Subject Index

Achalasia Aspergillosis 190 -- tumorectomy 90, 91 - classification 391 Aspiration, pericardial 54 - cyst, preoperative localization 79 - dilatation 398 Atelectasis, postoperative 180 - diagnostic procedures, indications -- balloon systems with endoscopic Atkinson tube 287, 288 77 guidance 399, 400 Atrium, left, partial removal 180 - gynecomastia 87 -- balloon systems without endo• Axillary approach 24 - inflammatory disease 86, 87 scopic guidance 400, 401 - mastectomy -- compared with esophagomyo• Babcok stripper, in esopha• -- extended radical (Urban's modi- tomy 391, 392 gectomy 328, 329 fication) 98, 99 -- Kaphingst dilator 399 Balloon catheter systems 270 -- modified radical 94-96 techniques 400, 401 Bilobectomy -- Patey's operation 96 -- Witzel dilator system 398, 399 lower 150, 151 -- radical (Rotter-Halsted modifica- - esophagomyotomy - upper 149 tion) 97, 98 -- lower sphincter Bochdalek hernia 217 -- skin incisions 94 --- dilatation compared with Bougienage -- subcutaneous 84, 85 391, 392 - blind dilatation 272 - periareolar incision 80, 81 --- indications 391 - Buess system 270, 271 - radiation ulcers 102 --- preoperative preparation 392 - guidewire systems -- latissimus dorsi flap 102 --- transabdominal approach -- balloon catheter systems 270 -- myocutaneous rectus flap 392-394 -- Celestin and Savary systems 103, 104 --- transthoracic approach 392, 269 -- omentoplasty 102, 103 394 -- Eder-Puestow system 266-269 -- thoracoepigastric flap 102 -- upper sphincter 388, 389 - Hendren and Hale electromagnetic - segmental resection (quadrantec- - stage 3 technique 450 tomy) -- mucosal plication 396, 397 - postdilatation monitoring 267 -- carcinoma 91 -- myoplication 395, 396 - Rehbein thread and olive tech- -- diagnostic 83 -- strip myectomy 396, 397 nique 444-447 Bronchial circulation 110, 111 Anal atresia, esophageal atresia and - sedation and anesthesia 266 Bronchial system, anatomy 109, 110 453 - timing steps and gauging extent Bronchiectasis 188 Anastomosis of 266, 267 Bronchogenic carcinoma 183 - colo gastric 380, 381 - using rigid endoscope 272 - lymph node involvement 114 - continent 358 Breast Bronchopleural fistula, post- - esophageal 228 - abnormal nipple discharge 81, 82 operative 181 -- in atresia 442, 443 - abscess 86, 87 Bronchus -- end-to-endjend-to-side 243 - biopsy 80, 81 - closure of 118, 119 -- technique 230-232 -- incision 80 -- coverage of stump 119, 120 - esophagocolic 381 -- tumor excision 81 -- staple 118 - Haight telescopic 443 - carcinoma -- suture 119 - inkwell 358, 370 biopsy excision 81, 90 - left main, exposure and closure - invagination 242, 243 -- classifications 89, 90 131-133 - jejunal patch 277 -- incidence 88 - resection - jejunoduodenal 369 -- local in operability 100 -- intubation 171 - jejunogastric 369 -- local recurrence 101,102 -- sleeve 170, 171 - see also individual operations -- male 101 --- of left main 173 Aneurysms, arteriovenous 182 preoperative localization 77-79 --- lower lobectomy with 174 Anterolateral approach, semilateral -- prognosis 88 --- of right main 172, 173 position 9, 10 - -- risk factors 88 -- wedge, of main 171 Antibiotic, perioperative therapy -- skin closure, difficult 100, 101 - right main, exposure and closure 39-41 -- see below Conservation tech- of 126, 127 Antral patch, for esophageal stricture niques; Mastectomy - stump leak 181 280 - conservation techniques 90-93 Broviac catheter 259, 260 Asepsis 8 axillary dissection 92, 93 Buess system of esophageal dilata• ASIF one-third tubular plate 50, 51 -- segmental resection 91 tion 270, 271 456 Subject Index

Buess tube 287, 288 Dead-space tubing 45 Esophagogastrostomy Bullectomy 4, 5 Diaphragm - continent 358 - congenital anomalies ~ end-to-side 357 Cardia -- accessory 218, 219 - manual 231, 357 ~ adenocarcinoma -- defect repaired with muscle flap - mechanical (EEA instrument) -- endoesophageal intubation 286 217,218 234-238, 357 -- resection 40, 295 ~ - eventration of 212 - reinforcement and reflux preven- Cardiac herniation 55 --- plication techniques 212-216 tion 357-360 Catheter-related complications -- hernias 216-218 Esophagojejunostomy 32,33 --- anterior parasternal 216 - manual 370 Celestin dilator system 269 --- posterolateral (Bochdalek) - mechanical (EEA instrument) 370 Celestin intubation system 291, 292 217 - reinforcement 370-372 Celestin tube 288 - incisions 211, 212 Esophagomyotomy Cerclage wires 51, 52 - indications for surgery 212 ~ extended 389~391 Chest cavity - innervation of 211 - indications 388 ~ drainage 120, 121 ~ pacing 221, 222 - lower sphincter 391~394 -- after pneumonectomy 121 -- cervical approach 222 -- dilatation compared with - exploration ~~ thoracic approach 222 391, 392 -- assessment of disease and resec- - pericardiophrenic hernia 219 -- indications 391 tability 116 - plication -- preoperative preparation 392 -- mobilization of lung 115 -- open 215, 216 -- transabdominal approach Chest wall -- transperitoneal 212, 213 392~394 - congenital deformities 67-71 -- transthoracic 213~215 -- transthoracic approach 392, - diseases 59~76 - pulmonary resection, removal 394 - hernias 57, 58 during 180 - upper sphincter 388, 389 - pulmonary resection, removal ~ reconstruction of esophagus and Esophagoplasty 447, 448 during 180 tracheobronchial tree 220, 221 Esophagopleural fistula, post- - resection - replacement 220 operative 182 -- indications 60 - rupture 56, 57 Esophagostomy -- procedure 60 -- traumatic 218, 219 - end cervical 256~258 - stabilization 48-50 - tumors, primary 219, 220 - lateral cervical 252-256 -- after sternectomy 61, 62 Dilatation therapy, see Bougienage ~ - closure 256 Chylothorax 209 Dilators -- double-barreled 254-256 Coccidioidomycosis 190 - with mercury-filled tips 272 -- percutaneous tube 253, 254 Collis gastroplasty 422, 423 - plastic and rubber 272 - ~ simple 252, 253 Colon Duodenum - thoracic 258 - anastomosis - atresia, esophageal atresia and Esophagotomy ~~ to esophagus 381, 382 453 - cervical 245-249 - ~ to stomach 380 - esophageal reconstruction - thoracic 249-251 - esophageal substitute 336, 337 354, 355 Esophagotracheal fistula, esophageal -- blood supply 372, 373 - Kocher's maneuver 354, 355 atresia and 437 ~ - bowel continuity restored 379 Esophagus -- intraabdominal transfer of mobi• Echinoccosis (hydatid disease) - achalasia, see Achalasia lized segment 379, 380 186, 187 - adhesives 240 ~ - left antiperistaltic transplant Eder-Puestow dilator system - agenesis 436 373-376 266-269 - anastomosis 228 -- left isoperistaltic transplant Emphysema -- end-to-end/end-to-side 243 373-376 - bullous 186 -- esophagocolic 381, 382 -- right antiperistaltic transplant - lobar 185 -- Haight telescopic 443 378 - mediastinal 47,48, 200, 201 -- invagination 242, 243 -- right isoperistaltic transplant -- collar mediastinotomy 48 - ~ technique 230-232 377, 378 - subcutaneous, management -- see also individual operations -- transverse isoperistaltic trans- 47 - anatomy plant 378, 379 Empyema, pleural 63-66 ~ - blood supply 226, 227 - esophagoplasty 447, 448 Endoesophageal tubes 286-294 ~ - lymphatic drainage 227, 228 Cricopharyngeal myotomy 388, 389 ~ indications 286, 287 -- wall structure 225, 226 Cryptococcosis 190 - intubation 289~293 - atresia Cystic adenomatoid malformations - nutrition 293, 294 -- anal atresia and 453 185 - tube designs 287-289 -- bougienage Cystosarcoma phylloides, mastec- Equipment --- Hendren and Hale electromag- tomy 85,86 - instrument sets 7, 8, 27-29 netic technique 450 Cysts - materials --- Rehbein thread and olive - bronchogenic 185 - ~ asepsis 8 technique 444-447 ~ congenital 185, 186 -- suture 25~27 -- choice of treatment 437, 438 ~ paratracheal 207 Esophagofundophrenicopexy 419 -- classification 436, 437 - pulmonary 185 Subject Index 457

-- diagnosis 436, 437 - dilatation therapy, see above - scleroderma, esophagectomy with- -- duodenal atresia and 453 Bougienage out thoracotomy 328 -- esophagotracheal fistula and - foreign body extraction 245 - strictures 437 - injuries 431~35 -- cervical -- gastrostomy 438, 439 - intubation, see Endoesophageal --- free jejunal patch 274--277 -- preoperative care 437 tubes --- longitudinal incision and -- repair of major gap 447,448 - perforations transverse closure 273, 274 --- using colon 447,448 -- abdominal 431 -- dilatation, see Bougienage --- using jejunum 448 -- thoracic 431~34 -- esophagectomy without thoraco- --- using stomach 448 --- exclusion techniques 433, tomy 328 -- staged repair 451~53 434 -- plastic repair procedures -- tracheoesophageal fistula, --- primary repair and drainage 272-284 closure 450, 451 432 -- severe inflammatory 258 -- Type II 448~50 - pharyngostomy 449 -- thoracoabdominal 277-283 --- elongation of segments - pulmonary resection, removal --- antral patch 280 449,450 during 180 --- fundic patch 280-283 -- Type lIla 450, 451 - reconstruction 333-383 --- jejunal patch 277-280 -- Type IIIb -- with colon, see under Colon - sutures 228-230 --- anastomosis of segments -- with diaphragmatic grafts -- manual 229, 230 442,443 220,221 -- mechanical 233-240 ---- postoperative care 444 -- with duodenum 354, 355 --- compared to manual --- extrapleural approach 439, -- intraabdominal placement of 228,229 440,441 substitute 337 - truncal vagotomy, drainage --- repair of major gap 44~46 -- with jejunum 335-337 355, 356 --- thoracotomy closure 443 -- nonvisceral 334 - varices, treatment 328 --- transpleural approach 439, -- pull-through of substitute Extracorporeal bypass tube, Nabeya 441,442 340, 341 258,264 -- Type IIIc 450, 451 -- with skin grafts 297 - benign tumours 245 -- with stomach, see under Forced expiratory volume in one sec• -- enucleation or excision Stomach ond (FEV1), and operative risk 385-387 -- thoracic placement of substitute 1, 2 - bougienage 266-272 337-340 Foreign bodies, esophageal 245 -- blind dilatation 272 -- tunnel creation Fundectomy 349 -- Buess system 270, 271 --- retrosternal route 339, 340 Fundic patch, esophageal stricture -- guidewire systems --- subcutaneous route 338, 280-283 --- balloon cathether systems 339 Fundophrenicopexy, and anterior 270 --- transpleural route 340 narrowing of hiatus 419, 420 --- Celestin and Savary systems - resection Fundoplication 269 -- antibiotic therapy 40 - protection of esophageal suture --- Eder-Puestow system 266, -- cervical line 242 267-269 --- extension to upper or entire - Rossetti modification 407, 408, -- postdilatation monitoring 267 thoracic 309, 310 413,414 -- sedation and anaesthesia 266 --- indications 297, 298 - transabdominal approach 408~11 -- timing steps and gauging extent --- infrahyoid 309 - transthoracic approach 411, 412 of 266,267 --- lymph node removal 300-307 - versus semifundoplication 407 -- using rigid endoscope 272 --- simple transverse 299, 300 Fungal infections of lung 189, 190 - carcinoma --- suprahyoid 309 Funnel chest (pectus excavatum) -- endoesophageal intubation --- thyroid preservation 307, 309 68-71 286-294 --- tracheal division and tracheos- -- esophagectomy without thora• tomy 306, 307 Gastrectomy, esophageal resection cotomy 328 --- tumor exploration 299, 300 with 317-322, 325 -- resection 295-297 -- extent of 295 Gastric construction, with stapling -- with or without bronchioesopha- -- with gastrectomy 317-322, 325 instruments 239 geal fistula 256 -- left thoracic approach 322-327 Gastric tube - constricting rings or webs 245 --- gastrectomy 325 - isoperistaltic 349, 350 - corrosive injuries 434 --- posterior mediastinectomy - reversed 352-354 - cysts, enucleation or excision 326,327 Gastroesophageal reflux 385-387 -- right throacic approach - operative choice 406, 407 - defunctionalization 310-322 - prevention after esophagogastros- -- esophagostomy 253 --- posterior mediastinectomy tomy 357-360 -- nutrition 313-317 - see also Fundoplication; Semi• --- extracorporeal bypass tube -- selection of approach 297 fundoplication 264 -- sequence 295, 296 Gastropexy, hiatal hernias 425 --- gastrostomies 260-264 -- without thoracotomy 328-331 426,428 --- parenteral 259, 260 - ruptures, see above Perforations Gastroplasty 422, 423, 448 458 Subject Index

Gastrostomy Ileum, as esophageal substitute 360 -- pulmonary vessels 157 - background 260 Instrument sets 7, 8, 27-29 - left upper - esophageal atresia and 438, 439 Intrathoracic injuries 52-58 -- anatomy 151, 152 - Glassman and Deucher 261, 262 -- lingular preservation 155 - Kader 260 Jejunal patch, for esophageal stric- -- operative technique 153-155 - needle 258, 262, 263 ture, free 273-280 -- pulmonary vessels 153, 154 - Rehbein 438, 439 Jejunoduodenal anastomosis 369 - lung function tests 4 - Witzel 260 Jejunogastric anastomosis 369 - middle Glassman and Deucher gastrostomy Jejunojejunostomy -- anatomy 144 261, 262 - end-to-end 367, 368 -- anterior approach 145, 146 Goitre, intrathoracic 207, 208 - end-to-side 368 -- indications 144 Gruntzig catheter 270 Jejunoplication 371, 372 -- interlobar approach 144, 145 Gynecomastia 87 Jejunostomy - right lower - conventional 258, 264 -- anatomy 146 Haight telescopic anastomosis - needle 258, 262, 263 -- bronchial dissection 148, 149 443 Jejunum -- lymph node dissection 148, 149 Haring tube 288, 289 - artery anastomosis to intrathoracic -- operative technique 147-149 Hemoptysis 188, 189 vessels 367 -- pulmonary vessels 147 Hemorrhage, postoperative 181 - esophageal reconstruction - right upper Hemothorax 335-337, 360-372 -- anatomy 138 - chest tube drainage 53 -- blood supply 361, 362, 367 -- bronchial dissection 141-143 - early decortication 53, 54 -- bowel continuity restored -- lymph node dissection 141 - pericardial aspiration 54 367, 368 -- operative technique 139-143 Hernias -- esophagojejunostomy -- pulmonary vessels 139-141 - cardiac 55 --- manual 370 - see also Bilobectomy - diaphragmatic 216-219 --- mechanical (EEA instrument) Lung - pericardiophrenic 219 370 - abscess 187 Hiatal hernias --- reinforcement 370-372 - amebiasis 187 - anatomic repairs 419 -- intraabdominal transfer of mobi- - assessment of disease and resecta- - approach 407 lized segment 368 bility 116 - classification 406 -- isolated loop 362-365 - bronchiectasis 188 - indications 406 -- jejunoduodenal anastomosis - cystic disease 184 - ligamentous flaps 420, 421 369 -- acquired 186, 187 -- omental cuff 420 -- jejunogastric anastomosis 369 -- congenital 185, 186 - operative choice, see also Fundo- -- technical complications 365-367 - flap 242 plication; Semifundoplication - - Y loop 365 - function - paraesophageal Judet plate 51, 52 -- postoperative, calculation of -- gastropexy (Nissen) 425, 426 5,6 -- operation choice 423 Kader gastrostomy 260 -- preoperative 1-5 -- reduction and hiatal repair Kaphingst dilator 399 - fungal infections 189, 190 424,425 Kirschner wires 51, 52 - inflammatory disease 187-189 - pediatric Kirschner's isoperistaltic total gastric - mobilization of 115 -- with congenital or peptic esophagoplasty 344--348 - resection stricture 429 - with fundectomy 349 -- left upper lobe -- operation choice 426 - and gastric tube creation 349, 350 --- anterior segment 163, 164 -- transabdominal approach Kocher's maneuver 354, 355 --- apical posterior segment --- gastropexy 428 162, 163 --- hiatal repair 427, 428 Laparotomy, separate, and thora- -- right upper lobe -- transthoracic approach cotomy 21 --- anterior segment 161, 162 428,429 Lateral position, full 10, 11 --- apical posterior segment - suture material 407 Latissimus dorsi flap 102 160, 161 Hilum Ligamentum teres flap 420, 421 -- wedge (local) 169, 170 - assessment 116 Ligation, mechanical 240 -- see also Segmentectomy - left Lingula, preservation in left upper - tuberculosis 188, 189 -- anatomy of 129 lobectomy 155 - tumors -- exposure of 129, 130 Lingulectomy 164, 165 -- benign 182 -- status following division of - in left lower lobectomy 158 -- bronchogenic 182 structures 131 Lobectomy -- metastases 184 - right - indications 138 -- Pancoast tumor 183, 184 -- anatomy of 122, 123 - left lower Lymph nodes -- exposure of 122, 123 -- anatomy 156 - anterior mediastinal 113 -- status following division of -- bronchial dissection 157, 158 - axillary dissection 92, 93 structures 127 -- lingulectomy 158 - bilobectomy 149 - sequence of management 120 -- lymph node dissection 158 - extrapulmonary 113 Histoplasmosis 189, 190 -- operative technique 157 - intrapulmonary 111, 112 Subject Index 459

- lobectomy - posterior - empyema 63-66 -- left lower 158 -- neurogenic tumors 208, 209 - flap 241, 242 -- left upper 155 -- other lesions 209 - tumors 74-76 -- right lower 148, 149 - thoracic duct injury 209 -- extended pleuropneumonec- -- right upper 141 - see also Sternotomy tomy 75,76 - pneumonectomy Myasthenia gravis, thymectomy -- palliative parietal pleurectomy -- left 133, 134 205,206 75 --- with en bloc removal 134 Myocutaneous rectus flap 103, 104 Pleurectomy, palliative parietal -- right 127, 128 75 --- with en bloc removal Nabeya extracorporeal bypass tube Pleuropneumonectomy, extended 128, 129 264 75, 76 - posterior mediastinal 113 Nerve palsy, recurrent, after medias• Pneumonectomy - pulmonary drainage 113,114 tinoscopy 198 - chest drainage after 121 - tracheobronchial 113 Nissen gastropexy 425, 426 - indications 121, 122 Lymphadenectomy, mediastinal Nottingham tube introducer - with intrapericardial dissection of - left 203, 204 289,290 pulmonary vessels 134-138 - right 202, 203 Nutrition -- and en block removal of lymph - transsternal 201-204 - esophagostomy for 252 nodes 138 - parenteral 31-37, 258-260 -- extended left 136-138 Mammography 78, 79 -- complications -- extended right 135, 136 Mastectomy --- catheter-related 32, 33 - left 129-134 - extended radical (Urban's modifi- --- metabolic 33-36 -- bronchus 132, 133 cation) 98, 99 --- thrombosis 32, 33 -- extended 137, 138 - modified radical 94-96 -- conduct of 35 -- lymph node dissection 133, 134 - Patey's operation 96 -- indications 31 --- en bloc removal 134 - physiotherapy 45 -- planning of 33, 34 -- pulmonary vessels 129-132 - radical (Rotter-Halsted modifi- -- recommended daily intakes 34 -- sleeve 177 cation) 97, 98 -- routes 32, 33 -- supraaortic 133 - and simultaneous reconstruction -- supervision of 37 -- technique 129 with tissue expander 86 - lung function tests 3, 4 - skin incisions 94 Olive dilator 267-269 - right 122-129 - subcutaneous 84, 85 Omental cuff 420 -- bronchus 126, 127 Materials 8, 25-27 Omental flap 241, 242 -- extended 135, 136 Mediastinectomy, posterior Omentoplasty 102, 103 -- lymph node dissection 127, 128 - left 326, 327 --- en bloc removal 128, 129 - right 313-317 Pancoast tumor 183, 184 -- pulmonary vessels 123-127 Mediastinitis Parathyroidectomy 204, 205 -- sleeve 176, 177 - after mediastinoscopy 198 Parenchymal fistula, postoperative -- technique 122, 123 - posttraumatic 200 181 - supraaortic 132, 133 Mediastinoscopy 196-199 Patey's mastectomy 96 Pneumothorax, chest tube drainage Mediastinotomy Pectus carinatum (pigeon breast) 52, 53 - anterior 199 67,68 Positioning of patient 8-11 - collar 48 Pectus excavatum (funnel chest) Posterolateral approach 11 Mediastinum 68-71 Prone position 11 - abscess 200 Peptic strictures Pulmonary lymphatic system - anterior - causes 421 111-114 -- intrathoracic goitre - in columnar-lined esophagus - drainage 113, 114 207,208 422,423 Pulmonary metastases 184 -- parathyroidectomy 204, 205 - high 421, 422 Pulmonary resection, complications -- paratracheal cysts 207 -- with local acid production 180-182 -- thymectomy 205, 206 421, 422 Pulmonary sequestration 185, 186 -- tumors 208 - low 421 Pulmonary surgery, perioperative - biopsy procedures - and pediatric hiatal hernia 429 antibiotics 40 -- anterior mediastinotomy 199 Pericardiophrenic hernias 219 Pulmonary vessels 110 -- mediastinoscopy 196-199 Pharyngostomy 449 - division 17 - emphysema 200, 201 Physiotherapy 42-46 - exposure 116, 117 - fine needle aspiration 195, 196 - postoperative 44, 45 - great - inflammatory diseases 200 - preoperative 44 -- intrapericardial anatomy of - lymphadenectomy - therapeutic goals 42-44 134, 135 -- left 203, 204 Pigeon breast (pectus carinatum) -- intrapericardial dissection of -- right 202, 203 67,68 --- and en bloc resection of -- transsternal 201-204 Pleura lymph nodes 138 - lymphangioma 210 assessment of disease 116 - -- left 136, 137 - lymphocele 210 - decortication, lung function tests --- right 135, 136 - middle, procedures 208 4 - intraoperative bleeding 117 460 Subject Index

Pulmonary vessels - GIA instrument 229, 234 Thoracoabdominal approaches - partial resection of artery - LDS-2 instrument 240 18-22 174,175 - ligation 240 - incision in bed of seventh rib - see also under individual opera• - other applications of 238, 239 19,20 tions - T A instruments 233, 234 Thoracoepigastric flap 102 Pyloromyotomy 356 - see also individual operations Thoracoplasty 71-74 Pyloroplasty 355, 356 Sternal fractures 52 - Bjork's osteoplastic 73, 74 Sternectomy - indications 71 Radiation ulcers of chest wall, see - partial 61 - Semb, with apicolysis 72, 73 under Breast - reconstruction after 61, 62 Thoracotomy Ravitch and Brunner operation 70 Sternotomy - anterolateral 16, 17 Reflux esophagitis, see Gastroesoph• - high partial 23 -- transverse sternotomy with ageal reflux - infected 200 bilateral 24 Rehbein gastrostomy 438, 439 - median 22, 23 -- unilateral partial sternotomy Rehbein thread and olive technique -- with laparotomy 20 with 23,24 444-446 - transverse 24 - 'closed' 22 Rehbein's operation 70 - unilateral partial 23, 24 - by phrenotomy 22 Rib Stomach - with phrenotomy 21 - fractures 48-52 - colo gastric anastomosis 380, 381 - posterolateral 17 -- chest wall stabilization 48-50 - esophageal reconstruction 334, -- oblique 18 -- plate fixation 50-55 335, 337, 342 - separate laparotomy and 21 - resection 58, 59 -- blood supply to mobilized - standard 12-16 -- after empyema drainage 64 343, 344 - Type IIIb esophageal atresia 443 -- Kirschner's isoperistaltic total Thymectomy Savary dilator system 269 gastric esophagoplasty 344-348 - transcervical 205 Segmentectomy --- with fundectomy 349 - transsternal 206 - indications 159 --- and gastric tube creation Thymic tumors, thymectomy 205, 206 - lower lobe 349, 350 Trachea -- basal 168, 169 -- reversed gastric tube 352-354 - assessment of function 5 -- superior 165-167 -- thoracic approach - pneumonectomy with removal - operative technique 159, 160 --- left 350-352 of bifurcation - see also Lingulectomy; Lung resec- --- right 352 -- left sleeve 177 tion - esophagoplasty 448 -- right sleeve 176, 177 Seldinger guidewire 270 Sulamaa and Willital operation - reconstruction 180 Semifundoplication 68-70 - resection - 270° (Belsey Mark IV) 407,· Supine position 9 -- of bifurcation 178 418, 419 Sutures -- of distal tracheal 178, 179 - anterior/posterior 414-416 - Albert 229, 230 -- indications 176 - lateral 416, 417 - Albert-Lembert 229, 230 -- mobilization 176 - protection of esophageal suture - Gambee 229, 230 -- wedge, with carina 176 242 - Herzog 229, 230 Tracheobronchial tree, diaphragmatic - versus fundoplication 407 - for hiatal hernias 407 reconstruction of 220, 221 Semilateral position 9, 10 - Lembert 229, 230 Tracheoesophageal fistula Skin, esophageal reconstruction - manual 229, 230 - closure, staged 453 334 - materials 8, 25-27 - esophageal ·atresia with 450, 451 Small intestine as esophageal - mechanical 233-240 - isolated 453, 454 substitute -- compared with manual Tuberculosis, pulmonary 188, 189 - bowel continuity restored 228, 229, 239 Vagotomy, truncal, drainage proce- 367, 368 -- EEA instrument 228, 233, 234 dures 355, 356 - ileocolon 360 --- esophagogastrostomy with Vecsei plate 51, 52 - ileum 360 234-238 Vena cava, partial resection of - jejunum, see Jejunum -- GIA instrument 229, 233, 234 superior 180 Stapling instruments 233-240 - - T A instruments 233, 234 Ventilatory support, antibiotic - complications 239, 240 - reinforcement 240-243 prophylaxis 40,41 - EEA instrument 228, 229, - wire, for rib fractures 51, 52 Vogt classification of esophageal 233,234 - Wolfler, modified 229, 230 atresia 436, 437 - esophagogastrostomy with 234-238 Thoracic duct injury 209 Witzel dilator system 398, 399 - gastric reconstruction 239 Thoracic organs, approaches 12-24 Witzel gastrostomy 260 K. Topography of Surgically Important Regions 15 Anatomic Plates

K. ZILLES and U. DEMMEL

This section presents 15 anatomic plates demon• References strating the topography of surgically important re• gions in the neck, , and upper abdomen. Braus H, Elze C (1956) Anatomie des Menschen, Bd II. Special emphasis is placed on portraying the as• Springer, Berlin Gottingen Heidelberg pects from which these regions are most commonly Corning HK (1939) Lehrbuch der topographischen Ana• viewed by the operating surgeon. Each plate is tomie. Bergmann, Miinchen Hafferl A (1969) Lehrbuch der topographischen Anato• accompanied by a brief explanation of the princi• mie. Springer, Berlin Heidelberg New York pal structures of interest. Thus, the present section Pernkopf E (1979/80) Atlas der topographischen und is concerned less with depicting topographic anat• angewandten Anatomie des Menschen. Band 1 + 2 omy in the conventional sense than with providing Rohen JW (1977) Topographische Anatomie. Schat• tauer, Stuttgart New York a practical guide to understanding problems of Rohen JW, Yokochi CH (1982, 1983) Anatomie des surgical anatomy. More comprehensive presenta• Menschen. Band 1 +2. Schattauer, Stuttgart New tions may be found in the pertinent literature. York Tondury G (1981) Angewandte und topographische Anatomie. Thieme, Stuttgart Lanz T von, Wachsmuth W (1955) Praktische Anatomie. 1. Band/Teil2: Hals. Springer, Berlin Heidelberg New York Plate I: The Arteries, , and Nerves of the Anterior and Lateral Chest Wall

The cutaneous and perforating branches of the in• tercostal arteries, the internal thoracic artery, the lateral thoracic artery, and the thoracodorsal ar• tery supply the skin of the anterior and lateral chest wall. The perforating intercostal arterial branch emerging from the corresponding intercos• tal space is usually of large caliber. All the cutane• ous arteries anastomose with one another. Venous drainage is accomplished by the lateral thoracic vein, the thoracoepigastric vein, and the median xiphoid vein, which likewise interanastomose. The thoracoepigastric vein forms an anastomotic chain with the superficial epigastric vein, which empties into the femoral vein via the saphenous vein; this system establishes a communication between the inferior and superior venae cavae. Impairment of portal venous drainage can cause the damming back of blood into the paraumbilical veins (" Me• dusa's head") and into the by way of the median xiphoid, thoracoepigastric, and lateral thoracic veins. The skin is innervated by the lateral and anterior branches of the intercostal nerves and by the supraclavicular nerves. Plate I

~~;.;-__ Perforating branch of first intercostat artery

tntercostobrachiat __.,.,.;;", nerve ~~~~~~~~'~~~~J~~l!~ ]t--- ofPerforating second inte branchrcostat artery

\-7;;""'-- Median xiphoid vein

Cutaneous branch Anterior cutaneous branch of thoracodorsat artery ~~~liiEiirbr-- of intercostat nerve

Laterat cutaneous branch 01 intercostat nerve---w~

Thoracoepigastric vein --;;;0.-; Plate II: Posterior View of the Neck, Shoulder, and Chest Wall

The trapezius muscle has been severed from its origins a few centimeters lateral to the spinous pro• cesses. This muscle is innervated from its inferior surface by the accessory nerve and cervical plexus. Removal of the trapezius exposes arteries that also enter the undersurface of the muscle: the superfi• cial cervical and transverse cervical arteries. A twig from the deep branch of the transverse cervical artery passes through the connective-tissue inter• val between the rhomboideus major and minor muscles. The latissimus dorsi muscle has been divided in its upper portion with a curved incision and re• flected medially downward. Branches of the inter• costal arteries and veins as well as the intercostal nerves of the lower thoracic segments pierce the muscle and supply the overlying skin. The serratus anterior and serratus posterior inferior muscles are visible below the reflected latissimus dorsi muscle. The suprascapular artery, vein, and nerve disap• pear beneath the supraspinatus muscle. Their infe• rior continuation can be seen by stripping the in• fraspinatus muscle from the scapular spine and from the upper part of the infraspinous fossa. The suprascapular artery anastomoses in the infraspin• ous fossa with the circumflex scapular artery, which passes through the medial triangular space. The deltoid muscle has been divided and reflected upward to expose the lateral quadrangular space, which is traversed by the axillary nerve and poste• rior circumflex humeral artery. Plate II

Superficial cervical artery Superficial cervical vein Omohyoid muscle

Suprascapular artery. vein and nerve Accessory nerve ---r.....:::'---';"""~~

l evator scapulae muscle ----:.:=~~-=.:...\ Branch of cervical plexus ---i,,-i_L";':;Irf~,\ Exte rna I jug ular ve i n-- --+---"'---<:'>7i:!!l~O:£'~

Serratus anterior muscle - --4;+--..ri Rhomboideus minor muscle -- ....;.,",,-""", Supraspinatus muscle Serratus post. sup. muscle -~--:.:.;..:; Transverse cervical artery and vein --"';"4: Axi lIary nerve and posterior circumflex Suprascapular artery. -- -4,..,!; humeral artery vein and nerve Rhomboideus major muscle ---:-~ ~,""':;;,..~ Teres minor muscle Scapula Radial nerve and Subscapular nerve - -...;.,.,--? radial collateral artery Circumflex scapular _ _ --.:.~~;.;;;;;...:~~~~~ artery and vein Triceps brachii muscle rn:~~':in------...::!~~~~- Infraspinatus muscle Trapezius muscle ----\...".....; ~------~~~ Teres major muscle

l ateral cutaneous :..;...;...T+i-- --,,- latissimus dorsi muscle and dorsal branches <:::o----n~~;n.__1l\II , of the thoracic nerves

Intercostal arteries and veins ___{2 ~~~'.jjJ+Q~~~~",\~~~,~~\~~~~rW;i--- External intercostal muscle

\ .:c:r,:n.;;:--- Serratus anterior muscle

~~~~~~~~-- serratus posterior inferior muscle

':':;;;m---latissimus dorsi muscle

I 1/A \ II ~,:.m--- Obliquus abdominis externus muscle Plate III: Anterior View of the Inferolateral Cervical Region and Right Chest Wall

The sternocleidomastoid muscle has been divided at its sternal and clavicular origins and removed, exposing the infrahyoid muscle group. The inter• mediate tendon of the omohyoid muscle crosses the . The phrenic nerve courses on the scalenus anterior muscle, and be• hind it the brachial plexus emerges in the posterior scalene interval. A large curved incision divides the clavicular, ster• nocostal, and abdominal portions of the pectoralis major muscle, which has been reflected laterally upward. From the superomedial border of the exposed pec• toralis minor muscle, the pectoral nerves pass to the undersurface of the pectoralis major and minor muscles, accompanied by the pectoral branches of the thoracoacromial artery. The lateral thoracic vessels run along the lateral border of the pectora• lis minor muscle, and behind them the long thorac• ic nerve courses on the serratus anterior muscle, which it innervates. The intercartilaginous muscles, covered in the par• asternal intercostal spaces by the external intercos• tal membrane, and the overlying pectoralis major are pierced by the anterior cutaneous branches of the anterior intercostal nerves. Plate III

Trunk of facial and retromandibular vein

Internal jugular vein Scalenus anterior muscle Omohyoid muscle Pectoralis major muscle St,.rn,onvoIO muscle

foIIil'""lis>;,:....+-~--'-ir- Cervical plexus

Brachial plexus--~~~~--~r-to-r-.-" !-ol:-m...,;..,---- -t--j- Phrenic nerve CI avicle ---'<---\----'.---'.,.t-Ti--r-<+--_ 'rf.?nrniri-r-H-T-r-;- Supraclavicular nerves

~"'/;;;;;'Hfj'++o-mf-icii-- Transverse cervical artery WJirn-r;-;-;.;-m'+ri'iii- Sternothyroid muscle

Pectoral branch cm~~'riiiifi+-- Sternocleidomastoid muscle of thoracoacromial ---iiHT:miiE"""t';-"ti,,~r:lrt:. ~~~~~ ;;;oi:i+.n;IIr'..\l';p~i-- Subclavius muscle artery ~~li~~~~~~~~~:~L Brachial plexus :\ Deltoid muscle ----ii-'i--f-~

B r ac h i a I pi e x u --s -ifii-'ri-i--Ti:n:7':;"': ~~~~!~~/lHi,-;r,i;J;!~§=~~ Pectoralis minor muscle

Med i a I cta u neo us --ftn;;-ij-iiiiiiiill"i':fr"""';;l-;r'7;"("" ~="':::-- Pectoralis major muscle nerve of the arm Intercosto• brachial nerve --":;';;;:;;;'-"IH-j---TT.-;h ~;"iiiliFii~§.:,,""_-lntercartilaginous muscles

Long thoracic nerve --=:'~~f/iT;1--\ Anterior intercostal nerves ~"""~- (anterior cutaneous branches)

I ntercostal nerves (lateral cutaneous branches) --f,iiN!Iill

Serratus anterior muscle

Latissimus dorsi muscle

Obliquus abdominis externus muscle ---Tirn·~ Plate IV: Right Axilla and Lateral Chest Wall

The sternal and abdominal portions of the pecto• ralis major muscle have been divided several centi• meters from their origin with a curved incision, and the whole muscle has been reflected superior• ly. The underlying pectoralis minor muscle has been detached from its three-part origin and re• flected superomedially. The pectoral branches of the thoracoacromial vessels and the pectoral nerves that supply the pectoralis major and minor muscles are visible on the undersurface of the mus• cles. In most cases the intercostobrachial nerve arises from the second thoracic segment (less frequently from Th3) and pierces the upper digitations of the serratus anterior muscle at the lateral border of the pectoralis minor muscle. Looping through the axilla, the nerve anastomoses with the medial cuta• neous nerve of the arm from the medial cord of the brachial plexus. The latissimus dorsi muscle has been divided and its lower portion reflected laterally to expose the thoracodorsal nerve and thoracodorsal vessels on its inferior surface. The broken line indicates the path of the incision through the deeper tissue layers in the anterior and posterior thoracotomy. The incision passes through the superior or transverse part of the ser• ratus anterior muscle twice and cuts the diverging and converging fibers almost at right angles to their course. It also divides the lateral thoracic ar• tery and the lateral thoracic vein, which anasto• moses inferiorly with the thoracoepigastric vein. Both vessels course on the serratus anterior mus• cle, which they supply. The incision spares the main trunk of the long thoracic nerve. From the depths of the axilla this nerve emerges from behind the brachial plexus and courses downward on the muscle, deep to the accompanying vessels. The nerve, unlike the vessels, is covered by the muscu• lar fascia. Plate IV

Triceps brachii muscle

_.'~ , ', \1 ':. • • Deltoid muscle

Pectoralis major muscle

Median ne:r~v:e~~~iiiiiiil~~~~~~~~~~~~~:===== Axillary artery 2:=-::::::====~---0~/:iI~=-~~ Pectoral branches Intercostobrachial nerve ~~~~~~~§;;;;;~~~~- of thoraco3cromial Thoracodorsal nerve artery

Thoracodorsal vessels -iiiliitfj-=5;;;;~S

Axillary vel n - .;;;,:;;.r-n.<-t..,...;r-\'I+'\ lfj~~~~~~=~~~:::"=lL~l:= Pectoralis minor muscle ~~~#-:;q,~.:i----,4.!J.!.~~ Serratus anterior Lateral muscle thoracic vessels

---:::_~~~- Fourth rib

Abdominal part Long thoracic nerve -- -'ri-i-t";r'm-r ~~~;;:.::::.... of pectoralis major muscle

Latissimus dorsi .------+1+ muscle Thoracodorsal nerve

\. ~~~~~:...;._ Obliquus abdominis externus muscle

~~~E~~~~~~~~~~~~~--- Thoracoepigastric vein

Serratus anterior muscle Plate V: Deep Lateral Cervical Region

The plastysma has been removed, and the underly• The posterior scalene interval between the scalenus ing cutaneous branches of the cervical plexus, anterior and medius muscles is traversed by the which have an almost common site of emergence brachial plexus and, at a more inferior level, by at the level of the third cervical vertebra (Erb's the subclavian artery. point) just above the center of the sternocleido• The bifurcation of the common carotid artery is mastoid muscle, are reflected and individually obscured by the laterally situated internal jugular shown. The sternocleidomastoid muscle has been vein. divided at its origin and insertion and removed. While the vagus nerve courses within the fibrous Deep to the upper third of this muscle the accesso• sheath of the vagina carotica along with the com• ry nerve crosses beneath the lesser occipital nerve mon carotid artery and internal jugular vein, the at right angles and terminates in the trapezius mus• cervical sympathetic trunk with its middle cervical cle. ganglion is embedded in the deep cervical fascia Except for the thyrohyoid muscle, the infrahyoid of the prevertebral muscles, where it is almost im• muscles have been removed, leaving only their ori• mobile. gins and insertions. The middle cervical fascia (not The superior thyroid artery springs from the exter• shown) forms a sheath enclosing the infrahyoid nal carotid artery and, after giving off the superior muscles and extends laterally to the omohyoid. laryngeal artery, passes to the superior pole of the The omohyoid muscles make this fascia tense thyroid. The inferior thyroid artery takes its origin when the head is sharply inclined, and in turn the from the thyrocervical trunk. fascia, which is adherent to the internal jugular The superior and middle thyroid veins are shown vein, keeps the lumen of this vein open. in their relation to the thyroid gland, and their The infrahyoid muscles are innervated by the ansa sites of entry into the internal jugular vein are indi• cervicalis profunda, which usually is placed on the cated. The unpaired thyroid plexus opens into the lateral wall of the internal jugular vein at the site inferior thyroid vein. where the vein is crossed by the intermediate ten• On the posterior surface of the pharynx, retracted don of the omohyoid muscle. anteromedially, is the pharyngeal plexus, supplied The phrenic nerve on the scalenus anterior muscle by afferent and efferent fibers from the glossopha• accompanies the ascending cervical artery as it ori• ryngeal nerve, vagus nerve, and sympathetic trunk. gins from the thyrocervical trunk. Plate V

Hypoglossal nerve Masseter muscle

- ParoUd g Iand Superior laryngeal nerve with --:-;--,::;--r;;"-ii-:-;---i-;;- int. and ext. branches ----.,ZJ:'c" ,,;-rnr--- Sternocleidomastoid muscle

Facial vein ---,-"-:':~~. ;mm;..-- Accessory nerve

Facial artery ---,.,;.;::...,..;.----,-_ Internal carotid artery Sup_ laryngeal --';;;----'::o:r-- Lesser occipital nerve artery ~n----'

Digastric muscle ;;~--r-- G l ossopharyngea l nerve

'U~--T'----T-- Great auricular nerve

InfrahYOmusclesid ..e::~~~~~~~~~ ~~ Transverse cervical

Pharyngeal plexus on the ~~W!~~~~~~1J~~ , . constr. phar. info muscle

Prevertebral muscles

r-ir---"--- Supraclavicular nerves

Brachial plexus on the ~.-;;,-- scalenus med_ muscle

.E:~iT-r;- Phrenic nerve and ascending cervical artery on the scalenus anI. ian artery Superior thyroid veins Subclav Middle thyroid veins '-'-'--,-.;:..,.:.n.<--- Thyrocervical trunk Inferior thyroid veins :;S!!~-----....,,;-:;--- Internal jugular vein

Esophagus ---iri--i--T: ~---- Vagus nerve Recurrent nerve --...;.;,n;-,7i::;';r,m Common carotid artery Infrahyoid muscles ---",,;;;;:;~~~~~JJl I,l»:~~'fI muscle '-+./...-~------=~-- Sternocleidomastoid Plate VI. View into the Right Thoracic Cavity from Below

The transverse section through this part of the posterior intercostal vessels disappear at the costal thorax is placed so that it cuts the second rib at angle between the internal and external intercostal its sternal attachment anteriorly and the body of muscles. the T 5 vertebra posteriorly. Behind the insertion of the scalenus anterior mus• The parietal pleura and endothoracic fascia have cle on the first rib, the subclavian artery and bra• been removed. The internal intercostal muscles ex• chial plexus cross the first rib through the" scalene tend anteriorly to the sternum (intercartilaginous interval," while the subclavian vein enters the muscles) and terminate posteriorly at the costal thorax in front of the scalenus anterior muscle, angle. The external intercostal muscles are exposed passing through the "anterior scalene interval." by removal of the internal intercostal membrane. There it is joined by the vertebral vein, which The arteries of the intercostal space form anasto• enters it from behind and above. moses between the thoracic aorta (posterior inter• The vagus nerve crosses the subclavian artery (ori• costal artery) and the internal thoracic artery (an• gin of the recurrent nerve). The sympathetic trunk terior intercostal branch). The first and second is visible behind the artery and forms the stellate posterior intercostal arteries usually arise from the ganglion on the head of the first rib. supreme intercostal artery (from the costocervical The internal thoracic vessels pass below the first trunk). The remaining right intercostal arteries rib to the parasternal chest wall and are directly spring from the posterior wall of the aorta and apposed in the upper intercostal spaces to the en• pass behind the esophagus and azygos vein. The do thoracic fascia and parietal pleura. posterior open into the right side The reflection at the junction of the epicardium of the azygos vein. The posterior intercostal artery and pericardium is clearly visible behind the re• and vein undercross the sympathetic trunk in front trosternal fat pad on the ascending aorta. of the heads of the ribs. The intercostal nerve and Plate VI

Superior vena cava

Internal thoracic vessels Sternum

Second rib --~~

Ascending aorta

Pulmonary artery

Right vagus nerve Scalenus ant. Stellate ganglion

Thoracic aorta Esophagus with right Brachial plexus and left vagus nerves (C8, Th 1> Longus colli muscle Sympathetic trunk Second intercostal Fifth thoracic vertebra

intercostal muscle Plate VII. Lower Cervical Organs and View into the Superior and Anterior Mediastinum (Sternum Split and Retracted)

The manubrium and body of the sternum have The phrenic nerve, which arises mainly from C been split and widely retracted laterally to so that 4, enters the chest cavity through the thoracic ap• the superior and anterior mediastinum can be visu• erture and descends in front of the pulmonary hi• alized. lum, passing through the connective tissue between The right and left pleural sac have been windowed the mediastinal pleura and pericardium. Accompa• in their anterior and mediastinal portions, and nied by the pericardiacophrenic vessels, this nerve slight lateral retraction has been placed on the provides the motor innervation for the diaphragm lungs to disclose the bilateral extent of the costo• on the right and left sides. Additionally, its pleural mediastinal recess. The retrosternal fat pad, a rest branches provide sensory innervation to the me• of the paired thymic bodies in the superior inter• diastinal and diaphragmatic pleura, its pericardial pleural triangle (" thymic triangle" ), is retracted branches to the pericardium, and its phrenicoab• laterally on both sides. The thymus or its remnant dominal branches to portions of the parietal peri• derives its blood supply from the internal thoracic toneum in the upper abdomen. The internal thor• artery and pericardiacophrenic arteries and is acic artery and vein pass over the anterior surface drained by the brachiocephalic and inferior thy• of the pleural apex to the parasternal chest wall. roid veins. The upper reflection of the pericardium The pre tracheal (or middle) cervical fascia has is applied to the anterior side of the superior vena been removed, and the infrahyoid muscles have cava and ascending aorta. Lateral to the ligamen• been divided over the thyroid gland. The unpaired tum arteriosum (of Botalli), the recurrent nerve thyroid plexus applied to the inferior poles of both winds around the aortic arch. The right recurrent thyroid lobes drains blood from the thyroid and nerve loops below the right subclavian artery as from the inferior laryngeal veins into the inferior it leaves the vagus nerve trunk. thyroid vein, which usually is unpaired. Plate VII

Unpaired thyroid plexus and inferior thyroid vein Right vagus nerve Sternocleidomastoid muscle Sternohyoid muscle

TIm+-H-rWm~t-:+;-- Omohyoid muscle

Ste rn othyro id m u sci e Internal jugular vein ----';..... ~,..;-{--fl:~ iW\\-t-\--i++-:';"';'If./---

Right subclavian artery ---r;--t-:r+m;;::• firicriliiT-i'-ir+--- Common carotid arteries Sternohyoid muscle ---';-;-;;;iihiffil~~~~ ~;;';~~~lH--- Left recurrent nerve and tracheal branches Sternothyroid muscle ---H!¥'-!;;;:"'.l:!.E..f; ~.,:,~,...,m--- Manubrium sterni Internal thoracic artery ---+fir+~~ Right subclavian vein ----ri~:,.:;...;:.. ,,",,"",""""';';'t--- Tr ac h ea Right recurrent nerve ----ff-4.;...,::...:,,; .~~~"'- Left internal thoracic artery

Thymic branch ------j'r'H'r-;F~"" "III'III Y?,·....,.;;.-.;:r:...;..'ct-- Pleu ra l apex Int. thoracic vein ----/-I-~::;.;.: ::;..::.;..:....i,-~-- Left subclavian Brachiocephalic artery veins i"*irif;:-~~\r-'-i~~';""-- Retrosternal fat pad

Right =~~~~~~-- Aortic arch phrenic nerve ----n..,..,r;;.~~...,.;.~ ~i-'-.;.r-- Left vagus nerve Sup, vena cava --~~~~~~~ ====~~;;:~=;;: and recurrent nerve Lig. arteriosum ~!:l...~- (of Botalli) T--""~mf~~fj-~~;.;...\,..\-- Left pulmonary artery

Thymicand __ nr.~.F~~~~~~~ .o...:.;~>.:.:,,:~- Sternal pleura pericardial veins..--'----'''-'-.!:!.....!.£E. Body of sternum

Phrenic nerve below the mediastinal pleura

Pericardiacophrenic Pericardium vessels

Cut edge T'-';;;;":';;';;""';'';;''';-:-- of mediastinal Middle lobe --!....\!J-~~~~+~l,- pleura Plate VIII. Brachial Plexus and Vessels of the Neck and Axilla; Neurovascular Bundle in the Upper Arm

The clavicle and pectoralis minor muscle have Farther distally the thoracodorsal artery arises been partially resected. With the right shoulder from the axillary artery via the subscapular artery. pulled slightly laterally, the pectoralis major mus• The thoracodorsal artery descends laterally with cle has been divided at its origins on the thorax the thoracodorsal nerve (from the posterior cord and reflected laterally and superiorly. The pectoral of the plexus), and they both disappear below the nerves that innervate the muscle are visible on its anterior border of the latissimus dorsi muscle, undersurface; like the pectoral branches for the which both supply. pectoralis minor muscle, these nerves arise from The cephalic vein courses between the clavicular the supraclavicular portion of the brachial plexus. part of the pectoralis major muscle and the clavi• The pectoral branches of the thoracoacromial ar• cular part of the deltoid muscle in Mohrenheim's tery supply the pectoralis major and minor mus• fossa. It passes deeply and pierces the clavipectoral cles. fascia to unite with the subclavian vein. The pretracheal layer of the cervical fascia and The has been resected to expose the its junction with the clavipectoral fascia have been axillary artery, around which are grouped the removed along with the axillary fascia so that cords of the brachial plexus (the key landmark deeper layers can be visualized. is the median nerve, which arises directly from the A "scalenus interval" is formed by the anterior lateral and medial cords). scalenus muscle, on which the phrenic nerve de• The axillary nerve arises from the posterior cord scends, and by the medial scalenus muscle. The behind the subclavian artery and passes through brachial plexus courses through the upper part of the quadrangular space in company with the pos• this interval. The subclavian artery emerges terior circumflex humeral artery. The musculocu• through the lower part of the" scalenus interval" taneous nerve leaves the lateral cord and passes passing directly over the first rib. Arising from to the coracobrachialis muscle, which it pierces the C 5 segment, the long thoracic nerve passes and innervates. The lateral cutaneous branch of through the scalenus medius and descends on the the second intercostal nerve passes as the intercos• serratus anterior, covered by its fascia. There it tobrachial nerve to the upper arm and anasto• is accompanied by the lateral thoracic artery, moses with the medial cutaneous nerve of the arm which arises from the axillary artery in its midaxil• from the medial cord of the brachial plexus. lary portion (behind the pectoralis minor muscle). Plate VIII

Suprascapular nerve Descend i ng scapular artery

~~~~~~~:c Ascending cervical artery ~ Scalenus medius muscle '/Iil~~IW'tV~~~~,--- Sternocleidomastoid muscle k'Ii....",...y,.,,~...rn""""- Long thoracic nerve Brach. plexus in scalenus interval Omohyoid muscle 'lmn~~~~-- Phrenic nerve on scalenus anI. PectoraliS G""....,...... ;,;C":;O~~'m<- Junction of cephalic vein maj or m usc I e -+-=---=-"==-==:'-'-- with subclavian vein Brachial plexus: Clavicle with clavicular part lateral cord ~~~:::::""'--=--~~~~~ of pectoralis major muscle Axi Ilary artery Thoracoacromial artery Axillary nerve First rib Post. circumf l ex -...:s;~~~:=;",=:::::--~~~M- Pectoral nerves humeral artery Lateral thoracic artery Coracobrachialis muscle --- frm: ~~~~~~~~$i--. Intercostobrachial nerve Musculocutaneous nerve Cephalic vein .-'lr-.....,.""",.....~~"Nmo;;;£.m"""- Long thoracic nerve Radial nerve ------15 """",""""",,,,,.m#'- Pectoralis minor muscle '--=':::::::3--WM-'k-- """"""'''''''''''--Serratus anterior muscle Median nerve Medial cu taneous nerve of the arm Brachial vein

Thoracodorsal nerve and artery Latissimus dorsi muscle Plate IX. Right Pulmonary Hilum and Organs of the Superior and Anterior Mediastinum

The right chest wall has been widely resected, and the upper and middle lobes of the right lung are retracted laterally to expose the right hilum. The mediastinal pleura and pulmonary pleura are not shown. The superior vena cava is located ventrally to the hilar structures of the right side. Just before its entry into the pericardium, the superior vena cava is joined by the azygos vein, which arches over the right main bronchus. This bronchus is the most posterior and superior of the hilar structures; cau• dal to it are the pulmonary artery and vein. The right upper lobe bronchus is eparterial to the pul• monary artery, which gives off a large branch to the upper lobe (the "anterior trunk") while still outside the hilum. The right superior pulmonary vein is the most an• terior of the hilar structures and largely obscures the right inferior pulmonary vein. The right vagus nerve descends on the lateral tracheal wall, passing behind the hilum to the esophagus in the posterior mediastinum. The right phrenic nerve, in company with the peri• cardiacophrenic vessels, courses somewhat more posteriorly than on the left side. It descends along the superior vena cava and then passes between the mediastinal pleura and pericardium, providing both with sensory fibers, before proceeding to the diaphragm. The internal thoracic vessels pass over the retrosternal fat pad to the anterior chest wall, upon which they descend in a parasternal position. Plate IX

Retrosternal fat pad Phrenic nerve Reflection of pericardium Pericardiacophrenic artery Pericardium Internal thoracic vessels

Superior vena cava -....,.:.->f::ir,,&---~iiii:!!i Vagus nerve Right main bronchus Right pulmonary artery First rib

Azygos vein Ant. trunk of right pulmonary artery Right superior pu lmonary vein Right inferior pulmonary vein

Upper lobe

Middle lobe Lower lobe Horizontal fissure Plate X. Left Pulmonary Hilum and Organs of the Superior and Anterior Mediastinum

The left chest wall has been widely resected and the upper lobe of the left lung retracted postero• laterally to expose the left hilum. The mediastinal and pulmonary pleurae are not shown. The internal thoracic artery arises from the subcla• vian and, accompanied by the , courses laterally and anteriorly over the re• trosternal fat pad. Both vessels reach the anterior chest wall and descend on it in a parasternal posi• tion. The left phrenic nerve crosses the aortic arch and descends in front of the pulmonary hilum with the pericardiacophrenic vessels, somewhat more anteriorly than on the right side, passing between the mediastinal pleura and pericardium, both of which receive sensory fibers from the nerve. The trunk of the phrenic nerve provides motor innerva• tion to the diaphragm, while its phrenicoabdomin• al branches pierce the diaphragm and send sensory fibers to portions of the parietal peritoneum in the left upper abdomen. The cardiac plexus, formed from branches of the vagus nerve and sympathetic trunk, presents on the anterior side of the aortic arch, which" rides" on the left main bronchus. Lateral to the ligamen• tum arteriosum (of Botalli) the left recurrent nerve leaves the vagus trunk and winds posteriorly around the aortic arch. The vagus nerve descends behind the left hilum into the posterior mediasti• num. The left superior pulmonary vein is the most ante• rior of the left hilar structures. The left pulmonary artery presents superior to the vein, coursing be• tween it and the arch of the aorta. The left inferior pulmonary vein is largely obscured by the left su• perior pulmonary vein, and a portion of it is just visible in the lower hilar region. The left main bronchus is deep to these structures and, like the right bronchus, cannot be seen from the anterior aspect. The accessory , represent• ing a superior continuation of the hemiazygos, ter• minates at the left . Plate X

Left recurrent nerve Left pulmonary artery Retrosternal fat pad Left superior pulmonary vein Aortic arch with cardiac plexus Left inferior pu lmonary vein Internal thoracic vessels Pericardiacophrenic artery Pericardium

+.+.:i""i-...... Left brachiocephalic vein

~-'i'i:T-;;-- Brachiocephalic trunk

i';M,...... ~-n-- Phrenic nerve ';:'-,--..:y 'it-- Le" common carotid artery Lig. arteriosum (of Botallij

5~r;;:;r Left vagus nerve

Esophagus

Accessory ~",!:i:?<;---=;::""""'::S7'5:i-"'''-+::5iiri;- hemiazygos vein

Left upper lobe Left lower lobe Cardiac impression Plate XI. Right Pulmonary Hilum and Organs of the Posterior Mediastinum

The right lateral chest wall has been widely re• The right vagus nerve descends parallel to the tra• sected, and the middle and lower lobes of the right chea, passing medial to the azygos vein and behind lung are retracted upward and forward. The pul• the right main bronchus (which here is retracted monary, mediastinal, and vertebral pleurae are not well forward) to reach the posterior aspect of the pictured. root of the right lung. From there it descends on The sympathetic trunk courses anterior to the the posterior aspect of the esophagus and pierces heads of the ribs and the intercostal nerves and the diaphragm. vessels. Communicating branches link it with the The esophagus, having undergone its second phys• intercostal nerves, and the trunk gives origin to iologic constriction behind the tracheal bifurcation the greater and lesser splanchnic nerves, which run and aortic arch, becomes closely related in its re• forward and downward. tropericardial portion to the left atrium of the The azygos vein is joined in this region by the heart and then, tending more toward the left side, segmental intercostal veins (posterior branches) enters the esophageal hiatus in the diaphragm (at and by the right superior intercostal vein (formed the level of the 10th-11th thoracic vertebra). from the union of the second and third posterior Because of the strong anterior retraction of the intercostal veins). Small veins in the mediastinum middle and lower lobes of the right lung, the most (the esophageal and bronchial veins, not shown) posterior of the hilar structures, the right main drain blood from the esophagus and main bronchi bronchus, largely obscures the right pulmonary ar• into the azygos vein. The azygos vein crosses the tery and its branches. The right inferior and supe• right main bronchus from behind and opens poste• rior pulmonary veins are visible in the inferior part riorly into the superior vena cava. of the hilum, and their site of entry into the peri• The thoracic duct is visible in the right posterior cardium is apparent. mediastinum in the loose connective tissue be• The phrenic nerve takes a more posterior course tween the aorta, esophagus, and azygos vein be• on the right side and reaches the diaphragm fore ascending and crossing to the left side. anterolateral to the inferior vena cava. Plate XI

Right phrenic nerve Inferior vena cava Middle lobe of right lung Pericardium Diaphragm Lower lobe of right lung

;---

Right lower --~"":":''--'--:-':'-f-~-...... lobe bronchus

Right -...--+--,....---'-'~:-:-'----:"'T".....-;~~ pulmonary artery Right sup. and -',L-~-""':'-=-:-'-=+-:-;-::'-:~4fii -- .. -- info pulm. veins ;;;~-:::.--:--~

Right main bronchus lt~7~"s:::~~I~~~~

Azygos vein

Vagus nerve

Right superior intercostal vein

Aorta Sympathetic trunk with communicating branches Esophagus

Thoracic duct Greater and lesser splanchnic nerves Plate XII: Left Pulmonary Hilum and Organs of the Posterior Mediastinum

The left lateral chest wall has been widely resected. behind the root of the left lung and descends on The upper and lower lobes of the left lung are the lateral and especially the anterior side of the retracted anteriorly and superiorly. The pulmo• esophagus, accompanying it as it pierces the dia• nary, mediastinal, and vertebral pleurae are not phragm. shown. The esophagus has its second physiologic constric• The sympathetic trunk, covered by parietal pleura, tion between the tracheal bifurcation and aortic courses anterior to the heads of the ribs and the arch. It passes behind the left atrium of the heart intercostal nerves and vessels and is linked by com• (retropericardiac part), usually slightly to the right municating branches with the intercostal nerves. of the midline, then turns back toward the left The greater and lesser splanchnic nerves arise from side to enter the esophageal hiatus (its third physi• the 6th-9th and 1Oth-ll th thoracic ganglia. ologic constriction). The posterior inferior" weak The hemiazygos vein is joined by the lower seg• spot" of the mediastinum occurs between the pos• mental intercostal veins (posterior branches). It terior wall of the esophagus, the anterior wall of has a superior continuation in the accessory he• the aorta, and the diaphragm. miazygos vein which, after receiving the left superi• The left pulmonary artery and its branches are or intercostal vein (union of the posterior superior visible between the aortic arch and the left main intercostal veins), usually establishes a communi• bronchus, which is retracted far anteriorly. Inferi• cation with the left brachiocephalic vein. The inter• or to the bronchus the left inferior pulmonary vein costal arteries (posterior branches) arise as paired partially obscures the left superior pulmonary vein branches of the thoracic aorta, which descends be• in the lower part of the hilum. The site of entry tween the vertebral pleura (not shown) and the of both veins into the pericardium is visible. esophagus. The aortic arch "rides" upon the left The left phrenic nerve, which courses more anter• main bronchus. There the left recurrent nerve iorly than on the right side, passes between the leaves the vagus trunk and loops upward behind pericardium and mediastinal pleura to reach the the aorta. The left vegus nerve, often dividing into diaphragm. branches between the bronchus and aorta, passes Plate XII

Left inferior pulmonary vein

Pericardium Lower lobe of left lung Diaphragm Left phrenic nerve Upper lobe of left lung ' I ::~"~)~i '.,1 ":f " 'f .. ;. ,~ .~J ,Jt\~.! , '

. , • i

Left pulmonary ...<'~--'-'7""- artery

:;..-,...,..-~;- Aortic arch Left vagus nerve Left common carotid artery Left subclavian artery Trachea Recu rrent nerve ~~?",!::;-- Accessory hemiazygos vein Left main bronchus

Left superior in tercostal vein Left superior pulmonary vein

Lesser splanchnic nerve Esophagus Accessory hemiazygos vel n Vagus nerve Hemiazygos vein Greater splanchnic nerve Plate XIII. View into the Oblique Fissure of the Right Lung

The right chest wall has been removed; the parietal and visceral pleurae are not shown. The right lower lobe is retracted far posteriorly, the right upper lobe anterosuperiorly, and the right middle lobe anteroinferiorly to expose the interlobar fissure, oblique fissure, of the right lung. The right pulmonary artery crosses anterior to the main bronchus and, ramifying, passes to the later• al side of the lower and middle lobe bronchi. The most medial structures are the pulmonary veins. Hence the lobar bronchi are placed between the arteries and veins, and the pulmonary artery and its branches are the first structures to be encoun• tered in the oblique fissure. While still in the mediastinum, the right pulmo• nary artery gives off branches to the upper lobe. Some of these branches enter the upper lobe poste• rior to the bronchus, and some medial to it. The arterial branches to the middle lobe are lateral and superior to the lobar bronchus, in close prox• imity to the superior pulmonary vein. The vein receives a posterior tributary venous branch from the upper lobe in this area. The azygos vein emerges from the posterior medi• astinum, crosses the right main bronchus, and "rides" on it before terminating at the superior vena cava. In the inferior part of the posterior mediastinum, the lower portion of the esophagus is visible be• tween the middle and lower pulmonary lobes. The right vagus nerve becomes the posterior vagal trunk on the right and posterior wall of the esoph• agus. The bronchial arteries and veins are not shown, nor are the pulmonary plexus or the lymph vessels and nodes. Plate XIII

Right upper lobe Right middle lobe bronchus Right upper lobe bronchus Right middle lobe Diaphragm

Right inferior pu lmonary vein

Right pu lmonary artery Right lower lobe Plate XIV. View into the Oblique Fissure of the Left Lung

The left hemithorax has been opened and most of the chest wall removed. The parietal and visce• ral pleurae are not shown. The left upper lobe is retracted anteriorly and superiorly, while the lo• wer lobe is retracted posteriorly to give an unob• structed view into the interlobar fissure, the obli• que fissure of the left lung. The trunk of the left pulmonary artery crosses the left main bronchus, "riding" on its posterior sur• face. On the lateral side of the lobar bronchi the pulmonary artery ramifies, usually into four bran• ches, that are distributed to the upper lobe and lingula and to the lower lobe, paralleling the bron• chial divisions. As on the right side, the left pulmonary veins are the most medial of the hilar structures. Only a few branches of the pulmonary veins are visible through the left oblique fissure. The pulmonary artery and its branches are encountered first, fol• lowed by the lobar bronchi, which occupy an inter• mediate position between the arteries and veins. The thoracic aorta is posterior and medial to the vessels and bronchi of the left hilum. It is visible in the upper part of the interlobar fissure at its junction with the aortic arch. The left vagus nerve crosses the aortic arch, giving off the left recurrent laryngeal nerve superiorly, and disappears behind the pulmonary hilum, which it supplies with bron• chial branches. The left phrenic nerve and pericar• diacophrenic vessels course on the pericardium, which is covered by mediastinal pleura (not shown). The phrenic nerve supplies the pericar• dium and pleura with sensory fibers, and its trunk descends to the diaphragm, which it provides with motor and sensory innervation. The bronchial arteries and veins, the pulmonary plexus, and the lymph nodes and vessels are not shown. Plate XIV

Left superior pulmonary vein Lingula of left I ung Left upper lobe bronchus Left inferior pu i monary vein Left pulmonary artery Left upper lobe

Left lower lobe

Vagus nerve with left recurrent laryngeal nerve Phrenic nerve Bronchial branches of the vagus nerve Pericardiacophrenic vessels Left lower lobe bronchus Plate XV. Upper Abdomen about the Esophageal Hiatus and Lesser Curvature of the Stomach

The attachment of the falciform ligament on the Behind the lesser curvature of the stomach, the superior surface of the liver marks the line of de• omental tuberosity of the pancreas bulges into the marcation between the right and left hepatic lobes. omental bursa. The splenic artery, the third branch (This division does not correspond to the lobation of the celiac trunk, disappears behind the stomach, defined by the vascular structure of the liver.) In which it supplies with short gastric arteries. the drawing the right lobe is elevated slightly with The celiac plexus with the celiac ganglia surrounds a retractor while most of the left lobe has been the origin of the celiac trunk from the aorta. It resected, exposing the caudate lobe, the abdominal contains parasympathetic fibers mainly from the part of the esophagus, the gastric cardia, and posterior vagal trunk, which traverses the dia• structures in the lesser omentum. phragm on the posterior wall of the esophagus. The parietal and visceral peritoneum are not The splanchnic nerves (not visible), which arise shown, nor are peritoneal folds such as the lesser from the 5th-ll th thoracic ganglia of the sympa• omentum and its parts (hepatogastric and hepato• thetic chain, transmit sympathetic fibers for the duodenal ligaments). All the biliary and vascular celiac plexus. The greater splanchnic nerve pierces channels leading to or from the porta hepatis the diaphragm together with the azygos or he• course within the hepatoduodenal ligament (not miazygos vein. The lesser splanchnic nerve accom• shown): the common bile duct on the right side, panies it or pierces separately the lumbar attach• the hepatic artery proper on the left side, and the ment of the diaphragm. portal vein behind and between them. In this area The esophageal hiatus is bounded chiefly by the the portal vein receives the left gastric vein, which right medial crus of the lumbar part of the dia• drains the lesser curvature of the stomach and phragm, for a large fiber bundle of the right medial forms anastomoses with the inferior esophageal crus crosses to the left side, forming also the left veins at the gastric cardia (portocaval anastomo• margin of the hiatal opening. ses). The caudate lobe of the liver, separated from the The common hepatic artery arises from the celiac left lobe by the fissure for the ligamentum ve• trunk and, after giving off the gastroduodenal ar• nosum, largely obscures the inferior vena cava, tery, reaches the porta hepatis as the hepatic artery which ascends in the sulcus venae cavae on the proper. The cystic artery originates from the right posterior surface of the liver. Three to five hepatic branch of the hepatic artery proper to supply the veins open into the inferior vena cava just before wall of the gallbladder. The right gastric artery it traverses the diaphragm. arises from the common hepatic artery (or the he• patic artery proper) and passes to the stomach, where it enters the arterial arcade of the lesser curvature. This arcade also receives blood from the left gastric artery, the smallest branch of the celiac trunk. Plate XV

Left lobe of the liver Hepatic vei ns Right lobe of the liver Falciform ligament of the liver

,1$~~~~~~i~~-'+-;- Inferior vena cava _ Caudate lobe of the liver

'p;.g..\--,---- Esophageal hiatus

I~.,L,..,....--- Fissure for ligamentum venosum

vagus trunk

fJ~~~C~~;;:~:::.. part of the right medial crus that crosses to th e left of the liver '~-.-!!~r:;;:~C;~~Sil'{{i;, ~.....,.:'-f{..+"'~;:-- Right medial crus Lig. teres --'------ii-. Left medial crus of th e Gallbladder ~\hll--I-"'-~ lumbar part of the diaphragm ~[lm;~~~~~--- Left gastric artery

Cystic artery -::::~~~~ ~~q...... ".-+-- Splenic artery Cystic duct --....",.--: -...... , ... ,.... !!~~~~l25~~:= Lesser curvature Common Si; Celiac ganglion bile duct --""'""'~ _ ....,.. 'I "' __!~~!e"P ~~~;s;.p~ and celiac plexus Hepatic artery --.,;.:,;,,;~ proper

Gastroduodenal artery Right gastric artery Common hepatic artery Portal vei n Inferior vena cava Left gastric vein Omental tuberosity of pancreas K. Topography of Surgically Important Regions 15 Anatomic Plates

K. ZILLES and U. DEMMEL