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LUNG

ANATOMYSEGMENTAL ANATOMY

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Note the continuity of the pulmonary parenchymabetween adjacent segments of each lobe.

In contrast, separation of the bronchial andvascular stalks allows subsegmental andsegmental resections, if the clinical situation

requires it or if lung tissue can be preserved.

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Lymph nodes that drain the lungs are divided into twogroups according to the tumor, node, and metastasis (TNM)staging system for lung cancer

pulmonary lymph nodes, N1

mediastinal nodes, N2

LYMPHATIC DRAINAGE

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N1 lymph nodes:

a) intrapulmonary or segmental nodes - lie at points of division ofsegmental bronchi or in the bifurcations of the pulmonary artery

b) lobar nodes - lie along the upper, middle, and lower lobe bronchi

c) interlobar nodes - located in the angles formed by the bifurcation of the

main bronchi into the lobar bronchi

d) hilar nodes - located along the main bronchi

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lymphatic sump of Borrie

-where all of the pulmonary lobes of the corresponding lung drain

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N2 lymph nodes:

a) anterior mediastinal

b) posterior mediastinal

c) Tracheobronchial

d) paratracheal

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Spiral (helical) CT

- allows continuous scanning as the patient is moved through a scanning

gantry

- entire thorax can be imaged during a solitary breath hold

- In general, slice thickness is proportional to image resolution

- Slice thickness is determined by the structure being imaged as well as bythe indication for the study

Thin sections (1- to 2-mm collimation)- used to evaluate pulmonary parenchyma and peripheral bronchi

- pulmonary metastases

COMPUTED TOMOGRAPHY

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For assessing the trachea and central bronchi,collimation of 3 to 5 mm is recommended

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video-assisted thoracic surgery (VATS)

Thoracotomy

Comparing this two, there has not been a documented change in mortality

using these approaches.

But in terms of pain level, functional status, and recovery, all favors VATS

over thoracotomy.

THORACIC SURGICAL

APPROACHES

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Special Circumstances under Which Lobectomy by Video-Assisted Thoracic Surgery May Be Preferable

Pulmonary compromise

Cardiac dysfunction Extrathoracic malignancy

Poor physical performance

Rheumatologic/orthopedic condition

Advanced age

Vascular problems

Recent or impending major operation

Psychologic/neurologic conditions

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Mediastinoscopy

- generally used for diagnostic assessment of mediastinallymphadenopathy and staging of lung cancer

- performed via a transverse 2- to 3-cm incision approximately 1 cmabove the suprasternal notch

- Care is taken to avoid any venous structures that may overlie themuscles

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posterolateral thoracotomy

- most frequently used incision for an open procedure in thoracicsurgery

- patient is placed in the lateral decubitus position

- A pitfall of thoracic incisions in a lateral decubitus position is thepotential for injury to the brachial plexus and axillary vascular structuressecondary to displacement of the shoulder

- skin incision typically starts at the anterior axillary line just below thenipple level and extends posteriorly below the tip of the scapula

- The pleural space is entered at the fifth interspace

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anterolateral thoracotomy

- traditionall used in trauma victims

- This approach allows quick entry into the chest with the patient supine

- When hemodynamic instability is present, the lateral decubitus positionsignificantly compromises control over the patient's cardiopulmonary systemand resuscitation efforts, whereas the supine position allows theanesthesiologist full access to the patient

- The incision is submammary, beginning at the sternal border overlyingthe fourth intercostal space and extending to the midaxillary line

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Bilateral anterior thoracotomy

- is a standard operative approach to the heart and mediastinum in certainelective circumstances

- incision with a transverse sternotomy (clamshell thoracotomy) is done