Chapter 6 Respiratory System

5/24/2014
Print: Chapter 6. Respiratory System

Print | C lose Window
Note: Large images and tables on this page may necessitate printing in landscape mode.
Skandalakis' Surgical Anatomy > Chapter 6. Respiratory System >
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 Smmering 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
Garr 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
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2006_%20Respiratory%20System.htm
1/46
5/24/2014
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
Bjrk 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.
2/46
5/24/2014
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
3/46
5/24/2014
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
4/46
5/24/2014
On the right
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). The pulmonary formation
ceases around the end of the 5th week.3
Fig. 6-3.
Development of trachea and bronchi. Anterior and lateral views at the beginning of the seventh week (horizon XVII). The trachea and esophagus have elongated,
and five orders of bronchial branching are visible. (Modified from 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.)
At this time, three antenatal periods or phases of ramification of the pulmonary systems commence sequentially. These are: glandular or pseudoglandular,
canalicular, and alveolar or terminal sac.
GLANDULAR OR PSEUDOGLANDULAR PHASE
This phase starts at the end of the 5th week and perhaps ends around the 16th week. This phase was named glandular or pseudoglandular because
5/46
5/24/2014
clusters of solid epithelial cuboidal cells surrounding each infundibulum of the bronchial tree give the pulmonary parenchyma the histologic appearance of an
exocrine gland. Gas exchange is not possible; therefore, the fetus born at this phase cannot survive.
CANALICULAR PHASE
This period starts around the 16th week and ends around the 25th week. 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. The pulmonary tissues become very vascular, and the multiple
bronchioles have enlarged laminae. Respiration at the 24th to 25th week is possible and the born fetus may be able to survive.
ALVEOLAR OR TERMINAL SAC PHASE
This period extends from the 24th to 26th week until birth. At its commencement, terminal sac (alveolar) formation overlaps the end of the previous period.
The development of terminal sacs multiplies during the terminal sac phase. The epithelium of the sacs becomes thin and flat.
This phase is associated with a rich vascular proliferation of blood capillaries and lymph capillaries. These are the alveolar epithelial cells (type I
pneumocytes). They will later become secretory epithelial cells (type II pneumocytes) and produce surfactant. Surfactant lines the terminal sacs in a
coatlike formation, lowering surface tension and preventing collapse during expiration of the alveoli.
The premature infant will survive only if adequate pulmonary vasculature and surfactant are present. A premature seven-month fetus may survive because
the respiratory system at this time has good function, the lungs have some secretory function, and the surfactant promotes maturity of the antenatal
lungs.
Postnatal Lung
During the first week, air inflates all the alveoli. Blood and lymphatic capillaries absorb the fluid occupying 50% of the lung. From the sixth through the
eighth week, there is rapid development of alveoli. Cormack4 stated that 95% of alveoli develop after birth.
NOTE: More alveoli are formed during the first postnatal years. The pulmonary alveoli of the newborn are said to be 20 million; the number in adults is
approximately 300 million.
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. Thus, a foreign body within the trachea will most often travel downward
into the right bronchus.
The embryonic right primary bronchus develops two primary buds, the upper for the upper lobe and the lower for the middle lobe. The blind end of the primary
bronchus then forms the right lower lobe. The left primary bronchus produces only one primary bud which forms the left upper lobe. The left lower lobe is produced
by the blind end of the primary left bronchus.
Typically 10 segmental bronchi form on the right lung and 8 form on the left.
Congenital Anomalies
Congenital anomalies of the trachea and lungs are shown in Table 6-2 and Fig. 6-4.
Table 6-2. 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, asplenia and

anomalous pulmonary veins
Bronchgenic cysts
Week 6-7
Infancy, 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, Gray SW. Embryology for Surgeons, 2nd Ed. Baltimore: Williams & Wilkins, 1994.
Fig. 6-4.
6/46
5/24/2014
Congenital anomalies of the trachea and lungs. (Modified from Skandalakis JE, Gray SW. Embryology for Surgeons, 2nd ed. Baltimore: Williams & Wilkins, 1994; with
permission.)
Accessory Lobes
According to Shields,5 the common accessory lobes are the posterior accessory, inferior accessory, middle lobe of the left lung, and "azygos lobe" of the
upper right lobe (Figs. 6-5, 6-6).
Fig. 6-5.
7/46
5/24/2014
Accessory lobes of the lungs.
Fig. 6-6.
Azygos lobe. a, Posterior thoracic structures, seen in anterolateral view; showing the azygos vein, the associated great vessels, and (at *) the transverse
connection between the azygos and hemiazygos veins. b, Contents of the right pleural cavity; upper pulmonary lobe is retracted to expose the accessory lobe and
the anomalous azygos vein. Inset: The anomalous azygos vein with part of its reflection of the parietal pleura. c, Transverse section through the right lung and
related structures at the level of the loop of the anomalous azygos vein. d to f, Upper portion of the right lung, showing the pulmonary relations of the anomalous
azygos vein and its connections; three aspects. Incidence of anomalous lobe, in the author's 65 laboratory, 0.4 percent (8 cases in 2,000 specimens). R.i.v., right
innominate vein (NA, brachiocephalic); L.i.v., left innominate vein; I.j.v., internal jugular vein; A.j.v., anterior jugular vein; S.v., subclavian vein; S.v.c., superior vena
8/46
5/24/2014
innominate vein (NA, brachiocephalic); L.i.v., left innominate vein; I.j.v., internal jugular vein; A.j.v., anterior jugular vein; S.v., subclavian vein; S.v.c., superior vena
cava; M.s., mediastinal surface; V.c.s., vertebrocostal surface. (Modified from Anson BJ. An Atlas of Human Anatomy, 2nd Ed. Philadelphia: WB Saunders, 1963; with
permission.)
There is confusion in the literature about the terminology for these "accessory lobes." The posterior, inferior and middle lobe of the left lung are true
accessory lobes. In reality, the azygos lobe is not an accessory lobe; it is a partial separation of a portion of the apical segment of the right upper lobe by
the azygos venous arch.
The azygos lobe varies in size and extent. 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.
Matawari et al.6 studied the segmental and vascular anatomy of the posterior pulmonary lobe. 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...Nineteen PPL cases
(15 right and 4 left) were found in 273 (116 right and 157 left) human lung specimens. The incidence of PPL was 13% on the right side and 3% on
the left side. The PPL frequently (right 87%, left 50%) corresponded to S(6) (superior segment). 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). Analysis of the
ramification of veins revealed that V(6) (superior vein) tributaries were often double, and V(6) tended to disperse widely. Anomalies in which the
segmental artery and vein communicated with other segments were found in seven cases (37%) (4 arteries and 3 veins, 6 right and 1 left) in PPL.
These results show that the PPL does not always correspond to S(6) and frequently has an anomalous vessel from other segments.
Unilateral Agenesis, Aplasia, and Hypoplasia of the Lung

Raffensperger7 provided pragmatic definitions of pulmonary unilateral agenesis (complete absence of bronchus, parenchyma, and vessels) and pulmonary
hypoplasia (various degrees of underdevelopment).
Schechter8 classified congenital deficiency of lung tissue as follows:
Class I bronchopneumonic aplasia (Fig. 6-7B)
Unilateral or bilateral absence of the entire lung and bronchial tree, called "agenesis of the lung" in earlier classifications
Class II bronchopneumonic dysplasia (Fig. 6-7C, D)
Interrupted formation of the bronchial tree with absence of alveoli, called "aplasia of the lung" in earlier classifications
Class III bronchopneumonic hypoplasia (Fig. 6-8A, B, C)
Entire lung is reduced in size or one lobe of lung is absent
Class IV bronchopneumonic ectoplasia (Fig. 6-8D, E, F)
Displacement of part or all of a lung has occurred, with bronchoesophageal fistula present
Fig. 6-7.
A. Normal lungs. B. Pulmonary aplasia, with complete absence of both bronchial and alveolar tissue. C and D, Pulmonary dysplasia. Some bronchial elements are
present, but there are no alveoli. Enlargement of the sound lung and the resulting displacement of the heart and mediastinum are not shown. (Modified from
Schechter DC. Congenital absence or deficiency of lung tissue: the congenital subtractive bronchopneumonic malformations. Ann Thorac Surg 1968;6:286-313; with
permission.)
Fig. 6-8.
9/46
5/24/2014
A to C. Pulmonary hypoplasia. Three conditions of different embryogenesis that all result in a smaller than normal lung. A, Alveolar tissue not functional. B, Reduced
size of one lung. C, Hypoplasia resulting from lobar dysplasia. The accompanying mediastinal shift is not shown. D to F. Pulmonary ectoplasia. Part or all of one
lung is attached to the esophagus and usually is supplied by a systemic artery. D, Bronchoesophageal fistula. E, Sequestration of right lower lobe. F,
Sequestration of lower lobe and dysplasia of upper lobe. (Modified from Schecter DC. Congenital absence or deficiency of lung tissue: the congenital subtractive
bronchopneumonic malformations. Ann Thorac Surg 1968;6: 286-313; with permission.)
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. This anatomic variant is
reported in approximately 1 of 250 patients at bronchoscopy. Although it is usually of little clinical significance, this atypical origin of the right upper
lobe bronchus may complicate one-lung ventilation during thoracic surgery.
Roque et al.10 presented a case of unilateral right pulmonary agenesis without mediastinal displacement. There was cervical ascent of the liver and right
hemidiaphragm.
We quote from Evrard et al.11 about congenital parenchymatous malformations:
[A]ny thoracic cystic lesion expanding on chest radiography should be an indication for surgical resection, even if asymptomatic, because of the risk
of pulmonary compression, infection, or malignant degeneration. In the few cases of a fetal intrathoracic mass, prenatal diagnosis and intrauterine
intervention may be indicated. . .
Congenital pulmonary venous obstruction causes pulmonary hypertension which, according to Endo et al.,12 seems to be reversible and amenable to
operation.
For details of congenital anomalies of the respiratory system, the interested student is encouraged to read Embryology for Surgeons.13
SURGICAL ANATOMY
Trachea
From a surgicoanatomic viewpoint, the trachea can be divided into two parts: upper (or cervical) and lower (or thoracic), including the tracheal bifurcation.
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. In upright posture, the trachea is located between C6 and T6 (Fig. 6-9). According to Kubik and Healey,14 the tracheal length may increase by
approximately 1.5-2.5 cm during the processes of swallowing or respiration.
Fig. 6-9.
10/46
5/24/2014
Origin of the trachea at the level of the sixth cervical vertebra. (Modified from Brantigan OC. Clinical Anatomy. New York: McGraw-Hill, 1963; with permission.)
Mulliken and Grillo15 stated that the trachea can be located totally within the mediastinum when the neck is flexed, because the cricoid cartilage drops to
the level of the thoracic inlet.
The position of the trachea is not fixed; 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. The trachea has 15 to 20 U-shaped rings of hyaline cartilage that are responsible for the lateral rigidity of the organ. The rings
are united by a thin elastic membrane. Posteriorly, the cartilages are united by the thin tracheal smooth muscle (the trachealis).
Topography and Relations

CERVICAL TRACHEA
According to Kubik and Healey,14 the cervical trachea at its origin is located 1.5-2 cm below the skin. The sternal notch is 4.5-5.0 cm beneath the skin,
and at the bifurcation the depth is at approximately 7 cm.
The following is a summary of the topographic relations of the cervical trachea (Fig. 6-10).
Fig. 6-10.
11/46
5/24/2014
Cross section of the neck showing fascial layers. D, the "danger space" within the prevertebral fascia. RV, retrovisceral or retropharyngeal space between the
prevertebral fascia and the pretracheal (visceral) facial layers. (Modified from Colborn GL, Skandalakis JE. Clinical Gross Anatomy. New York: Parthenon, 1993; with
permission.)
Anterior
Skin
Subcutaneous fascia with platysma
Investing layer of deep cervical fascia
Sternohyoid and sternothyroid muscles
Pretracheal fascia
Inferior thyroid and thyroid ima veins. Occasionally the thyroid ima artery is located just below the isthmus; these vessels and the isthmus are covered with a thin
connective tissue stroma.
The thyroid isthmus is in front of the 2nd, 3rd, and 4th tracheal cartilages.
Lateral
Skin, superficial fascia, and platysma
Sternocleidomastoid muscle and cervical investing fascia
Carotid sheath with common carotid artery, internal jugular vein, and vagus nerve
Omohyoid, sternohyoid, 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. The topographic relations of the thoracic part of the trachea follow.
Anterior
Skin, superficial fascia, manubrium of sternum
Thymus and thymic fat, thymic vessels (Fig. 6-11)
Left brachiocephalic vein
Brachiocephalic artery and left common carotid artery, aortic arch
Cardiac plexus (Fig. 6-12)
Fig. 6-11.
12/46
5/24/2014
The thymic vessels.
Fig. 6-12.
The lower end of the trachea, showing the deep cardiac plexus.
Lateral
On the right: right vagus nerve, paratracheal lymph nodes, mediastinal pleura, azygos venous arch (Figs. 6-12, 6-13)
On the left: paratracheal nodes, left recurrent laryngeal nerve, left common carotid artery
Fig. 6-13.
13/46
5/24/2014
Right vagus nerve.
Posterior
Esophagus
TRACHEAL BIFURCATION
At the level of the sternal angle anteriorly and the fifth thoracic vertebra posteriorly, just above the left atrium, the trachea bifurcates into the right and
left primary bronchi. The topography and relations of tracheal bifurcation are:
Anterior
Superior and inferior tracheobronchial lymph nodes, right pulmonary artery
Posterior
Pulmonary plexus, bronchial arteries
The carina is an inside ridge at the bifurcation of the trachea at the level of the last tracheal cartilage. Schuster et al.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. Because the
pericardium cannot be seen on chest x-ray, an alternative radiographic marker is needed for correct placement of central venous catheters...The
carina was a mean distance of 0.4 (0.1) cm above the pericardial sac as it transverses the superior vena cava. In no case was the carina located
below the pericardial sac. The carina is a reliable, simple anatomical landmark for the correct placement of central venous catheters. In almost all
cases, the carina is radiologically visible even in poor quality, portable chest x-rays. Central venous catheter tips should be located in the superior
vena cava above the level of the carina in order to avoid cardiac tamponade.
Vascular Supply
14/46
5/24/2014
Vascular Supply
ARTERIES
The arterial supply of the trachea is from the inferior thyroid arteries and from branches originating from the superior thyroid arteries, bronchial arteries, and
internal thoracic arteries.
VEINS
The inferior thyroid veins drain the trachea, emptying into one or both brachiocephalic veins.
LYMPHATICS
The tracheal lymphatic vessels drain into the cervical, tracheal, and tracheobronchial lymph nodes.
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. Parasympathetic fibers arise from the vagus nerves and the recurrent laryngeal nerves and pass to the mucosa and tracheal
muscle. These fibers are bronchoconstrictive. Many small clusters of ganglionic cells are present in the autonomic plexuses of the walls of the trachea and
bronchi.
Bronchi
(Fig. 6-14) Each primary bronchus extends from the tracheal bifurcation to the hilum of the related lung. The shorter and larger (2.5 cm) right bronchus
turns only slightly from the vertical orientation of the trachea through the mediastinum. The length of the left primary bronchus, almost double that of the
right primary bronchus, passes more obliquely laterally to the left. The left bronchus crosses anterior to the esophagus to reach the left hilum behind the
left third costal cartilage. Both bronchi have mobility and elasticity comparable to that of the trachea, although the irregularity of the cartilaginous plates
increases distally. The plates of cartilage decrease in prominence within the lungs, disappearing at the level of the bronchioles.
Fig. 6-14.
The primary bronchi (A) and some of their anterior vascular relations (B and C). The reflection of the pericardial sac upon the great vessels is shown in C.
15/46
5/24/2014
We agree with the anatomic observations of Ashour et al.17:

[The] left lung is more vulnerable to bronchiectasis than the right, a clinical observation that could be explained on the basis of the anatomic
peculiarities of the left main bronchus. The latter, when compared to the right bronchus, has a longer mediastinal course, a narrower diameter, and
limited peribronchial space as it passes through the subaortic tunnel (Fig. 6-15) . . .the left lung, when compared to the right, is more vulnerable to
the bronchiectatic process both in frequency and severity. Anatomic features of the left main bronchus make it more prone to obstruction than the
right.
Fig. 6-15.
Anatomy of the left main bronchus as it passes through the subaortic tunnel. (Modified from Ashour M, Al-Kattan K, Rafay MA, Saja KF, Hajjar W,
Al-Fraye AR. Current surgical therapy for bronchiectasis. World J Surg 1999;23: 1096-1104; with permission.)
According to Trotter et al.,18 torsion of the lung in toto or torsion of a lobe may be spontaneous or occur after trauma. 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.
RIGHT PRIMARY BRONCHUS
Anterior
Right pulmonary artery, ascending aorta, 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, giving origin to its pulmonary branch to the right lung
LEFT PRIMARY BRONCHUS

Anterior
The aortic arch, main pulmonary artery, left pulmonary artery and vein
NOTE: The pulmonary artery is located between the left upper lobe bronchus and the left primary bronchus.
Posterior
Descending aorta, esophagus, and pulmonary plexus
16/46
5/24/2014
The left vagus nerve crosses behind the left bronchus, 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, but capable of giving vital help when needed.Deffebach
et al.20
The bronchial blood supply has been studied in detail by Cauldwell et al.,21 Olson and Athanasoulis,22 Deffebach et al.,20 Miller and Nelems,23 and several
other investigators. The origins of the bronchial arteries and the pattern of bronchial venous drainage are both highly variable.
ARTERIES
(Fig. 6-16, Table 6-3) The origin of the right and left bronchial arteries is very variable. They may arise from the internal thoracic artery, subclavian artery,
or inferior thyroid arteries. In most cases the single right bronchial artery arises from the aorta or the third right posterior intercostal artery. The left lung is
nourished by two bronchial arteries that arise directly from the beginning of the descending thoracic aorta. Variations in origin of bronchial arteries are
shown in Figs. 6-17A & B.
Table 6-3. 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
40.8
II
21.3
III
20.8
IV
9.7
4.0
VI
2.0
VII
0.6
VIII
0.6
IX
4*
0.6
*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.
Source: Caudwell EW, Siekert RG, Lininger RE, Anson BJ. The bronchial arteries: an anatomic study of 150 human cadavers. Surg Gynecol Obstet 1948;86:395-412;
with permission.
Fig. 6-16.
17/46
5/24/2014
The four most common sites of origin and numbers of bronchial arteries to the right and left lungs. See Table 6-3 for percentage of occurrence of each. (Modified
from Cauldwell EW, Siekert RG, Lininger RE, Anson BJ. The bronchial arteries: an anatomic study of 150 human cadavers. Surg Gynecol Obstet 1948;86:395-412;
with permission.)
Fig. 6-17.
18/46
5/24/2014
Variations in origin of bronchial and esophageal arteries. A, left view. B, right view.
According to Deffebach et al.,20 the systemic bronchial arterial blood network "appears to be quite unimportant" at first, since its abolition is possible during
lung transplantation (Fig. 6-18). Their excellent article explores the "small, but vital" role of bronchial circulation in health and disease.
Fig. 6-18.
Schematic of the systemic blood supply to the lung. Note that the flow from the extrapulmonary airways and supporting structures returns to the right heart,
whereas intrapulmonary flow becomes anastomotic with the pulmonary circulation and returns to the left heart. (Modified from 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; with permission.)
After Carles et al.24 dissected 40 fresh cadavers, they reported that the bronchial blood supply is dominated by the intercostobronchial trunk and
anastomotic networks of different territories of the bronchial tree. Their findings on the feasibility of bronchial artery revascularization may be applicable to
pulmonary transplantation.
VEINS
The right bronchial veins (usually two) drain to the terminal part of the azygos vein, and the left bronchial veins end in the left superior intercostal vein or
the accessory hemiazygos vein (Figs. 6-19, 6-20).
Fig. 6-19.
19/46
5/24/2014
Right bronchial veins.
Fig. 6-20.
20/46
5/24/2014
The main veins of the thorax. A dashed line indicates the course of a left superior vena cava (a rare anomaly) on its way to the coronary sinus. (Modified from
O'Rahilly RO. Gardner-Gray-O'Rahilly Anatomy: A Regional Study of Human Structure, 5th Ed. Philadelphia: WB Saunders, 1986; with permission.)
LYMPHATICS
Lymphatic vessels from the bronchi pass to the bronchopulmonary and tracheobronchial lymph nodes (Fig. 6-21).
Fig. 6-21.
Pulmonary lymphatics: overall view of regional drainage. (Modified from Rouvire H. Anatomie des Lymphatiques de l'Homme. Paris: Masson, 1932; with
permission.)
Innervation
Sympathetic and parasympathetic innervation occurs through the pulmonary and cardiac plexuses. The bronchi are relatively insensitive to pain, and
stimulation of their mucosal lining produces coughing.
Lungs
Topography and Relations
The lungs are movable organs within the thoracic cavity; however, both are anchored to the heart and trachea. The right lung is composed of three lobes
and the left lung of two lobes.
Both the liver and heart modify the external contour of each lung. The right lung is shorter because of the right hepatic lobe; the left lung is narrower
because of the leftward location of the heart and pericardium. Each lung accepts the bronchi as well as the pulmonary vessels.
Both lungs exhibit the following characteristics: apex, base, three surfaces, three borders, and fissures (Figs. 6-22A & B).
Fig. 6-22.
21/46
5/24/2014
22/46
5/24/2014
23/46
5/24/2014
Projections of thoracic viscera. A, anterior view of male. B, posterior view of male. (Modified from Frick H, Kummer B, Putz R. Wolf-Heidegger's Atlas of Human
Anatomy (4th ed). Basel: Karger, 1990; with permission.)
APEX
The apex is covered by pleura. It projects above the clavicle into the base (root) of the neck. The extent of the lung above the clavicle varies with
respiration, posture, body build, and the angle of view. The apex of the left lung is a little longer than that of the right.
The relations of the apex are as follows:
Anterior: subclavian artery, anterior scalene muscle, subclavian vein, phrenic nerve, vagus nerve
Posterior: sympathetic trunk, 1st thoracic nerve, superior intercostal artery
Medial: brachiocephalic trunk, right brachiocephalic vein, trachea on the right, left subclavian artery and left brachiocephalic vein on the left
Lateral: scalenus medius muscle, first rib
BASE
The base is related to the superior surface of the diaphragm and several subdiaphragmatic organs. The right lower lobe is related to the pleura, diaphragm,
peritoneum, and right lobe of the liver. The left lower lobe is related to the pleura, diaphragm, peritoneum, left lobe of the liver, gastric fundus, and spleen.
THREE PULMONARY SURFACES
The costal surface of each lung is related to the thoracic wall. It ends at the anterior, posterior, and inferior pulmonary borders.
The medial or mediastinal surface of the lung is in contact with the organs of the mediastinum (Fig. 6-23). The posterior part of the medial surface is
related to the spine. Its medial mediastinal part is related to the superior, middle, and posterior mediastinum. The hilum (pulmonary porta) is the most
important anatomic area for the entrance and exit of bronchi, vessels, and nerves.
Fig. 6-23.
24/46
5/24/2014
Relationships between the lungs and organs of the mediastinum. Sup.v., superior pulmonary vein; Inf. v., inferior pulmonary vein. (From Healey JE Jr, Hodge J.
Surgical Anatomy (2nd ed). Philadelphia: BC Decker, 1990; with permission.)
The right diaphragmatic surface is related to the right hemidiaphragm and right lobe of the liver. The left diaphragmatic surface is related to the gastric
fundus, the spleen, and occasionally to the splenic flexure of the colon and the left lobe of the liver.
Frija et al.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%). Its height was 8.7 1.6 cm. Its most inferior
part faced L1 or L2 in 92% of cases. It was continuous medially inside with the azygo-esophageal recess in 96% of cases. The left posterior ILM was
not visible laterally in 34% of cases and medially in 60% of cases. It was most often concave upward (82% of cases). Its height was 6.9 1.5 cm.
Its most inferior part was at the level of L1 or L2. It was continuous medially with either the left paraspinal line or the paraaortic line. The right
anterior ILM was visible in 76% of cases. It was most often oblique upward and medially (46%) or concave upward (33%) and often notched (38%).
The left anterior ILM was visible in 64% of cases and more often oblique inward and upward (58%). It was continuous medially with the left inferior
precardiac recess. The anterior ILMs were more variable than the posterior. 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.
THREE PULMONARY BORDERS
The three pulmonary borders (anterior, inferior, posterior) correspond to the lines of pleural reflection (Figs. 6-24, 6-25).
Fig. 6-24.
25/46
5/24/2014
Borders of the pleurae and lungs in anterior and posterior views. (Modified from McVay CB. Anson & McVay Surgical Anatomy (6th ed). Philadelphia: WB Saunders,
1984; with permission.)
Fig. 6-25.
Borders of the pleurae and lungs in lateral views. (Modified from McVay CB. Anson & McVay Surgical Anatomy (6th ed). Philadelphia: WB Saunders, 1984; with
permission.)
Both right and left borders are atypical and not always constant. Deep or shallow respiration changes the topography. 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,
such as the liver on the right and the spleen on the left.
FISSURES
(Fig. 6-26) The left oblique fissure begins posteriorly at the 4th rib or occasionally at the 3rd or 5th. It ends at the area of the 6th or 7th rib with a
downward and forward pathway, almost reaching the hilum.
Fig. 6-26.
26/46
5/24/2014
External fissures of the lungs, and the frequency of their occurrences. Absence of a fissure does not imply alteration in the underlying bronchial pattern. The less
common fissures create dorsal and cardiac lobes. (Modified from Skandalakis JE, Gray SW. Embryology for Surgeons (2nd ed). Baltimore: Williams & Wilkins, 1994;
with permission.)
The right oblique fissure begins posteriorly approximately at the level of the 5th rib. With a downward and forward pathway, it ends at the 6th
costochondral junction. The left and right oblique fissures cross the midaxillary line on their respective sides at the level of the 5th or 6th rib.
The horizontal fissure begins at the level of the 6th rib near the midaxillary line where the pathway of the oblique fissure is located. The medial end of the
horizontal fissure is located at the 4th costal cartilage or 4th intercostal space, adjacent to the sternum.
Segmentation of the Lungs

The three lobes of the right lung and the two lobes of the left lung are composed of bronchopulmonary segments. The right lung has 10 segments and the
left lung has 8 segments (Table 6-4, Fig. 6-27). However, some writers count the two terminal branches of the apicoposterior segment separately, and
consider the anteromedial basal segment of the lower lobe as medial basal and anterior basal; thereby giving the left lung also 10 bronchopulmonary
segments. By definition, however, a bronchopulmonary segment is that portion of pulmonary tissue served by a tertiary bronchus.
Table 6-4. 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 divisionlingula
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, 1989.
27/46
5/24/2014
Note: Terms and numerals in brackets are those of the Nomina Anatomica, 1989.
Source: Shields TW. Surgical anatomy of the lungs. In: Shields TW, LoCicero J III, Ponn RB (eds). General Thoracic Surgery, 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2000, pp. 63-75; with permission.
Fig. 6-27.
The bronchopulmonary segments. AB, anterior basal; AMB, anteromedial basal; An, anterior segment (of the upper lobe); Ap, apical; ApP, apical-posterior; IL,
inferior lingular; LB, lateral basal; LM, lateral segment of the middle lobe; MB, medial basal; MM, medial segment of the middle lobe; P, posterior segment (of the
upper lobe); PB, posterior basal; S, superior segment of the lower lobe; SL, superior lingular. (Modified from Hollinshead WH. Anatomy for Surgeons. New York:
Hoeber-Harper, 1961; with permission.)
The segments are characterized by the central location of a bronchus and a branch of the pulmonary artery. The pulmonary venous tributaries run between
28/46
5/24/2014
The segments are characterized by the central location of a bronchus and a branch of the pulmonary artery. The pulmonary venous tributaries run between
segments.
The bronchopulmonary segments of both lungs have specific topographic locations. Their names indicate their positions relative to the thoracic wall and
mediastinum.
RIGHT LUNG
The 3 lobes of the right lung (upper, middle, and lower) are defined by an oblique major fissure separating the lower lobe from the middle lobe, and by a
horizontal minor fissure separating the upper lobe from the middle lobe. The upper lobe of the right lung has three bronchopulmonary segments: apical,
posterior, and anterior. The middle lobe is characterized by two segments, medial and lateral. The lower lobe has a superior segment and 4 basal segments:
anterior basal, medial basal, posterior basal, and lateral basal.
LEFT LUNG
The 2 lobes of the left lung (upper and lower) are separated by the oblique fissure. The distribution of bronchopulmonary segments differs from that of the
right lung. Characteristically, the apical and posterior segments of the upper left lobe form the "apicoposterior segment" of the upper lobe. The medial basal
and anterior basal segments have a common origin from the anteromedial segment of the lower lobe.
The inferior part of the left upper lobe is called the lingula, because of its thin prolongation in front of the left side of the heart. The lingula contains
superior and inferior bronchopulmonary segments which correspond to the anteroinferior position of the lingula. Topographically, the lingula is related to the
left 6th rib and left ventricle. It is the homologue of the right middle lobe.
According to Woniak,26 despite the fact that supernumerary segments are common, the supernumerary bronchi almost never arise from the trachea.
Lung Roots and Hila

The hilum is the area of the mediastinal surface that transmits the bronchi and pulmonary vessels. The lung root consists of a group of structures that
enter and exit the hilum.
The two lungs differ not only in number of lobes and arrangements of segments, but also in topographic relations with surrounding structures. Knowledge of
these differences is essential for the surgeon when approaching the right and left lung hila.
RIGHT LUNG HILUM
Anterior Approach
(Fig. 6-28.1). The most anterior anatomic entity in the hilum is the superior pulmonary vein. It partially covers the right pulmonary artery. Posterior to the
pulmonary artery is the bronchus. The azygos vein and the vagus and phrenic nerves are nearby.
Fig. 6-28.
29/46
5/24/2014
Approaches to the right lung hilum. 1, Anterior approach. 2, Interlobar approach. 3, Posterior approach. RUL, right upper lobe; RML, right middle lobe; RLL, right
lower lobe. (From Healey JE Jr, Hodge J. Surgical Anatomy (2nd ed). Philadelphia: BC Decker, 1990; with permission.)
Interlobar Approach
(Fig. 6-28.2). The interlobar approach to the right lung hilum is through the oblique fissure. The pulmonary artery and its branches are the most superficial
structures.
Posterior Approach
(Fig. 6-28.3). The inferior pulmonary vein and/or its branches are side by side with the intermediate bronchus. The esophagus, vagus nerve, and azygos
vein are visible.
LEFT LUNG HILUM
Anterior Approach
(Figs. 6-29.1, 6-29.2). 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. Close to the vein and a little posterior, the lower lobe bronchus can be seen. One can also observe the aortic arch, the
ligamentum arteriosum, and the left recurrent nerve. With lateral and posterior lung retraction, the vagus and phrenic nerves are visible.
Fig. 6-29.
30/46
5/24/2014
Approaches to the left lung hilum. 1, Anterior approach. 2, Interlobar approach. 3, Posterior approach. LLL, left lower lobe; LUL, left upper lobe. (From Healey JE Jr,
Hodge J. Surgical Anatomy (2nd ed). Philadelphia: BC Decker, 1990; with permission.)
Interlobar Approach
(Fig. 6-29.2). The left pulmonary artery is the dominant anatomic entity in the interlobar approach to the left lung hilum.
Posterior Approach
(Fig. 6-29.3). The most superficial structures are the inferior pulmonary vein and the left pulmonary artery side by side. The left main bronchus lies anterior
to and between the vein and artery.
Remember
The root of the lung is enveloped by the mediastinal pleura, which inferiorly forms the pulmonary ligament.
The right lung root is located under the azygos venous arch, SVC, and both atria. The phrenic nerve lies posteriorly, and the esophagus and right vagus nerve lie
anteriorly.
The left lung root is located under the aortic arch, with the ligamentum arteriosum fixed to the right. The left vagus nerve and its branch and the left recurrent
laryngeal nerve are also associated with the left lung root. The left atrium and main pulmonary artery are related anteriorly to the left lung hilum; the descending
aorta lies posteriorly and laterally. The esophagus is related more medially to the left lung hilum.
On the left mediastinal surface (the hilum of the left lung) the pulmonary artery lies above the bronchus.
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, the pulmonary artery crosses the bronchus anteriorly on the left, but on the right the pulmonary artery passes laterally to the
bronchus.
31/46
5/24/2014
The bronchi do not have a connective tissue sheath. The veins are surrounded by a thin, tissue-paperlike sheath. The arteries have a well formed sheath.
Bronchial Trees
RIGHT BRONCHIAL TREE
(Figs. 6-30, 6-31, 6-32) The upper right lobe bronchus has a length of 1-1.5 cm. It originates from the lateral wall of the right main bronchus below the
carina, and gives off 3 segmental bronchi (apical, posterior, and anterior). The genesis of the segmental bronchi is quite variable. It is probable that they
form by trifurcation of the right upper lobe bronchus.
Fig. 6-30.
Right bronchial tree. A, anterior view. B, lateral view. Boyden's modification of numerical nomenclature used. (Modified from Shields TW. Surgical anatomy of the
lungs. In: Shields TW (ed). General Thoracic Surgery (5th ed). Philadelphia: Lippincott Williams & Wilkins, 2000, pp. 63-75; with permission.)
Fig. 6-31.
32/46
5/24/2014
Tracheal bronchus supplying the apical segment of the right upper lobe. A, Anterior view. B, Lateral view. (Modified from Shields TW. Surgical anatomy of the lungs.
In: Shields TW (ed). General Thoracic Surgery (5th ed). Philadelphia: Lippincott Williams & Wilkins, 2000, pp. 63-75; with permission.)
Fig. 6-32.
Schema of the segmental bronchi of the right lung. A, Anterior view. B, Lateral view. (Modified from Hollinshead WH. Anatomy for Surgeons. New York: HoeberHarper, 1961; with permission.)
The right middle lobe bronchus arises perhaps 1 cm below the orifice of the upper lobe. The lateral and medial segments are formed by bifurcation.
The right lower lobe bronchus is located inferiorly and posteriorly. For all practical purposes, it is the caudal end of the right primary bronchus. It provides
origin for five segmental bronchi (superior, medial basal, anterior basal, lateral basal, and posterior basal).
LEFT BRONCHIAL TREE
33/46
5/24/2014
(Figs. 6-33, 6-34) The left upper lobe bronchus originates anterolaterally from the main bronchus, approximately 5 cm distal from the carina. It divides into
2 branches: the ascending superior and the descending inferior. The superior division bifurcates into: (1) the apicoposterior and the anterior bronchi, and
(2) the inferior, the well known lingula (Fig. 6-35), which divides into superior and inferior lingular bronchi.
Fig. 6-33.
Left bronchial tree. A, Anterior view. B, Lateral view. Boyden's modification of numerical nomenclature used. (Modified from Shields TW. Surgical anatomy of the
lungs. In: Shields TW (ed). General Thoracic Surgery (5th ed). Philadelphia: Lippincott Williams & Wilkins, 2000, pp. 63-75; with permission.)
Fig. 6-34.
34/46
5/24/2014
Schema of the segmental bronchi of the left lung. A, Anterior view. B, Lateral view. (Modified from Hollinshead WH. Anatomy for Surgeons. New York: HoeberHarper, 1961; with permission.)
Fig. 6-35.
Typical branchings of the chief bronchi of the left lung, anterior view. For identification of segmental bronchi, see Fig. 6-37. (Modified from Hollinshead WH. Anatomy
for Surgeons. New York: Hoeber-Harper, 1961; with permission.)
The left lower lobe bronchus is the caudal end of the main left bronchus. At approximately 0.5 cm below the orifice of the upper bronchus, it gives origin to
the superior segmental bronchus. The four remaining basal bronchi are formed by bifurcation and trifurcation. There are multiple variations, the most
common being the presence of a combined anteromedial basal segment.
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]).
ARTERIES
(Fig. 6-36)
Fig. 6-36.
35/46
5/24/2014
Pulmonary arteries, segmental arteries. 1, Right pulmonary artery (mediastinal portion). 2, Pulmonary trunk. 3, Left pulmonary artery (mediastinal portion). 4,
Lingular artery. 5, Interlobar portion of the pulmonary artery. 6, Middle lobe artery. (Modified from Kubik S, Healey JE. Surgical Anatomy of the Thorax. Philadelphia:
WB Saunders, 1970; with permission.)
Pulmonary Trunk
The right and left pulmonary arteries arise from the pulmonary trunk, which in turn arises from the right ventricle. The pulmonary trunk may be considered in
two parts: intrapericardial (3.75 cm long) and extrapericardial (1.25 cm long). The extrapericardial portion lies to the left of the ascending aorta.
The pulmonary trunk bifurcates in the concavity of the aortic arch below the trachea and in front of the left main bronchus. 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).
Right Pulmonary Artery. The right pulmonary artery is longer and larger than the left pulmonary artery (Fig. 6-37A). It is located below the carina and
anterior to the right main bronchus. Its anterior relations are as follows: ascending aorta, SVC, phrenic nerve. At the root, the right bronchus is above and
the pulmonary veins below.
Fig. 6-37.
Common pattern of branching. A, Right pulmonary artery. B, Left pulmonary artery. (Modified from Shields TW. Surgical anatomy of the lungs. In: Shields TW (ed).
General Thoracic Surgery (5th ed). Philadelphia: Lippincott Williams & Wilkins, 2000, pp. 63-75; with permission.)
Left Pulmonary Artery. The left pulmonary artery is attached to the concavity of the aortic arch by the ligamentum arteriosum (Fig. 6-37B). 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, with the superior
lobar and apical veins in front.
VEINS
(Fig. 6-38) The pulmonary veins are highly variable and do not contain valves. There are usually two pulmonary veins in each side, the superior and inferior.
The veins are formed by intersegmental tributaries, and do not follow the bronchi very closely.
Fig. 6-38.
36/46
5/24/2014
Pulmonary veins, segmental veins. 1, Apical vein. 2, Posterior vein. 3, Anterior vein. 4, Lingular vein. 5, Apical basal vein. 6, Superior basal vein. 7, Inferior basal
vein. 8, Anterior basal vein. 9, Lateral basal vein. 10, Posterior basal vein. 11, Superficial intersegmental vein between segment 7 and segment 10. 12, Left inferior
pulmonary vein. 13, Left superior pulmonary vein. 14, Right superior pulmonary vein. 15, Right inferior pulmonary vein. 16, Middle lobe vein. (Modified from Kubik S,
Healey JE. Surgical Anatomy of the Thorax. Philadelphia: WB Saunders, 1970; with permission.)
Right Pulmonary Veins

The right superior pulmonary vein is located anterior and occasionally inferior to the right pulmonary artery. It is formed by four tributaries which drain the
upper and middle lobes of the right lung, three from the upper and one from the middle. The right inferior pulmonary vein is located inferior and posterior to
the right superior vein.
Left Pulmonary Veins

The left superior pulmonary vein is formed by 3 or 4 branches, which drain the upper lobe in toto. Its location is roughly anterior to the left pulmonary
artery. The left inferior pulmonary vein is formed by two branches and is located inferior and posterior to the superior vein.
LYMPHATICS
(Figs. 6-39, 6-21, and Table 6-5) For all practical purposes, the lymphatics of the lung belong to the greater group of the lymphatics of the thorax. This is
due to their rich intercommunication with each other, as well as their special groups of lymph nodes which also communicate with each other. There are
several classifications, confusing not only to the student but also to the practicing surgeon.
Table 6-5. 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.
Source: Borrie J. Lung Cancer. Surgery and Survival. New York: Appleton-Century-Crofts, 1965; with permission.
Fig. 6-39.
37/46
5/24/2014
Highly schematic diagram of the respiratory lymphatic system. 1 and 2 = Superficial groups of lymphatics. 3 and 4 = Deep groups of lymphatics. Rich
communications exist between superficial and deep groups, including hilar, lobar, and bronchopulmonary areas.
The pulmonary lymphatic network can be divided into two groups: superficial and deep. The superficial group is formed by the lymphatics under the visceral
pleura and by those of the interlobar septa. The deep group is formed by lymphatics located around vessels and bronchi. Rich communication between the
two networks takes place in the hilar area.
Remember
Intrapulmonary lymph nodes are rare.
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, close to the reflection of the
visceral pleura.
The lobar lymph nodes are situated at the origin of the lobar bronchi, close to the pulmonary vessels.
The lungs have an extensive formation of lymphatic plexuses with intercommunication, and multiple nodes that communicate with each other.
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
38/46
5/24/2014
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. Both divisions contribute to form the pulmonary plexuses, which are located at
the root of the lung, anterior and posterior.
SYMPATHETIC
The sympathetic nervous system participates in the formation of the plexuses by postganglionic fibers. These arise from the first 5 thoracic sympathetic
ganglia, and supply blood vessels, glands, and smooth muscles of the bronchi. Their purpose is uncertain; perhaps they inhibit the action of the smooth
muscles.
According to Rosse and Gaddum-Rosse,27 the sympathetic visceral efferents are motor to the bronchial glands and also produce vasoconstriction of
pulmonary blood vessels. The same authors questioned whether such fibers terminate on bronchiolar muscles even though it is well established that
sympathomimetic drugs produce bronchial dilation.
PARASYMPATHETIC (VAGUS NERVE)
The contribution of the vagus nerve to the plexuses is by fibers which synapse upon intrapulmonary ganglion cells and their axons. Glands and the smooth
muscle of the bronchi may or may not be innervated by an antiinhibitory action. Most likely, sensory fibers carried by the vagus nerve affect the pulmonary
vessels. This may cause severe hypotension, and the heart rate changes. These vagal sensory fibers also innervate the bronchial mucosa and are involved
in the cough reflex.
Regarding innervation of the pleura, the parietal pleura is a somatic structure and thus receives generous general somatic sensory innervation via the
intercostal and phrenic nerves. These mediate touch and pain modalities. In some cases when the mediastinal and medial diaphragmatic areas of parietal
pleura are irritated, 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, C4, C5) and supraclavicular nerves (C3, C4). The visceral pleura's innervation via vagal fibers mediates no pain sensations, but it has been
reported to contribute in complex ways to the function of respiration.
Rosse and Gaddum-Rosse27 also stated that the vagus nerve is motor to bronchial and bronchiolar smooth muscle, and produces bronchoconstriction. Most
likely the vagus nerve does not innervate smooth muscle in the wall of the pulmonary vessels.
HISTOLOGY AND PHYSIOLOGY

The histologic features of the trachea and bronchi are practically the same. The four layers from the inside to the outside are:
1a. Mucous membrane with ciliated pseudostratified columnar epithelium
1b. Lamina propria
2. Submucosa with mixed seromucous glands
3. Cartilaginous smooth layer. Characteristically, this layer is formed by hyaline cartilage of incomplete rings, united by smooth muscle and some fibrous elements.
4. Adventitia
The physiology of the respiratory system concerns the transport and exchange of oxygen and carbon dioxide. It is not within the scope of this book to
discuss respiratory mechanisms, ventilation with transport and exchange, or pulmonary blood flow. But a very brief description of the physiology of the
trachea and bronchi, together with respiratory physiology, follows.
The formation of air flow depends upon the synergistic action of atmospheric, alveolar, and intrapleural pressures.
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, air (containing oxygen) enters the lungs.
When atmospheric pressure is lower than the alveolar pressure, air (containing carbon dioxide) exits the lungs.
Intrapleural (thoracic cavity)
By its own intrapleural pressure, the thoracic cavity negotiates both atmospheric and alveolar pressure.
The inspiratory muscles are the
39/46
5/24/2014
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, respectively. The sternocleidomastoid muscles and scalenes
(the upper airway muscles) are innervated by the cervical nerves.
The expiratory muscles are the
Three flat muscles (external oblique, internal oblique, transversus abdominis)
Rectus abdominis
Internal intercostals
The entire right ventricular output enters the lungs. The low-pressure, low-resistance pulmonary circulation causes the gas exchange.
The respiratory centers of the pontomedullary area of the brain are responsible for breathing.
SURGICAL APPLICATIONS
Trachea
Some of the most common surgical procedures of the trachea are tracheostomy, tracheal resection, treatment of tracheal stenosis, and treatment of
tracheoesophageal fistulas. The last is considered in the chapter on the esophagus.
At its beginning, the arch of the aorta is located anterior to the trachea; thereafter it is above the left main bronchus. The brachiocephalic artery is in front
of the trachea and then to its right. The left common carotid artery is at first anterior to the trachea and then passes to its left.
Deviation of the trachea to the right or left results from pressure in the neck and mediastinum. The inner surface of the tracheal bifurcation is a sharp ridge
(membranous or cartilaginous) called the tracheal keel or carina. It separates the proximal ends of both bronchi and is a bronchoscopic landmark.
Penetrating wounds of the neck and chest can involve the cervical or thoracic trachea or even one or both bronchi. Blunt chest trauma can produce severe
injuries of the trachea or bronchi, due to the various forces generated during the impact.
The usual site of a tracheostomy is between the second and fourth tracheal rings. The structures encountered are the skin and superficial fascia, investing
layer of deep cervical fascia, and the visceral compartment under the pretracheal fascia. The platysma lies in the superficial fascia, but is absent in the
midline. The anterior jugular veins may lie close to the midline. More importantly, they may be united by a jugular venous arch at the level of the seventh to
eighth tracheal rings.
The sternohyoid and sternothyroid muscles lie between the investing layer of fascia and the pretracheal fascia on either side of the midline.
The inferior thyroid veins arise as a venous plexus on the anterior surface of the isthmus of the thyroid gland. Left and right descending veins enter the
respective brachiocephalic veins (Fig. 6-40). The two veins may form a common trunk entering the superior vena cava or the left brachiocephalic vein.
Fig. 6-40.
40/46
5/24/2014
The venous drainage of the thyroid gland. The inferior thyroid veins are quite variable. (Modified from Tzinas S, Droulias C, Harlaftis N, Akin JT Jr, Gray SW,
Skandalakis JE. Vascular patterns of the thyroid gland. Am Surg 1976;42:639-644; with permission.)
The isthmus of the thyroid gland commonly lies at the level of the second and third tracheal rings; it is often more cranial, less often more caudal. In about
10 percent of individuals, the two lobes of the thyroid are not connected by an isthmus.28 The isthmus can be retracted upward or downward to reach the
trachea; if necessary, it can be ligated and incised. The possibility of a thyroid ima artery (10 percent of individuals)29 should not be forgotten. A
suspensory ligament of the thyroid and a levator thyroid muscle may also be present in or close to the midline.
Remember
Tracheostomy in children remains controversial because of the possibility of complications. Rocha et al.30 considered the risks resulting from tracheostomy
and intubation acceptable for comatose children in need of prolonged ventilatory support. In an editorial comment on Rocha, Tepas31 questioned the
necessity of early tracheostomy.
Bronchi
To aid the healing of the bronchus, it is prudent for the bronchial stump to be covered by tissue (such as pleurae, muscles, or omentum); this avoids air
leaks and bronchopleural fistula.
Surgery of the bronchi, as well as their surgical complications, are described below in the discussion of the lungs.
Fernando et al.32 advise bronchial artery embolization for treatment of hemoptysis, thereby reducing the need for lung resections.
Lungs
Bronchoscopy, biopsy, segmentectomy, lobectomy, partial lobectomy, total pneumonectomy, and transplantation are done according to the underlying
pathology.
Segments
Each bronchopulmonary segment is an independent and separate unit from a surgical standpoint. It can be excised in toto since there is minimal
anastomosis between the adjacent segments. Pulmonary segmental veins are located between the segments; they are good landmarks for intersegmental
separation and segmental resection.
The apicoposterior segments of the upper lobes and superior segments of the lower lobes are common sites for tuberculosis.
Fissures
Congenital anomalies and variations as well as pathological processes can distort the pathway of the fissures. However, remember that the fissures may be
absent or not well developed, especially the horizontal one.
Thoracoscopy
McFadden and Robbins33 stated that video-assisted thoracoscopy may be used in selected patients. Yim et al.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. Liu et al.35
recommended thoroscopy as the treatment of choice for patients with pneumothorax requiring surgical treatment.
Thoracotomy
The lung can be approached by a posterior or anterior thoracotomy or a median sternotomy. The posterior thoracotomy is through the 5th intercostal
space; the anterior thoracotomy is through the 3rd intercostal space. Asaph et al.36 advocate median sternotomy instead of thoracotomy in treatment of
primary pulmonary carcinoma, citing completeness of lymph node staging and favorable wound infection and mortality rates.
Total Pulmonary Resection (Pneumonectomy)

The thin-walled pulmonary artery should be dissected with extreme care by sharp and blunt dissection and finger mobilization. Remember that the recurrent
laryngeal nerve on the left side passes under the aortic arch.
During ligation of the pulmonary veins, shunting of the blood takes place and pulmonary distention does not occur.37 If necessary, enter the pericardium in
order to have enough room for a good pulmonary vein ligation.
To prevent cardiac herniation, either open the pericardial defect widely or repair it with bovine pericardium or prostheses, or primarily.
Close the main bronchus near the carina. This prevents a blind pocket with subsequent breakdown of the bronchial stump or hemoptysis.
Successful video-assisted thoracoscopic lung resection for infants and children was reported by Rothenberg.38 Two patients with metastatic disease
requiring extensive resections were converted to standard thoracotomy.
41/46
5/24/2014
requiring extensive resections were converted to standard thoracotomy.
Segmental and Lobar Resection

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

PNEUMOMEDIASTINUM AND PNEUMOTHORAX
The following observations may provide some explanation about the pathway of formation of spontaneous pneumomediastinum and pneumothorax.
1. Mechanical stress is stronger in the apices.
2. This stress produces enlargement of the apical alveoli and compression of the basilar alveoli.
3. Because of the high pressure, the apical alveoli are ruptured and produce pneumomediastinum due to rupture of a bleb within the pulmonary parenchyma, which
creates interstitial emphysema. Air dissects within peribronchial or perivascular planes into the hilum and, finally, into the mediastinum.42 When blebs under the
visceral pleura rupture, pneumothorax is produced.
Additional information about pneumomediastinum and pneumothorax is found in the chapter on the neck under "Radical Neck Dissection."
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).
VOCAL CORDS
Too high a tracheostomy can result in direct injury to the vocal cords. Placement of the tube through the thyrohyoid membrane can also produce vocal
cord injury.43 The stoma should be formed below the first ring.
POSTTRACHEOSTOMY SWALLOWING DYSFUNCTION
The adverse effect of a cuffed tracheostomy tube on the swallowing mechanism was reported by Bonanno.44 Evaluation of the trigeminal,
glossopharyngeal, recurrent, and external laryngeal nerves revealed that nerve injury was not a factor. 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.
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. The distal
end of a tube with too much curvature will erode the anterior tracheal wall.45 Roe46 recommended a 60 curvature (Fig. 6-41C).
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. Fahimi et al.47 advised wedge carinal resection with
rotational approximation for securing the challenging bronchial stump closure.
Resection and reimplantation of an injured lobar branch is feasible even in a delayed setting. Pilcher et al.48 reported correction of a left upper lobe
bronchus separation secondary to nonpenetrating thoracic trauma.
Wood and Vallires49 reported that of 50 patients who underwent tracheobronchial resection and reconstruction, there were no deaths, and the morbidity
rate was 32%.
In comparing bronchial closure by manual suturing to closure by conventional staplers and endostaplers, Asamura50 found acceptable rates of failure,
including rate of bronchopleural fistula, with the newly developed endostaplers.
Tracheobronchial rupture may occur following intubation. Jougon et al.51 stated, "Aggressive surgical repair is not always mandatory after delayed diagnosis
of iatrogenic tracheobronchial rupture. Conservative treatment must often be considered, except after lung resection."
Lung Resection
VASCULAR INJURY
Massive bleeding from the major pulmonary vessels is possible, as is bleeding from a bronchial or intercostal artery. Peterffy and Henze52 reported 0.1%
mortality in 1428 resections. These authors observed 113 episodes of bleeding: 30% after pneumonectomy, 66% after lobectomy, 4% after
segmentectomy.
Spinal cord injury with paraplegia may be averted by careful hemostasis of a bleeding intercostal artery at the posterior corner of the intercostal incision,
and by avoiding cautery or packing. Remember that dorsal branches of intercostal arteries, especially the more caudal ones, may contribute critical radicular
branches to the spinal cord.
ORGAN INJURY
Esophagus
Esophageal injury of up to 0.5% was reported by Shama and Odell.53 If injury is recognized in the operating room, esophageal repair is essential to avoid
fatal mediastinitis.
Pneumothorax and Chylothorax

The development of contralateral pneumothorax is 0.08% as reported by Vogt-Moykopf.54 This is most likely secondary to a contralateral bleb.
Chylothorax with thoracic duct injury is very rare. Incidence is 0.05% according to Simpson55 and 0.3% according to Brie.56 The thoracic duct can be
ligated with impunity because of the gradual expansion of collateral lymphatic vessels.
43/46
5/24/2014
ligated with impunity because of the gradual expansion of collateral lymphatic vessels.
Lobar Torsion
A 180 rotation can produce right or left lobar torsion in the operating room or postoperatively, as reported by Wong and Goldstraw.57 Occasionally,
lobopexy is necessary.
Nerve Injury
Right or left phrenic nerve injury is a rare phenomenon. It may be accidental or for the purpose of paralyzing the hemidiaphragm for volume reduction of the
ipsilateral hemithorax, a procedure which is not recommended. Left recurrent nerve injury following mediastinal lymph node dissection was reported by Bollen
et al.58
Read an Editorial Comment
PULMONARY TRANSPLANTATION
In 1963, Hardy and his colleagues reported the first human lung transplant.59 Since then, several centers in the United States and abroad have advanced
the technical aspects for single and double sequential lung transplantation.
McFadden and Emory (1998)60 reported that infection is the major cause of morbidity and mortality in lung transplantation. Bronchiolitis obliterans is the
second most common complication. These authors stated that lung rejection, bacterial infection and cytomegalovirus infection produce lung dysfunction. In
a study of single and bilateral lung transplantation, Garfein et al.61 found a higher incidence of anastomotic complications and postoperative pneumonia with
telescoped bronchial anastomosis than with end-to-end anastomosis.
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.
Faughnan et al.63 caution against lung transplantation for patients with diffuse pulmonary arteriovenous malformations.
We strongly advise the interested reader to study the article of Grover et al.64 on lung transplantation.
REFERENCES
1. Jackson C. The Life of Chevalier Jackson. An Autobiography. New York: Macmillan, 1938.
2. O'Rahilly R, Boyden EA. The timing and sequence of events in the development of the human respiratory system during the embryonic period proper. Z
Anat Entwicklungsgesh 1961;141:237. [PubMed: 16453390]
3. Ninth International Congress of Anatomists (Leningrad), 1970.
4. Cormack DH. Ham's Histology (9th ed). Philadelphia: JB Lippincott, 1987.
5. Shields TW. Surgical anatomy of the lungs. In: Shields TW (ed). General Thoracic Surgery (5th ed). Philadelphia: Lippincott Williams & Wilkins, 2000, pp.
63-75.
6. Mawatari T, Murakami G, Koshino T, Morishita K, Abe T. Posterior pulmonary lobe: segmental and vascular anatomy in human specimens. Clin Anat
2000;13:257-262. [PubMed: 10873217]
7. Raffensperger JG. Congenital malformations of the lung. In: Raffensperger JG (ed). Swenson's Pediatric Surgery (5th ed). Norwalk CT: Appleton & Lang,
1990, pp. 743-753.
8. Schechter DC. Congenital absence or deficiency of lung tissue: The congenital subtractive broncho-pulmonary malformations. Ann Thorac Surg
1968;6:286-313.
9. Peragallo RA, Swenson JD. Congenital tracheal bronchus: the inability to isolate the right lung with a univent bronchial blocker tube. Anesth Analg
2000;91:300-301. [PubMed: 10910836]
10. Roque AS, Burton EM, Boedy RF, Falls G, Bhatia JS. Unilateral pulmonary agenesis without mediastinal displacement. South Med J 1997;90:335-337.
[PubMed: 9076309]
11. Evrard V, Ceulemans J, Coosemans W, De Baere T, De Leyn P, Deneffe G, Devlieger H, De Boeck C, Van Raemdonck D, Lerut T. Congenital
parenchymatous malformations of the lung. World J Surg 1999;23:1123-1132. [PubMed: 10501874]
12. Endo M, Yamaki S, Ohmi M, Tabayashi K. Pulmonary vascular changes induced by congenital obstruction of pulmonary venous return. Ann Thorac Surg
2000;69:191-197.
13. Skandalakis JE, Gray SW. Embryology for Surgeons (2nd ed). Baltimore: Williams & Wilkins, 1994.
14. Kubik S, Healey JE. Surgical Anatomy of the Thorax. Philadelphia: WB Saunders, 1970.
15. Mulliken J, Grillo HC. The limits of tracheal resection with primary anastomosis: further anatomical studies in man. J Thorac Cardiovasc Surg
1968;55:418. [PubMed: 5642707]
16. Schuster M, Nave H, Piepenbrock S, Pabst R, Panning B. The carina as a landmark in central venous catheter placement [comment]. Br J Anaesth
44/46
5/24/2014
16. Schuster M, Nave H, Piepenbrock S, Pabst R, Panning B. The carina as a landmark in central venous catheter placement [comment]. Br J Anaesth
2000;85:188-191.
17. Ashour M, Al-Kattan K, Rafay MA, Saja KF, Hajjar W, Al-Fraye AR. Current surgical therapy for bronchiectasis. World J Surg 1999;23:1096-1104.
[PubMed: 10501869]
18. Trotter MC, McFadden PM, Ocshner JL. Spontaneous torsion of the right lung: a case report. Am Surg 1995;61:306-309. [PubMed: 7893092]
19. Felson B. Lung torsion: radiographic findings in nine cases. Radiology 1987;162:631-638. [PubMed: 3809475]
20. 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. [PubMed: 3544986]
21. Cauldwell EW, Siekert RG, Lininger RE, Anson BJ. The bronchial arteries: an anatomic study of 150 human cadavers. Surg Gynecol Obstet 1948;86:395412.
22. Olson PR, Athanasoulis CA. Hemoptysis: treatment with transcatheter embolizations of the bronchial arteries. In: Athanasoulis CA (ed). Interventional
Radiology. Philadelphia: WB Saunders, 1982.
23. Miller RR, Nelems B. Mediastinal lymph node necrosis: a newly recognized complication of mediastinoscopy. Ann Thorac Surg 1989;48:247. [PubMed:
2764616]
24. Carles J, Clerc F, Dubrez J, Couraud L, Drouillard J, Videau J. The bronchial arteries: anatomic study and application to lung transplantation. Surg Radiol
Anat 1995;17:293-299. [PubMed: 8896146]
25. Frija J, de Kerviler E, Zagdanski AM. Radiologic anatomy of the inferior lung margins as demonstrated on computed radiography with enhancement of low
frequencies. Surg Radiol Anat 1997;19: 257-263. [PubMed: 9381333]
26. Woniak W. Folia Morphol (Praha) 1966;14:148. Cited in: Gardner E, Gray DJ, O'Rahilly R. Anatomy (3rd ed). Philadelphia: WB Saunders, 1969, p. 313.
[PubMed: 11604798]
27. Rosse C, Gaddum-Rosse P. Hollinshead's Textbook of Anatomy, 5th Ed. Philadelphia: Lippincott-Raven. 1997.
28. Gray SW, Skandalakis JE. Embryology for Surgeons. Philadelphia: WB Saunders, 1972, p. 32.
29. Montgomery RL. Head and Neck Anatomy with Clinical Correlations. New York: McGraw-Hill, 1981, p. 59.
30. Rocha EP, Dias MD, Szajmbok FEK, Fontes B, Poggetti RS, Birolini D. Tracheostomy in children: there is a place for acceptable risk. J Trauma
2000;49:483-486. [PubMed: 11003327]
31. Tepas JJ III. Editorial comment. Rocha EP, Dias MD, Szajmbok FEK, Fontes B, Poggetti RS, Birolini D. Tracheostomy in children: there is a place for
acceptable risk. J Trauma 2000;49:483-486.
32. Fernando HC, Stein M., Benfield JR, Link DP. Role of bronchial artery embolization in the management of hemoptysis. Arch Surg 1998, 133:862-866.
[PubMed: 9711960]
33. McFadden PM, Robbins RJ. Thoracoscopic surgery. Surg Clin North Am, 1998,78(5):763-772.
34. Yim APC, Izzat MB, Lee TW. Thoracoscopic surgery for pulmonary tuberculosis. World J Surg 1999;23:1114-1117. [PubMed: 10501872]
35. Liu HP, Yim APC, Izzat MB, Lin PJ, Chang CH. Thoracoscopic surgery for spontaneous pneumothorax. World J Surg 1999;23: 1133-1136. [PubMed:
10501875]
36. Asaph JW, Handy JR Jr, Grunkemeier GL, Douville EC, Tsen AC, Rogers RC, Keppel JF. Median sternotomy versus thoracotomy to resect primary lung
cancer: analysis of 815 cases. Ann Thorac Surg 2000;70:373-379. [PubMed: 10969647]
37. Miller GE, Aberg THJ, Gerbode F. Effect of pulmonary vein ligation on pulmonary artery flow in dogs. J Thorasc Cardiovasc Surg 1968;55:668. [PubMed:
5651580]
38. Rothenberg SS. Thoracoscopic lung resection in children. J Ped Surg 2000;35:271-274.
39. MacCallum PL, Parnes LS, Sharpe MD, Harris C. Comparison of open, percutaneous, and translaryngeal tracheostomies. Otolaryngol Head Neck
2000;122:686-690. [PubMed: 10793347]
40. Escarment J, Suppini A, Sallaberry M, Kaiser E, Cantais E, Palmier B, Quinot JF. Percutaneous tracheostomy by forceps dilatation: report of 162 cases
[comment]. Anesth 2000:55:699 and 704-705.
41. Artz CP, Hardy JD. Management of Surgical Complications (3rd ed). Philadelphia: WB Saunders, 1960.
42. Davis RD Jr, Oldham HN Jr, Sabiston DC Jr. The mediastinum. In: Sabiston DC Jr, Spencer FC. Surgery of the Chest, 5th Ed. Philadelphia: WB Saunders,
1990, pp. 498-535.
43. Kirchner JA. Tracheotomy and its problems. Surg Clin North Am 1980;60:1093. [PubMed: 7434153]
45/46
5/24/2014
44. Bonanno PC, Swallowing dysfunction after tracheostomy. Ann Surg 1971;174:29. [PubMed: 5092509]
45. Conley JJ. Complications of Head and Neck Surgery. Philadelphia: Saunders, 1979.
46. Roe BB. Bedside tracheostomy. Surg Gynecol Obstet 1962;115: 239. [PubMed: 14493231]
47. Fahimi H, Casselman F, Mariani MA, van Boven WJ, van Swieten H. Wedge carinal resection for closure of the main bronchus after pneumonectomy. Ann
Thorac Surg 2000;70:987-989. [PubMed: 11016356]
48. Pilcher JA Jr, Ishitani MB, Rodgers BM. Left upper lobe bronchus reimplantation for nonpenetrating thoracic trauma. Ann Thorac Surg 2000;69:273-275.
[PubMed: 10654534]
49. Wood DE, Vallires E. Tracheobronchial resection and reconstruction. Arch Surg 1997;132:850-856. [PubMed: 9267268]
50. Asamura H, Kondo H, Tsuchiya R. Management of the bronchial stem in pulmonary resections: a review of 533 consecutive recent bronchial closures.
Eur J Cardio Thorac Surg 2000;17:106-110. [PubMed: 10731644]
51. Jougon J, Ballester M, Choucroun E, Dubrez J, Reboul G, Velly JF. Conservative treatment for postintubation tracheobronchial rupture. Ann Thorac Surg
2000;69:216-220. [PubMed: 10654516]
52. Peterffy A, Henze A. Hmorrhagic complications during pulmonary resection: a retrospective review of 1428 resections with 113 hmorrhagic episodes.
Scand J Thorac Cardiovasc Surg 1983;17: 283.
53. Shama DM, Odell JA. Esophageal fistula after pneumonectomy for inflammatory disease. J Thorasc Cardiovasc Surg 1985;89:77. [PubMed: 3965819]
54. Vogt-Moykopf I. Contralateral pneumothorax occurring after pulmonary surgery. In: Deslauriers J, Lacquet LK (eds). Thoracic Surgery: Surgical
Management of Pleural Diseases. St Louis: CV Mosby, 1990.
55. Simpson L. Chylothorax in adults. In: Deslauriers J, Lacquet LK (eds). Thoracic Surgery: Surgical Management of Pleural Diseases. St Louis: CV Mosby,
1990.
56. Brie M. Chylothorax complicating pulmonary resection. In: Deslauriers J, Lacquet LK (eds). Thoracic Surgery: Surgical Management of Pleural Diseases.
St Louis: CV Mosby, 1990.
57. Wong PS, Goldstraw P. Pulmonary torsion: a questionnaire survey and a survey of the literature. Ann Thorac Surg 1992;54:286. [PubMed: 1637221]
58. Bollen ECM, van Duin CJ, Theunissen PHMH, v.'t Hof-Grootenboer BE, Blijham GH. Mediastinal lymph node dissection in resected lung cancer: morbidity
and accuracy of staging. Ann Thorac Surg 1993;55:961-966. [PubMed: 8385446]
59. Hardy JD, Webb WR, Dalton ML, Walker GR. Lung transplantation in man. JAMA 1963;186:1065-1074. [PubMed: 14061414]
60. McFadden PM, Emory WB. Lung transplantation. Surg Clin North Am, 1998, 78(5):749-762.
61. Garfein ES, McGregor CC, Galantowicz ME, Schulman LL. Deleterious effects of telescoped bronchial anastomosis in single and bilateral lung
transplantation. Ann Transplant 2000;5:5-11. [PubMed: 10850603]
62. Meyers BF, Patterson GA. Lung transplantation: current status and future prospects. World J Surg 1999;23:1156-1162. [PubMed: 10501878]
63. Faughnan ME, Lui YW, Wirth JA, Pugash RA, Redelmeier DA, Hyland RH, White RI Jr. Diffuse pulmonary arteriovenous malformations: characteristics and
prognosis. Chest 2000;117:31-38. [PubMed: 10631195]
64. 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. [PubMed: 9207168]
65. Anson BJ. An Atlas of Human Anatomy, 2nd Ed. Philadelphia: WB Saunders, 1963, p. 266.
C opyright 2006 The McGraw-Hill C ompanies. All rights reserved.
Privacy Notice. Any use is subject to the Terms of Use and Notice. Additional C redits and C opyright Information.
46/46

Chapter 6 Respiratory System

Hochgeladen von

Dokumentinformationen

Originalbeschreibung:

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Chapter 6 Respiratory System

Hochgeladen von

Copyright:

Verfügbare Formate

5/24/2014

Print: Chapter 6. Respiratory System

Skandalakis' Surgical Anatomy > Chapter 6. Respiratory System >

Galen (ca. 130200 A.D.)

Resected part of a lung visible from a hernia of the chest wall

Used endotracheal intubation for anesthesia in animal surgery

First description of pulmonary agenesis

von Smmering 1808

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

Developed an intratracheal tube with an inflatable cuff

Developed artificial respiration via intralaryngeal insufflation

Advocated adding intrapleural or extrapleural pneumolysis to thoracoplasty

Proposed the use of peroral intubation to facilitate positive pressure anesthesia

Performed the first thoracotomy under intratracheal anesthesia

Performed a one-stage lobectomy

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

Developed selective apical thoracoplasty

Print: Chapter 6. Respiratory System

Originated the term "bronchopulmonary segments" to describe lung anatomy

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

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

Reported an unsuccessful case of pulmonary lobectomy

Removed an adenoma originating in the lower left lobe bronchus

Repaired a bronchus using fascia after removing a bronchial adenoma

Performed a bronchial sleeve lobectomy

Performed a pulmonic valvotomy

Systematized operative methods for segmental resection

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

Performed a simultaneous bilateral resection for bronchiectasis

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

Advocated parietal pleurectomy to treat recurrent pneumothoraces

Transplanted a human lung. The patient survived 17 days.

Advocated irradiation before bronchopulmonary sleeve resection for lung cancer

Explained en-bloc heart-lung transplantation in primates

Reported successful human heart-lung transplant

Developed and performed limited (less than segmental) pulmonary resection

History table compiled by David A. McClusky III and John E. Skandalakis.

Print: Chapter 6. Respiratory System

Print: Chapter 6. Respiratory System

Print: Chapter 6. Respiratory System

Print: Chapter 6. Respiratory System

approximately 300 million.

Three Embryoanatomic Pulmonary Asymmetric Curiosities

First Appearance (or Other

Congenital tracheal stenosis

Usually fatal soon after birth

Late childhood or later

Bilateral agenesis of the lungs

Unilateral agenesis and

Infancy and childhood

50% die in first 5 yrs

Associated with heterotaxy, asplenia and

Compression of trachea may be fatal

Infancy and childhood

Eventually fatal if untreated

Congenital cysts of the

Print: Chapter 6. Respiratory System

Print: Chapter 6. Respiratory System

Accessory lobes of the lungs.

Print: Chapter 6. Respiratory System

Unilateral Agenesis, Aplasia, and Hypoplasia of the Lung

Print: Chapter 6. Respiratory System

Peragallo and Swenson9 studied congenital tracheal bronchus: