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Thoracic Surgery

Dale A. Dangleben

INTRODUCTION

Test Taking Tips

All general surgery residents should have a working knowledge of basic thoracic surgical conditions. Focus on the common problems you may encounter as incidental findings—such as managing a solitary pulmonary nodule or a newly found mediastinal mass. Be familiar with the common surgical approaches such as median sternotomy, posterolateral thoracotomy, etc.

ANATOMY/PHYSIOLOGY

Which ribs are true ribs (directly articulate with the sternum by means of cartilages)?

  • The upper 7 ribs (numbered 1–7)

Which ribs are false ribs (no direct connection with the sternum anteriorly; usually connect with the costocartilage above)?

  • The lower 5 ribs (numbered 8–10)

Which ribs are floating ribs (articulate only with the thoracic spine)?

  • Ribs 11 and 12

FIGURE 27-1

The thorax, showing rib cage, pleura, and lung fields. (Reproduced with permission from Doherty GM. CURRENT Diagnosis & Treatment Surgery, 15th ed. New York, NY: McGraw Hill; 2020.)

An illustration shows the anatomy of the thorax. The illustration shows the thorax with left lung, right lung. The midsternal line is at the center followed by the parasternal line, midclavicular line, and midaxillary line at the periphery. The ribcage has ribs 1 to 10 with the pleura above rib number 1.
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What structure perforates and connects the alveoli?

  • The pores of Kohn

What type of epithelium lines the larger upper airways as a single layer?

  • Ciliated tall columnar epithelium

What are type I pneumocytes?

  • Gas exchange; constitute ∼40% of the number of cells lining the alveoli and cover >90% of the alveolar lining

What are type II pneumocytes?

  • Granular pneumocytes that contain lipid inclusion bodies and manufacture surfactant, a lipoprotein (dipalmitoyl-lecithin) that decreases surface tension

What are the lobes and fissures of the right lung?

  • The right lung is composed of 3 lobes: the upper, middle, and lower

  • The major (oblique) fissure separates the right lower lobe from the right upper and middle lobes

  • The minor (horizontal) fissure separates the right upper lobe from the right middle lobe

FIGURE 27-2

Segmental anatomy of the lungs and bronchi. (Reproduced with permission from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery, 11th ed. New York, NY: McGraw Hill; 2019.)

A two-part illustration shows the segmental anatomy of the lungs and bronchi. The first part shows the bronchi and the anterior and posterior view of the right lung. The anterior side has an apical segment at the top followed by the posterior segment and anterior segment, superior, lateral segment, and medial segment, anterior basal segment, lateral basal segment, and posterior basal segment. The posterior side has the Apical segment, Posterior segment, Anterior segment, medial segment, superior segment, medial base segment, anterior basal segment, lateral basal segment, and posterior basal segment. The second part shows the bronchi and the anterior and posterior view of the left lung. The anterior side of the left lung and bronchi shows apical and posterior segments fused and followed by anterior segment, lateral segment, medial segment, superior segment, anterior basal segment, lateral basal segment, and posterior basal segment. The medial basal is not present in the left lung. The posterior side of the left lung shows the segments in the following order: apical and posterior segments fused, superior, anterior, lateral, posterior basal, anterior basal, medial, and lateral basal at the bottom center.
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What are the lobes and fissures of the left lung?

  • The left lung has 2 lobes—the left upper lobe and the left lower lobe

  • The lingula is a portion of the left upper lobe and corresponds embryologically to the right middle lobe

  • A single oblique fissure separates the left upper lobe from the left lower lobe

What is the blood supply to the lung?

  • Unoxygenated blood is pumped to the lung from the right ventricle through ...

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