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1. Anatomical Basis of Thoracic Surgery

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1. Anatomical Basis of Thoracic Surgery BWH 2015 GENERAL SURGERY RESIDENCY PROCEDURAL ANATOMY COURSE 1. ANATOMICAL BASIS OF THORACIC SURGERY Contents Lab objectives ............................................................................................................................................... 2 Knowledge objectives ............................................................................................................................... 2 Skills objectives ......................................................................................................................................... 2 Preparation for lab ....................................................................................................................................... 2 1.1 BASIC PRINCIPLES OF ANATOMICAL ORGANIZATION ............................................................................ 4 1.2 THORACIC CAVITY AND CHEST WALL ..................................................................................................... 9 1.3 PLEURA AND LUNGS ............................................................................................................................. 13 1.4 ORGANIZATION OF THE MEDIASTINUM .............................................................................................. 19 1.5 ANTERIOR mediastinum ....................................................................................................................... 23 Thymus .................................................................................................................................................... 24 1.6 MIDDLE MEDIASTINUM (PERICARDIUM AND HEART)......................................................................... 25 Pericardium ............................................................................................................................................. 26 Heart external features .......................................................................................................................... 26 1.7 Superior mediastinum .......................................................................................................................... 27 Venous layer of the superior mediastinum ............................................................................................ 28 Arterial layer of the superior mediastinum ............................................................................................ 30 1.8 VISCERAL LAYER OF THE SUPERIOR AND POSTERIOR MEDIASTINUM ................................................ 32 1.9 LYMPH NODE STATIONS FOR LUNG CANCER STAGING ....................................................................... 33 1.10 POSTEROLATERAL THORACOTOMY ................................................................................................... 35 1.11 ANTEROLATERAL THORACOTOMY ..................................................................................................... 42 1.12 EMERGENCY LEFT ANTEROLATERAL THORACOTOMY....................................................................... 46 1.13 MEDIAN STERNOTOMY ...................................................................................................................... 58 1.14 SUBCLAVIAN ARTERY EXPOSURE ....................................................................................................... 62 BWH 2015 GENERAL SURGERY RESIDENCY PROCEDURAL ANATOMY COURSE 1. ANATOMICAL BASIS OF THORACIC SURGERY LAB OBJECTIVES After successfully completing Laboratory 1, you will be able to do the following. Knowledge objectives 1. Explain four meanings of the term ligament. Describe the common features of the Scarpa fascia, the ligament of Treitz, Gerota fascia, and cardinal ligaments of the uterus. 2. Describe the layers and organization of the chest wall, including bones, joints, intrinsic muscles, connective tissue layers, and neurovascular supply. Explain the primary anastomoses between the intercostal arteries, internal mammary arteries, and aorta. 3. Describe the topography of the pleural sacs and the specific terms used for various regions of the pleural sac. Explain the distinction between a pleural reflection and a pleural recess. Explain the distinction between the lung root and lung hilum. Describe the relative positions of the lung root structures on the hila of the left and right lungs. 4. Contrast the organization and composition of the two types of pericardium. Describe the pericardial sinuses and put your fingers in them. Describe the topography of the heart and the utility of the coronary sulcus, anterior interventricular sulcus, and posterior interventricular sulcus for locating the cardiac vessels. Explain three functions of the cardiac skeleton. 5. Explain the boundaries and basic organization of the mediastinum. Describe the structures located in the anterior mediastinum, middle mediastinum, superior mediastinum, and posterior mediastinum. Skills objectives 1. Complete the anatomy lab equivalent of a posterolateral thoracotomy. 2. Complete the anatomy lab equivalent of an anterolateral thoracotomy. 3. Complete the anatomy lab equivalent of an emergency left anterolateral thoracotomy. 4. Complete the anatomy lab equivalent of a median sternotomy. 5. Complete the anatomy lab equivalent of an subclavian artery exposure. PREPARATION FOR LAB Review this guide. Watch the SCORE videos listed at the end of some procedures. BWH ABS Lab 1. THORAX Page 1‐3 Figure 1‐1. Anatomical organization of the crus, axial view. (Modified from Netter Atlas of Human th Anatomy, 5 Edition. Philadelphia: Elsevier, 2010.) BWH ABS Lab 1. THORAX Page 1‐4 1. ANATOMICAL BASIS OF THORACIC SURGERY 1.1 BASIC PRINCIPLES OF ANATOMICAL ORGANIZATION The basic principles of anatomical organization include the following. Organization of superficial layers 1. Skin forms the outermost layer in all anatomical regions (Figures 1‐1, 1‐2, and 1‐3). Skin is the largest body organ, accounting for approximately 8 to 10% of total body mass. Skin consists of an outer epidermis, composed of epithelium, and an inner dermis, composed of dense irregular connective tissue. Skin is continuous with the mucosa lining the respiratory, digestive, and urogenital systems; with the conjunctiva of the eye; and with the lining of the nasolacrimal duct. Skin lines the external auditory canal and forms the outer layer of the tympanic membrane. 2. Subcutaneous loose connective tissue supports skin function by providing thermal insulation, energy storage, and pathways for neurovascular structures serving skin but arising from larger nerves and vessels within deep fascial compartments. Subcutaneous loose connective tissue (subcutaneous fat, hypodermis, subcutis, superficial fascia) extends from the dermis to the deep investing fascia surrounding musculoskeletal compartments (Figures 1‐1 and 1‐2). All fat consists of adipocytes, collagen fibers, and elastin fibers. The proportions of the three components vary according to body region and local mechanical requirements. The subcutaneous fat of the hands and feet is very fibrous to resist local shear forces. Collagen fibers in subcutaneous fat form a distinct membranous layer variably present throughout the body. This membranous layer is described as Scarpa fascia over the anterior abdomen in contrast to the fatty Camper fascia forming the rest of the subcutaneous fat. It is present in all regions of the body, however, and may be confused with deep fascia. 3. An extensive network of superficial veins runs within the subcutaneous fat. In the limbs, the superficial veins receive blood from the skin and subcutaneous fat, drain through perforating tributaries to deep veins within the fascial compartments, and end by piercing the deep fascia to enter deep veins. Small cutaneous arteries usually arise as perforating branches of larger arteries supplying muscles within the fascial compartments. Cutaneous nerves often arise from large mixed nerves running within the fascial compartments. Lymphatic vessels draining superficial layers generally follow superficial veins to lymph node basins in the neck, axilla, and groin (inguinal region). Organization of deep fascial compartments 4. Deep fascia, consisting of dense connective tissue, forms fascial compartments surrounding muscles, bones, and joints in all body regions (Figure 1‐1 and 1‐1). Deep fascia is robust where it forms the investing deep fascia surrounding muscle groups in the limbs and neck and the masticatory muscles in the head. Deep fascia is thinner where it forms the investing fascia surrounding muscle groups in the shoulder, hip, trunk, and face. A layer of investing fascia, distinct from the epimysium surrounding individual muscles, always surrounds muscle groups in the head, limbs, and trunk. In the limbs, investing deep fascia surrounds all muscle groups. Fascial septa connect the deep investing fascia with the periosteum of underlying bones, enclosing the muscle compartments of the limbs, and providing the anatomical basis of compartment syndrome. In the trunk, investing BWH ABS Lab 1. THORAX Page 1‐5 Figure 1‐2. Anatomical organization of the thorax, axial view at the level of the L3‐L4 intervertebral disk. (Modified from Netter Atlas of Human Anatomy, 5th Edition. Philadelphia: Elsevier, 2010.) BWH ABS Lab 1. THORAX Page 1‐6 deep fascia covers the outer surfaces of muscles, bones, and joints, and lining deep fascia covers the inner surface of the trunk wall, both the thoracic and abdominal surfaces of the diaphragm, and the pelvic surface of the pelvic sidewalls and pelvic
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