Thoracic and Pulmonary Anatomy

Question 1

Number of ribs

Answer 1

12

Question 2

True ribs

Answer 2

Ribs 1-7

Articulate directly with sternum

Question 3

False Ribs

Answer 3

Ribs 8-10

Articulate with costal cartilage

Question 4

Floating ribs

Answer 4

Ribs 11-12

No anterior articulations (floating)

Question 5

Rib that articulates with manubrial sternal junction (Angle of Louis)

Answer 5

2nd rib

Question 6

Structures inserting on OR arising from the 2nd rib

Answer 6

• Posterior scalene muscle (inserts onto 2nd rib)
• Pectoralis major muscle (arises from 2nd rib)

Question 7

Caval hiatus (level and structures passing through)

Answer 7

• Level T8
• Structures
  
  • IVC
  • Right phrenic nerve

Question 8

Esophageal hiatus (level and structures)

Answer 8

• Level T10
• Structures
  
  • Esophagus
  • Anterior (left) vagus nerve
  • Posterior (right) vagus nerve

Question 9

Aortic hiatus (level and structures)

Answer 9

• Level T12
• Structures
  
  • Aorta
  • Azygous vein
  • Thoracic duct

Question 10

Course of sympathetic trunk

Answer 10

Runs posterior to diaphragm along lateral aspect of vertebral column

Question 11

Thoracic inlet relationships of vessels and nerves

Answer 11

• Anterior to Anterior Scalene muscle
  
  • Subclavian vein (over first rib, beneath clavicle)
• Between Anterior and Middle Scalene muscle
  
  • Subclavian artery (over first rib, beneath clavicle)
  • Brachial plexus

Question 12

Nerve that descends on anterior surface of Ant Scalene m

Answer 12

Phrenic n

Question 13

Chest wall muscles utilized for tissue coverage

Answer 13

• Pectoralis major (pectoralis branch of thoracoacromial artery)
• Latissimus dorsi (thoracodorsal artery)
• Serratus anterior (lateral thoracic artery)
• Pedicaled intercostal muscle
• Rectus abdominus for TRAM flap (superior epigastric artery)
  
  • Not appropriate if ipsilateral IMA has been harvested for CABG

Question 14

Average length of the trachea?

Number of cartilagenous rings of trachea?

Answer 14

10-11 cm

17-21 incomple anterior cartilagenous rings

Question 15

Blood supply to trachea

Answer 15

Inferior thyroid artery (anastomotic arcade on posterolateral aspect of trachea)

Question 16

Individuals responsible for regional lymph node classification system

Answer 16

Mountain and Dresler

Question 17

Mediastinal lymph node levels

Answer 17

Levels 1-9 (single digit levels)

• N2 disease (ipsilateral LN involvement)
• N3 disease (contralateral LN involvement)

Question 18

MLN Level 1

Answer 18

Supraclavicular LN

Question 19

MLN Levels 2 and 4

Answer 19

• Level 2: upper paratracheal
  
  • above Ao arch
• Level 4: lower paratracheal
  
  • below Ao arch

Question 20

MLN Level 3

Answer 20

Prevascular or prevertebral (immediately adjacent to trachea)

Question 21

LN Levels 5 and 6

Answer 21

• Level 5: aortopulmonary window (btw aorta and PA)
  
  • watch injury to recurrent laryngeal nerve
• Level 6: anterior to Ao arch

Question 22

LN Levels 7, 8, 9

Answer 22

• Level 7: Subcarinal
• Level 8: Paraesophageal
• Level 9: Along inferior pulmonary ligament

Question 23

Pulmonary LN

Answer 23

• Levels 10-14
  
  • Level 10: hilar
  • Level 11: interlobar
  • Level 12: lobar
  • Level 13: segmental
  • Level 14: subsegmental
• Ipsilateral involvement (N1 disease)

Question 24

Cervical mediastinoscopy allows sampling of which LN stations?

Answer 24

Levels 2, 4, 7

• N2 disease (ipsilateral LN involvement)
• N3 dieaese (contralateral LN involvement)

Question 25

LN levels sampled by Chamberlain procedure (anterior mediastinoscopy)

Answer 25

Levels 2,4,5,6,7

Question 26

LN levels sampled by EBUS

Answer 26

Levels 1, 2,3,4,7,10,11

Question 27

Can be used to sample Level 8 LN

Answer 27

EUS

Question 28

Number and distribution of bronchopulmonary segments in RIGHT LUNG

Answer 28

* 10 total segments * RUL=3 * apical, anterior, posterior * RML=2 * medial, lateral * RLL=5 * superior segmental * basilar (anterior, posterior, medial, lateral)

Question 29

Number and distribution of bronchopulmonary segments in LEFT LUNG

Answer 29

* 8 total segments * LUL = 4 * Apicoposterior * Anterior * Superior lingular * Inferior lingular * LLL=4 * Superior segment * Basal segments * Anteromedial * Posterior * Lateral

Question 30

Course of RIGHT MAIN PA

Answer 30

Behind aorta and SVC and anterior to right main bronchus

Question 31

Braches of Right Main PA

Answer 31

* RUL: * Trucus anterior (anterior and posterior segments) * Posterior ascending * RML: * Middle lobe branch at level of fissure * RLL: * Superior segmental branch (arrising posteriorly at level of RML artery) * Medial basal branch * Common basal trunk

Question 32

Course of Left Main PA

Answer 32

* Runs anterior to descending aorta and left main bronchus * Attached to Aorta by ligamentum arteriosum (left recurrent LN)

Question 33

Typical branch pattern of Left Main PA

Answer 33

* LUL: 4 branches (range 2-7) * Anterior * Apical * Several posterior * Lingula branch (arises anteriorly, single supply to linguala in 80% of pts) * LLL: * Superior segmental branch (arises posteriorly, usually proximal to lingula b) * Common basal trunk

Question 34

Anatomical relationships of Right Pulmonary Veins

Answer 34

* Right superior pulmonary vein * Crosses anterior to bronchus intermedius * 3 branches to RUL (apical, anterior, posterior) * Single branch to RML * Right inferior pulmonary vein * Superior segmental vein * Common basal vein

Question 35

Anatomical relationships of Left Pulmonary Vein

Answer 35

* Superior pulmonary vein * 3 branches: anterior, apical, lingular * Inferior pulmonary vein * Superior segmental vein (posterior to bronchus) * Common basal vein (anterior)