KHARKIV NATIONAL MEDICAL UNIVERSITY Department of operative surgery and topographic anatomy

Lecture # 4

TOPOGRAPHIC ANATOMY AND OPERATIVE SURGERY OF THE THORAX

Lecturer: Assistante Professor, Ph.D., Vdovichenko Viacheslav Yurievich

Kharkiv, 2013

Parts and regions of the thorax

Surface anatomy & regions of the chest

Landmarks of thorax
Jugular Notch (T2 Vertebral Level)

Sternal Angle (T4 Vertebral Level)

Landmarks of thorax
Clavicle Papillae

Costal arch

Xiphoid Process (T9 Vertebral Level)

Surface Anatomy of the Posterior Thoracic Wall

C7 Spinous Process (Veterbra Prominens) Vertebral Border of Scapula

Inferior Angle of Scapula 12th Rib

Vertebral Levels of Thoracic Landmarks

(T2)

(T4)

(T9)

Lines of the Thorax

Surface anatomy & borders of the pectoral region

Superior Thoracic Aperture (Thoracic Outlet ) The apex of the each lung extends above the first rib.

10

Inferior Thoracic Aperture

11

The Thoracic Cage

T2 T4

T9

ThreeTypes of Ribs
True Ribs (1-7)
Attach directly to the sternum

False Ribs (8-10)

Attach to the 7th costal cartilage

Floating Ribs (11-12) No anterior attachment

Typical rib

Rib 3-10 Head: Vertebrae facet Neck Tubercle: Costotransverse ligament Join with Transverse process Body

Angle of rib: Abrupt change of

Curvature Costal grove: Inter costal vessels

Atypical rib

The Sternum

Thoracic Vertebrae

Thoracic Vertebrae

Three Joints of Thoracic Cage

Movements of the Ribs

pump-handle movement

bucket-handle movement

Ratio of Anterior-Posterior Diameter : Transverse Diameter

Post.

Children
(< 6yrs old)

1:1 Adults
(> 6yrs old) Between

1:1.4 - 1:2
Ant.

Normal

Barrel Chest

Scoliosis

Pectus Carinatum

Pectus Excavatum

Kyphosis

Thoracic wall

Mammary gland

Lymphatic drainage of breast

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33

Thoracic wall

Anterior Thoracic Wall Muscles

Subclavius m.

Pectoralis major

Pectoralis minor

Serratus anterior m.

Acromial branch Deltoid branch Pectoral branch Clavicular branch

Intercostal space
Posterior intercostal v. Posterior intercostal a. Intercostal n.

Technique for thoroacocentesis (in midaxillary line)

Intercostal nerve block

Diaphragm: Inferior view

Caval aperture central tendon esophageal aperture

aortic aperture right crus Psoas major

left crus Quadratus lumborum

Muscles of Respiration

Muscles of Respiration
External Intercostals (Inspiration)

Internal Intercostals (Forced Expiration)

Inspiration

Expiration

Respiration can be aided by the abdominal wall muscles

Internal thoracic vessels

Arteries of the Posterior Thoracic Wall

Thoracic aorta

Intercostal arteries

Arteries of the Thoracic Wall

Internal thoracic a. Subclavian a.

2nd Intercostal a.

Intercostal a.

Internal thoracic a.

Nerves of the Posterior Thoracic Wall

- major pathway for the sympathetic division of the autonomic nervous system

- supply intercostal muscles, abdominal muscles, and skin of thorax & abdomen

- supply visceral organs.

Thoracic Cavity

3 Compartments of the Thorax

(Great Vessels)

(Heart)

Pleural Membranes
rib

Visceral Pleura [on the surface of the lung itself]

Parietal Pleura

Pleural Membranes
VISCERAL PLEURA PARIETAL PLEURA

PLEURAL CAVITY (SEROUS FLUID)

Parietal Pleura: four parts

cervical

costal

mediastinal

diaphragmatic

At the edges of the thoracic cavity the pleura extend lower

than the lungs to form the Pleural

Gutter

Midclavicular
Lung Pleura 6th rib 8th rib

Midaxillary
8th rib 10th rib

Paravertebral
10th rib 12th rib

Hemothorax - Blood in the pleural cavity

Pleurisy (Pleuritis) Inflammation of the pleura

Thoracentesis

Chest Tube Placement

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Trachea
thyroid cartilage

right main bronchus

left main bronchus

tracheal bifurcation

Anterior View

Trachea

cricoid cartilage tracheal cartilage mucosa carina membranous wall with tracheal glands

Posterior view

Lungs

R
SUP SUP

L
2 Lobes

3 Lobes MIDDLE INF INF

Lobes Divided into 10 Bronchopulmonary Segments on each Side

Dont need to name them individually

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82

83

Lungs in situ ( Heart removed)

Hilumwhere air and blood enter and leave

Superficial lungs: lateral view

right lung

apex superior lobe

left lung

middle lobe

horizontal fissure oblique fissure inferior lobe lingula

Right lung related structur es

Left lung related structur es

Mediastinum

The Mediastinum

Subdivisions of mediastinum

Left side of mediastinum

Left vagus n. Left recurrent n. Phrenic n. & pericardiacophrenic a.
Root of lung Pericardium Esophagus Left subclavian a. Thoracic duct Aortic arch Thoracic aorta

Sympathetic trunk

Greater splanchnic n

Right side of mediastinum

Trachea Right vagus n. Arch of azygos v. Azygos v. Superior vena cava Phrenic n. & pericardiacophrenic a. Root of lung Pericardium

Sympathetic trunk
Esophagus Inferior vena cava

Superior mediastinum
Locatingfrom inlet of thorax to
plane extending from level of sternal angle anteriorly to lower border of T4 vertebra posterioly

Contents
n

Superficial layer
q q

Thymus Three veins n Left brachiocephelic v. n Right brachiocephelic v. n Superior vena cava

Superior mediastinum
Contents
n

Middle layer
q

q q

Aotic arch and its three branches Phrenic n. Vagus n.

Superior mediastinum
Contents
n

Posterior layer
q q q

Trachea Esophagus Thoracic duct

Relations of aortic arch

Relations of aortic arch

Triangle of ductus arteriosus

Boundaries
q q q

Phrenic n. Left vagus n. Left pulmonary a. Arterial ligament Left recurrent n. Superficial cardiac plexuses

Contents
q q q

Inferior mediastinum
Anterior mediastinum
n

Locationposterior to body of sternum and attached costal cartilages, anterior to heart and pericardium Contents q Fat q Remnants of thymus gland q Anterior mediastinal lymph nodes

Inferior mediastinum
Middle mediastinum
n

Locationbetween anterior mediastinum and posterior mediastinum Contents q Heart and pericardium q Beginning or termination of great vessels q Phrenic nerves q Pericardiacophrenic vessels q Lymph nodes

Inferior mediastinum
Posterior mediastinum
n

Locationposterior to heart and pericardium, anterior to vertebrae T5T12

Inferior mediastinum
Posterior mediastinum
n

Contents:
q q q q q q q

Esophagus Vagus n. Thoracic aorta Azygos system of veins Thoracic duct Thoracic sympathetic trunk Posterior mediastinal lymph nodes

Relations of esophagus
n

Anteriorly
q q q q q q q q q

Trachea Bifurcation of trachea Left principal branchus Left recurrent n. Right pulmonary a. Anterior esophageal plexus Pericardium

Left atrium
Diaphragm

Relations of esophagus
n

Posteriorly
q q q

q
q q q

Posterior esophageal plexus Thoracic aorta Thoracic duct Azygos v. Hemiazygos v. Accessory hemiazygos v. Right posterior intercostal v.

Relations of esophagus
n

Left
q q q q q

Left common carotid a. Left subclavian a. Aortic arch Thoracic aorta Superior part of thoracic duct Arch of azygos v.

Right
q

Relations of thoracic aorta

n

Anteriorly
q q q

Left root of lung Pericardium Esophagus Hemiazygos v. Accessory hemiazygos v. Azygos v. Thoracic duct

Posterior
q q

Right
q q

Leftmediastinal pleura

Mediastinal spaces