SEGMENTAL ANATOMY

LUNG ANATOMY

Note the continuity of the pulmonary parenchyma between adjacent segments of each lobe.
In contrast, separation of the bronchial and vascular stalks allows subsegmental and segmental resections, if the clinical situation requires it or if lung tissue can be preserved.

LYMPHATIC DRAINAGE

Lymph nodes that drain the lungs are divided into two groups according to the tumor, node, and metastasis (TNM) staging system for lung cancer
pulmonary lymph nodes, N1 mediastinal nodes, N2

N1 lymph nodes: a) intrapulmonary or segmental nodes - lie at points of division of segmental 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

lymphatic sump of Borrie - where all of the pulmonary lobes of the corresponding lung drain

N2 lymph nodes: a) anterior mediastinal b) posterior mediastinal c) Tracheobronchial d) paratracheal

COMPUTED TOMOGRAPHY

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 by the indication for the study Thin sections (1- to 2-mm collimation) - used to evaluate pulmonary parenchyma and peripheral bronchi - pulmonary metastases

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

THORACIC SURGICAL APPROACHES

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.

Special Circumstances under Which Lobectomy by VideoAssisted 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

Mediastinoscopy - generally used for diagnostic assessment of mediastinal lymphadenopathy and staging of lung cancer - performed via a transverse 2- to 3-cm incision approximately 1 cm above the suprasternal notch - Care is taken to avoid any venous structures that may overlie the muscles

posterolateral thoracotomy - most frequently used incision for an open procedure in thoracic surgery - patient is placed in the lateral decubitus position - A pitfall of thoracic incisions in a lateral decubitus position is the potential for injury to the brachial plexus and axillary vascular structures secondary to displacement of the shoulder - skin incision typically starts at the anterior axillary line just below the nipple level and extends posteriorly below the tip of the scapula - The pleural space is entered at the fifth interspace

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 position significantly compromises control over the patient's cardiopulmonary system and resuscitation efforts, whereas the supine position allows the anesthesiologist full access to the patient - The incision is submammary, beginning at the sternal border overlying the fourth intercostal space and extending to the midaxillary line

Bilateral anterior thoracotomy - is a standard operative approach to the heart and mediastinum in certain elective circumstances - incision with a transverse sternotomy (clamshell thoracotomy) is done