to a contralateral bleb.56 The thoracic duct can be ligated with impunity because of the gradual expansion of collateral lymphatic vessels.uni-plovdiv. Resection and reimplantation of an injured lobar branch is feasible even in a delayed setting. Chylothorax with thoracic duct injury is very rare.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. glossopharyngeal. there were no deaths.1% mortality in 1428 resections. Spinal cord injury with paraplegia may be averted by careful hemostasis of a bleeding intercostal artery at the posterior corner of the intercostal incision. The distal end of a tube with too much curvature will erode the anterior tracheal wall.3% according to Brie. including rate of bronchopleural fistula.htm 43/46 . Because of the high pressure. This stress produces enlargement of the apical alveoli and compression of the basilar alveoli. especially the more caudal ones.43 The stoma should be formed below the first ring. Remember that dorsal branches of intercostal arteries. and the morbidity rate was 32%. and by avoiding cautery or packing. Inadequate Procedure A proper appreciation of the angle of the trachea relative to the surface of the neck is important in selecting a tube with the proper curvature. Pilcher et al. the apical alveoli are ruptured and produce pneumomediastinum due to rupture of a bleb within the pulmonary parenchyma. as is bleeding from a bronchial or intercostal artery. 66% after lobectomy. Respiratory System use and manipulation may cause a tracheoesophageal fistula. Resection Tracheobronchial Resection Tracheobronchial resection with or without pulmonary resection is recommended for benign and malignant lesions involving the trachea or the trachea and bronchi. Efforts should be made to employ bronchoplastic procedures to allow pulmonary preservation. ORGAN INJURY Esophagus Esophageal injury of up to 0. Asamura50 found acceptable rates of failure.5/24/2014 Print: Chapter 6. Fahimi et al.44 Evaluation of the trigeminal. "Aggressive surgical repair is not always mandatory after delayed diagnosis of iatrogenic tracheobronchial rupture. may contribute critical radicular branches to the spinal cord. Additional information about pneumomediastinum and pneumothorax is found in the chapter on the neck under "Radical Neck Dissection. into the mediastinum. 6-41C)." RECURRENT LARYNGEAL NERVES Injury to the recurrent laryngeal nerves can occur during tracheostomy as well as during thyroidectomy (see "Anatomic Complications of Thyroidectomy" in the thyroid chapter for details).

Z Anat Entwicklungsgesh 1961. Nerve Injury Right or left phrenic nerve injury is a rare phenomenon. Evrard V. The Life of Chevalier Jackson. Congenital malformations of the lung.57 Occasionally. Cormack DH. The limits of tracheal resection with primary anastomosis: further anatomical studies in man. Panning B. Shields TW. Schechter DC. Congenital parenchymatous malformations of the lung. General Thoracic Surgery (5th ed). Posterior pulmonary lobe: segmental and vascular anatomy in human specimens. World J Surg 1999. 6. In: Raffensperger JG (ed). Congenital absence or deficiency of lung tissue: The congenital subtractive broncho-pulmonary malformations. De Baere T. a procedure which is not recommended. Roque AS. 8. Boedy RF. pp. McFadden and Emory (1998)60 reported that infection is the major cause of morbidity and mortality in lung transplantation. An Autobiography. Koshino T. [PubMed: 9076309] 11. South Med J 1997. Clin Anat 2000. REFERENCES 1. Grillo HC. Lerut T. Coosemans W. De Leyn P. Piepenbrock S. Ann Thorac Surg 2000. We strongly advise the interested reader to study the article of Grover et al.55:418. Baltimore: Williams & Wilkins. 5.htm 44/46 . [PubMed: 16453390] 3. [PubMed: 10910836] 10. Van Raemdonck D. O'Rahilly R. lobopexy is necessary. 1994.91:300-301. Mulliken J. These authors stated that lung rejection. Ceulemans J. Skandalakis JE. Endo M.141:237.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System. Falls G.13:257-262.58 Read an Editorial Comment PULMONARY TRANSPLANTATION In 1963.uni-plovdiv.6:286-313. Gray SW. [PubMed: 10501874] 12. Ham's Histology (9th ed). 13.69:191-197. 2. Kubik S.90:335-337. It may be accidental or for the purpose of paralyzing the hemidiaphragm for volume reduction of the ipsilateral hemithorax. Unilateral pulmonary agenesis without mediastinal displacement. 63-75.5/24/2014 Print: Chapter 6. Raffensperger JG. Boyden EA. Bronchiolitis obliterans is the second most common complication. 1970. New York: Macmillan. Schuster M. 1987. Jackson C. Surgical Anatomy of the Thorax. [PubMed: 10873217] 7. Tabayashi K. pp. Philadelphia: JB Lippincott. Embryology for Surgeons (2nd ed). 2000. Deneffe G. The timing and sequence of events in the development of the human respiratory system during the embryonic period proper. Bhatia JS. De Boeck C. Healey JE.61 found a higher incidence of anastomotic complications and postoperative pneumonia with telescoped bronchial anastomosis than with end-to-end anastomosis. 1938. Mawatari T. [PubMed: 5642707] 16.59 Since then. Burton EM. Morishita K. Yamaki S. Ann Thorac Surg 1968.63 caution against lung transplantation for patients with diffuse pulmonary arteriovenous malformations. Hardy and his colleagues reported the first human lung transplant. In a study of single and bilateral lung transplantation. Pulmonary vascular changes induced by congenital obstruction of pulmonary venous return. Devlieger H. 1970. 4. several centers in the United States and abroad have advanced the technical aspects for single and double sequential lung transplantation. Lobar Torsion A 180° rotation can produce right or left lobar torsion in the operating room or postoperatively. Surgical anatomy of the lungs. Nave H.64 on lung transplantation. Meyers and Patterson (1999)62 cited a current one year survival rate of over 75% and excellent functional results for lung transplantation patients with a range of diagnoses. Philadelphia: Lippincott Williams & Wilkins. Abe T. Respiratory System ligated with impunity because of the gradual expansion of collateral lymphatic vessels. In: Shields TW (ed).23:1123-1132. Congenital tracheal bronchus: the inability to isolate the right lung with a univent bronchial blocker tube. J Thorac Cardiovasc Surg 1968. Anesth Analg 2000. The carina as a landmark in central venous catheter placement [comment]. bacterial infection and cytomegalovirus infection produce lung dysfunction. 14. 15. Murakami G. Br J Anaesth http://web. 1990. 743-753. Garfein et al. Philadelphia: WB Saunders. Norwalk CT: Appleton & Lang. as reported by Wong and Goldstraw. Ninth International Congress of Anatomists (Leningrad). Peragallo RA. Swenson JD. Ohmi M. 9. Pabst R. Left recurrent nerve injury following mediastinal lymph node dissection was reported by Bollen et al. Faughnan et al. Swenson's Pediatric Surgery (5th ed).

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