SURGICAL ANATOMY

ON CHEST WALL

KEERTHANA. B
ASSISTANT PROFESSOR
PSG COLLEGE OF NURSING
 INTRODUCTION

 The thorax consists of the chest wall comprising the sternum, ribs, and thoracic
vertebrae; the mediastinum containing the pericardium, heart, esophagus, trachea,
great vessels, thoracic duct, and thymus; and the paired pleural cavities containing
the lungs.

 Today we will discuss the anatomy of these structures and spaces, as pertinent to
trauma surgery and the surgical intensive care unit.
 CHEST WALL

 The muscular, tendinous, and bony structures of the chest serve several functions.
The chest wall must be rigid enough to protect the thoracic viscera and serve as a
fixation point against which the muscles of the upper extremity and abdomen can
work yet flexible enough to expand and contract with vigorous respirations.
 With gentle respirations, the chest wall is a cylinder with the diaphragm as its piston. With inspiration,
the diaphragm contracts, its dome is flattened, and, like a piston, it descends in the chest. This motion
increases the volume of the thorax, and actively expands the lungs by drawing in air through the
trachea. The lungs are very elastic and tend to collapse without outward forces keeping them expanded.

 With exhalation, the diaphragm relaxes, the elasticity of the lungs causes lung volume to decrease, and
air is expelled. Ultimately, the tendency of the lung to collapse is countered by the outward
force/rigidity of the chest wall.
 With vigorous respirations, the intercostal muscles, scalene, and other accessory muscles of respiration
elevate the ribs and increase the thoracic volume much more than usual. With vigorous respirations, the
chest wall and diaphragm act in concert like a bellows increasing thoracic volume and then relaxing and
allowing the elasticity of the lung to decrease thoracic volume.
 The bony structures of the chest wall include
12 ribs, 12 thoracic vertebrae, and the
sternum. All ribs articulate posteriorly with
the transverse processes and vertebral bodies
of their respective thoracic vertebrae and the
vertebral body directly superior.
 Ribs 1 through 7 are called true ribs because
they articulate anteriorly directly with the
sternum through their own costal cartilage.
Ribs 8, 9, and 10 are called false ribs because
they articulate anteriorly to the costal
cartilage of the rib above. This creates a
construct of stair stepping costal cartilages,
which ultimately articulates with the sternum
and creates the costal arch or costal margin.
Ribs 11 and 12 are called floating ribs
because they do not articulate with any
structure anteriorly. Rather, they attach to the
abdominal wall musculature, primarily the
internal oblique muscle.
 Because ribs 1 through 10 are fixed
anteriorly and posteriorly, they function
much like a bucket handle. When
performing a tube thoracostomy, as you
approach the sternum anteriorly and the
transverse processes posteriorly, the size of
the interspace becomes fixed and narrow.
Laterally, away from these points of
attachment, the ribs separate and the
interspace opens. The widest portion of the
interspaces can be found at the lateral
apogee or “keystone” of the rib.
 Tube thoracostomies placed laterally will
be easier to place through the interspace
and more comfortable for the patient. Also,
when creating a thoracotomy, division of
the intercostal muscles far anterior and
posterior will create a larger working space
without tearing the intercostal muscle or
fracturing a rib with placement of the rib
spreader. The skin need only be divided
over the working space, not over the entire
intercostal incision.
 The sternum has three parts, the manubrium, the body, and the xiphoid process. The manubrium is thick
and broad, articulating with the clavicle, first rib, and sharing the second rib articulation with the body of
the sternum. The sternoclavicular articulation is the only bony articulation of the thorax to the shoulder
girdle. Understanding the angle of the clavicle, manubrium, and first rib is important in safe placement of
central venous catheters into the subclavian vein. The subclavian vein and artery leave the arm and enter
the thoracic inlet over the top of the first rib and under the clavicle. Once under the clavicle, a needle
directed parallel to the clavicle and first rib will not enter the chest and cause a pneumothorax before
finding the subclavian vein. A needle directed too steeply in its approach will quickly enter and exit the
triangle where the subclavian vein is found, penetrate the intercostal space, and puncture the lung.
 The second rib inserts into the sternomanubrial junction
(angle of Louis). This can be easily palpated in most
people as a horizontal ridge in the sternum or where the
two planes that make up the sternum intersect interspace
immediately below the angle of Louis is the second
interspace. The angle of Louis serves as a landmark to
rapidly locate the second rib and second interspace for
placement of a catheter to decompress a tension
pneumothorax or to place an anterior tube thoracostomy
for an apical pneumothorax.
 The first rib is short, broad, flat, and arches sharply from posterior to anterior. The
second rib is longer than but very similar to the first rib. The first slip of the
serratus anterior muscle attaches to the second rib approximately one-third of the
arc from posterior to anterior—this slip also attaches to the inferior aspect of the
first rib. Posterior to this attachment, the scalenus posterior attaches to the second
rib.
 When performing a thoracotomy, counting ribs can identify the correct interspace. Once the latissimus
dorsi muscle has been divided and the serratus anterior muscle divided or swept anterior, the scapula
is elevated. Thin fibrous attachments hold the undersurface of the scapula to the chest wall. A hand
placed deep to the scapula, posterior near the spine, and apically can palpate ribs. The first rib is
identified by its conspicuously broad and flat contour. Inferior to this, the second rib can be identified
by the attachment of the scalenus posterior muscle. This muscle body is palpable by sweeping the
finger from posterior to anterior along the second rib. Less distinct will be the third rib, which seems
to “turn the corner” from the apex of the chest to the lateral chest wall . In a lateral decubitus position,
the tip of the scapula overlies the sixth interspace. In a male, the nipple overlies the fourth interspace.
MUSCLES OF THE CHEST WALL

 Integral to safe thoracentesis, placement of a tube thoracostomy, or a thoracotomy, is

understanding the layers of the chest wall and the anatomy of the interspace.

 The paired pectoralis major muscles cover the majority of the anterior chest wall. The pectoralis
major muscle originates from the clavicle and anterior aspects of ribs 1 through 6 inserting on the
proximal humerus. Its origin from the chest wall is broad and an anterior thoracotomy will divide
or separate its fibers.
 Inferiorly, the rectus abdominus muscle inserts onto
the costal cartilages of ribs 5 through 7 and the
xiphoid process. Lateral to this, the muscle fibers of
the external oblique insert onto ribs 5 through 12. The
external oblique muscle interdigitates with the serratus
anterior muscle as it inserts on ribs 1 through 8. Most
thoracotomies do not traverse the interspaces guarded
by the rectus abdominus and external oblique. These
muscles will be encountered with thoracoabdominal
incisions crossing the costal margin.
 Laterally and posteriorly, two musculo-fascial layers guard
the ribs. The more superficial layer contains the latissimus
dorsi muscle laterally. Posteriorly, at the auscultatory triangle,
or posterior border of the latissimus dorsi, this layer becomes
a thin but tough layer of fascia, which more posteriorly
envelopes the trapezius muscle. The second Musculo-fascial
layer contains the serratus anterior muscle laterally,
becoming a broader sheet of thin but tough fibrous tissue
posteriorly and then becoming the rhomboid major muscle
then the rhomboid minor muscle posteriorly and superiorly
 A tube thoracostomy will traverse these muscle layers to reach the ribs and interspaces. Knowing where you
are in these layers allows precious time to be saved in traversing them and getting to where you need to be to
complete the procedure.

 A typical tube thoracostomy is placed in the fifth interspace at the anterior axillary line. The muscle bodies
traversed are thinner here. From superficial to deep, the surgeon will separate skin, subcutaneous fat, the
latissimus dorsi/trapezius musculo-fascial layer, and then the serratus anterior musculo-fascial layer. At this
depth, the shiny surface of the periosteum of the ribs and the oblique fibers of the external intercostal muscle
can be seen.
 A thoracotomy can be fashioned to divide
or spare these muscles as needed in order
to gain access to the rib cage. A full
thoracotomy will divide the latissimus
dorsi laterally and the trapezius posteriorly.
The incision sweeps from horizontal across
the lateral chest to vertical and parallel to
the spine posteriorly.
  Deep to this layer, the serratus anterior can be swept anterior or divided. Posteriorly, the
fascial layer coming off the serratus anterior is divided and then the rhomboid major and
rhomboid minor muscles are divided. The innervation of the trapezius muscle and rhomboid
muscles runs from medial to lateral. The more muscle body that is left medially, the more
muscle function will be retained. Enough muscle needs to be left attached to the scapula to
allow suture repair of the muscle, and the muscle should not be stripped from the scapula. The
posterior and vertical aspect of this incision where the trapezius and rhomboids are divided is
done to elevate the scapula off the chest wall, to access the interspaces underneath.
A thoracotomy can be extended anterior, dividing the pectoralis major muscle
overlying the interspace of interest. The sternum can be split transversely, and a
thoracotomy continued on the contralateral side. This is termed a “clam shell”
thoracotomy. The left and right mammary artery will be found 1 cm lateral to and on
either side of the sternum, deep to the ribs and intercostal muscles, but superficial to
the pleura. These vessels can be cauterized if speed is needed, but are prone to spasm
and late bleeding, and should be sought and ligated when possible.
 INTERCOSTAL SPACE

 Each intercostal space from superficial to deep, has two layers of muscle; an artery, a vein,
and a nerve; and a diminutive inner layer of muscle. The external intercostal muscles run
obliquely with fibers in the same orientation as the external oblique muscle of the abdomen
(fingers in pockets). Deep are the internal intercostal muscles running in the opposite
direction. The intercostal artery, vein, and nerve run along the inferior aspect of each rib,
occasionally running underneath a ledge in the costal groove. To avoid injury to these three
structures, tube thoracostomies and thoracotomies are directed over the superior aspect of
each rib or through the middle of the interspace, but not the inferior aspect of the rib
 The innermost intercostal muscles are located deep to the neurovascular bundle and
run in the same direction as the internal intercostal muscles. While mentioned in
anatomy texts, surgically, the innermost intercostal muscles do not need to be
considered separately from the internal intercostal muscle. The intercostal arteries
originate as segmental branches off the descending aorta. The intercostal space,
including the underlying pleura, can be harvested as a posteriorly based pedicled
muscle flap. This flap is useful for reinforcing bronchial or esophageal repairs.
 PLEURAL SPACE

 Normally the lung is coupled to the chest wall by the vacuum, which exists between the visceral and parietal
pleura. With penetration of the chest wall air is allowed into the pleural space from the outside or more
commonly, penetration of the lung allows air to escape from air spaces within the lung (alveoli, bronchioles,
bronchi) into the pleural space. The coupling of the visceral and parietal pleura is broken and the potential
space, which is the pleural space, becomes a real space. The elasticity of the lung causes it to collapse and a
pneumothorax is formed. The pleural space extends superiorly to where it rises above the circumference of the
first rib to inferiorly where the diaphragm inserts on the costal margin and the 12th rib. Lung may or may not be
present between the diaphragm and ribs in the lower most recesses of the pleural space. Anterior to the
pericardium and posterior to the sternum, the two pleural cavities can abut but rarely communicate.
 DIAPHRAGM

 The diaphragm is the movable dome-shaped partition between the thoracic and abdominal cavities.
With full exhalation, the dome of the diaphragm can rise to the level of the fourth interspace anteriorly
(nipple level). With full inhalation, the diaphragm flattens, bringing the thoracic cavity down to the
level of the costal margin anteriorly and the 12th rib posteriorly. The muscle fibers of the diaphragm
originate from the sternum, the ribs, and the vertebral column. All three groups insert on a tough,
fibrinous central tendon. Fibers of the sternal portion are short, arising as small slips from the back of
the xiphoid process.
 Laterally on either side of the xiphoid, fibers originate from the inner surface of the lower six costal
cartilages (costal margin). Posteriorly, fibers originate from a thick band arching over the quadratus
lumborum (lateral arcuate ligament) and the psoas major (medial arcuate ligament). The paired lateral
arcuate ligaments extend from the tip and lower margin of the 12th ribs and arch over the quadratus
lumborum muscle to the transverse processes of L1. The paired medial arcuate ligaments complete the
journey, arching over the psoas major from the tip of the transverse process of the first lumbar
vertebrae to the tendinous portion of each diaphragmatic crus.
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