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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2702_Библиотеки_им_академика_М_И_Перельмана
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Fig. 2.111 Bronchial
anatomy in the left superior
segment
2 Actual Identication ofBronchial Branch
1+2
B
a
1+2
b
B
3
c
B
1+2
c
B
3
a
B
3
b
B
front view lateral view
Fig. 2.112 Typical branching of the left superior segment bronchus
1+2
B
a
3
c
B
3
B
b
3
B
a
1+2
b
B
1+2
B
c
the position of the peripheral pulmonary lesion by the
radial-type ultrasonic probe, internal structural analysis of
EBUS, biopsy technique, which could be repeated at
accurate position using the guide sheath, and virtual bronchoscopic navigation.
What is the next step? What is necessary to catch up with
CT-guided biopsy? I think that the next steps are the
enhancement of the biopsy procedure and the development of the evaluation method of biopsy specimens.
Regarding the enhancement of the biopsy procedure, the
development of the puncture needle through the 2-mm
thin guide sheath is under way. In addition, regarding the
enhancement of the biopsy procedure, we anticipate
reducing the diameter of the convex ultrasonic bronchoscope. I would like to insert the convex ultrasonic bronchoscope in the peripheral bronchus so that the lesion
could be punctured by the needle in real time.
At present, the rapid diagnosis of cytological evaluation is
available in several facilities. However, the development
of a rapid assessment method for biopsy specimens has
2 Actual Identication ofBronchial Branch
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83
1+2
a
B
1+2
B
b
1+2
B
cB
Fig. 2.113 Left superior segment bronchus on the CT image rotated clockwise 90º
been delayed, and we still have about ve to six bronchoscopic biopsies awaiting reports with permanent
pathology. One of the complications of the bronchoscopic procedure is bleeding, which requires the utmost
1+2
a
B
1+2
b
B
B3c
3
b
B
care. Thus, one plan is to decrease the number of biopsies to decrease the risk of bleeding. Hence, I aim to
develop a method that can diagnose whether biopsied
tissue is sufcient for diagnosis during the bronchoscopic procedure.
3
c
B
3
b
B
3
a
1+2
B
c
Fig. 2.114 The typical branching of the left superior segment
bronchus using the bronchoscope
3
B
a
84
caudal
cranial
Left
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B
1+2
2 Actual Identication ofBronchial Branch
a
1+2
B
1+2
B
a+
1+2
B
b
1+2
c
B
1+2
B
b
1+2
B
ai
1+2
B
aii
1+2
aiii
B
1+2
B
aiii
1+2
B
aiii
3
B
1+2
3
B
1+2
B
b
a
cranial
1+2
aii
B
1+2
ai
B
1+2
B
b
1+2
B
a
1+2
B
c
1+2
B
aiii
3
B
ventraldorsal
+
B
B
caudal
1+2
B
c
1+2
B
1+2
aiiia
B
1+2
B
aiiib
1 2
B
ai
1 2
aii
B
1 2
B
aiiib
1+2
B
ai
a
ventral
1 2
B
aiiia
1+2
B
aiiib
dorsal
1 2
B
aiiib x
dorsal
1+2
B
aiiib
1+2
A
aiiibx
1+2
aiiiby
A
1+2
A
aiiiby
1 2
B
ventral
aiiib y
1+2
B
aii
1+2
B
aiii
1+2
B
aiiia
1+2
B
aiiib
Fig. 2.115 CT, bronchial branch diagram and bronchoscopic ndings
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85
Fig. 2.118 EBUS (2)
Fig. 2.116 Fluoroscopy
Fig. 2.117 EBUS (1)
Left B3c (Figs. 2.138, 2.139, 2.140 and 2.141)
Rotate the CT images clockwise 90°, and follow the CT images
from the caudal side to the cranial side because of the lesion
in the left superior segment. B3 branches into B3a and
B3b+B3c. B3c branches into B3ci in the dorsal and lateral
directions and B3cii in the ventral and medial directions.
B3c on the left is a bronchus corresponding to B1b on the
right. As B3ci is advancing from the caudal side to the
cranial and ventral sides (close to B
1 + 2
a + B
1 + 2
b), B3ci is
named “i.” B3ci branches into B3ciα in the cranial direc-
tion and B
3
ciβ in the lateral direction, and B3ciα further
branches in the cranial direction, and B3ciαy branches
into the lateral and ventral directions. B3ciαy enters the
lesion (Fig. 2.138).
On the X-ray uoroscopic screen, the tip of the 4-mm
bronchoscope can be inserted up to B3ci, and the ultrasonic probe/GS is inserted into B3ciα close to B3cii
(Fig. 2.139).
When inserting the probe/GS into B3ciα, the probe is adja-
cent to the lesion. The EBUS image has blood vessels
and hyperechoic short lines inside the lesion; it is diagnosed as type IIb and suspected to be relatively soft (Fig.
2.140).
From the tip of the guide sheath that reached the lesion on
the uoroscopic screen, the biopsy forceps are pushed out
slightly, and cups are opened and closed (Fig. 2.141).
Left lingular segment (Figs. 2.142, 2.143 and 2.144)
Typical branching of the left lingular segment bronchus.
The procedure for the reading branch of the left lingular seg-
ment bronchus from the axial CT images is as follows:
1. In the left lingular segment bronchus, reverse the CT
images left to right.
2. Follow the bronchi to nd in which subsegment the
lesion is approximately located.
3. From the slice at the entrance of the left lingular seg-
ment bronchus to the slice where the lesion is located,
follow the bronchus gradually.
86
caudal
cranial
Left
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B
1+2
2 Actual Identication ofBronchial Branch
b
cranial
1 2
B
1 2
B
3
B
1+2
B
b
dorsal
3
B
ventral
caudal
1 2
B
1 2
B
b
1 2
bii a
B
1 2
B
bii
1 2
B
bi
a
1 2
B
a
1+2
B
bi
close to B
1+2
a
1 2
B
bii bx
biib
1 2
B
1 2
B
Fig. 2.119 CT and bronchial branch diagram
1+2
B
a
dorsal
ventral
bi
3
B
1+2
B
bii b y
1+2
B
biia
dorsal
1+2
B
bii bx
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candal
3
B
87
ventral
B
cranial
1+2
B
a
1+2
bii b x
dorsal
1+2
B
b
3
B
1+2
B
1+2
B
bii
1+2
B
bi
1+2
a
B
1+2
bii a
B
1+2
B
bii
Fig. 2.120 Bronchial branch diagram and bronchoscopic ndings
3
B
1+2
B
bii b
1+2
a
B
1+2
B
bi
88
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Fig. 2.124 Fluoroscopy (3)
Fig. 2.121 EBUS
Fig. 2.122 Fluoroscopy (1)
Fig. 2.123 Fluoroscopy (2)
4. In the peripheral bronchi of left B4a, B4b, and B5a, several bronchi branching from the bronchi run parallel to
the CT horizontal section. We read that the horizontal
bronchus diverges to the dorsal and ventral directions,
the lateral and medial sides, and considering which
other bronchi are approaching or leaving. MPR images
are highly useful for bronchi running parallel to the
axial CT images. By tracing the cross-sectional images
of the bronchus orthogonal to the lesion, it is possible
to read the bronchial branch more accurately.
5. In the left B5b, many bronchi diverge in a direction
nearly orthogonal to the axial CT images, and the
angle of the spur at the bifurcation is drawn similar to
that on the axial CT images on the bronchial branch
diagram.
Bronchoscopic ndings of the left lingular segment
bronchus.
4
Left B
b (Figs. 2.145, 2.146, 2.147, 2.148 and 2.149)
Follow the reversed CT images from the caudal side to the
cranial side. Observing the lingular segment bronchus,
the top is the cranial side, the bottom is the caudal side,
the left is the lateral side, and the right is the medial side.
The lingular segment bronchus branches into B4 in the
cranial and lateral directions and B5 in the medial, ventral,
and caudal directions. B4 branches into B4a in the lateral,
cranial, and dorsal directions and B4b in the medial, caudal, and ventral directions. B4b branches into B4bi in the
lateral direction close to B4a and B4bii in the medial direction far from B4a. As the branching of B4bi and B4bii
exhibits a horizontal–horizontal pattern, we draw B4bi
and B4bii in the left and right. Subsequently, B4bi branches
into B4biβ in the caudal direction close to B5 and B4biα in
the cranial direction far from B5. As the branching of
B4biα and B4biβ exhibits a horizontal–vertical pattern, we
draw branches B4biα and B4biβ in the up and down direction. The reason for drawing bronchi that branch horizontally, such as the lingular segment, is to consider which
bronchus is approaching or leaving from another
bronchus.
B4biα branches into B4biαx (far from B5) in the medial and
cranial directions and B4biαy (close to B5) in the lateral
4
and ventral directions. B
biαy branches into B4biαyy in
the medial direction (far from B4a) and B4biαyx in the
lateral direction (close to B4a). As the branching of
B4biαyx and B4biαyy exhibits a horizontal–horizontal
caudal
cranial
Left
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1+2
B
c
89
cranial
1+2
a+B
ci
(caudal)
1+2
b
B
B
caudal
1+2
ciib
1+2
ci
3
B
ventral
B
dorsal
1+2
B
1 2
B
c
3
B
1+2
ciia
B
1 2
B
ci
1+2
cii
B
1+2
c
B
(cranial)
1+2
B
ciia
(dorsal)
1+2
B
ciibx
(cranial)
1+2
B
1+2
B
ci
1+2
B
ciia
1+2
B
ciibyy
1+2
B
cii
1+2
B
ciib
ciib
(ventral)
1+2
B
(dorsal)
ciibyxx
1+2
B
ciibyxy
(ventral)
1+2
ciiby
B
(caudal)
1+2
B
c
1+2
B
c
1+2
B
ci
1+2
cii
B
1+2
B
cii bx
1+2
cii by
B
1+2
ciia
B
1+2
B
B
B
B
1+2
1+2
1 2
ciibyx
ciibyxy
ciibyxx
ciibyxx
1+2
B
ciiby
1+2
B
ciibx
1 2
B
ciiby
Fig. 2.125 CT, bronchial branch diagram and bronchoscopic ndings
1+2
B
cii by
1+2
B
cii byx
1+2
B
cii byy
1+2
B
cii byx
90
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Fig. 2.126 Fluoroscopy (1)
Fig. 2.127 EBUS
ndings. The lingular segment bronchus branches into
4
a, B4b, and B5. B4b branches into B4bi and B4bii, and
B
B4bi branches into B4biα and B4biβ. After pushing the
tip of the bronchoscope to the bronchus where it cannot
be advanced further, we inject about 7mL of physiological saline into the bronchus from the working channel of
the bronchoscope to ll the lumen of the bronchus. As
retreating sputum in the bronchial lumen, it was possible
to insert the ultrasonic probe into B4biα while observing
the lumen (Fig. 2.146).
In the sagittal images of MPR, we follow the sagittal images
from the medial side to the lateral side. B5 branches in the
caudal direction; B4 branches into B4a in the cranial, lateral, and dorsal directions; and B4b branches in the cranial
and ventral directions. B4b branches into B4bii in the ventral direction and B4bi in the lateral direction. B4bi
branches into B
4
biα in the cranial direction and B4biβ in
the caudal direction.
B4biα branches into B4biαx in the cranial direction and
B4biαy in the caudal direction.
B4biαy branches into B4biαyx in the dorsal direction and
B4biαyy in the ventral direction. B4biαyx is the leading
bronchus.
The bronchoscopic ndings rotated clockwise 90° match the
bronchial branch diagram using the sagittal CT images
(Fig.2.147).
Fig. 2.128 Fluoroscopy (2)
pattern, we draw B4biαyx and B4biαyy in the left and
right. B4biαyx is the leading bronchus (Fig. 2.145).
During the bronchoscopic examination, the assistant rotates
the bronchial branch diagram to match the bronchoscopic
The screen of X-ray uoroscopy is rotated 180°. The 4-mm
bronchoscope is inserted up to B4bi where the bronchoscope cannot be pushed any further, and the ultrasonic
probe is inserted toward B4biαy of the inferior branch
from B4biα (Fig.2.148).
When inserting the probe toward B4biαy, the probe is located
within the lesion (Fig.2.149).
Column
The necessity of the procedure standardization
Steps in bronchoscopic procedures are as follows:
Pharyngeal laryngeal anesthesia
Preparation of the bronchoscope and ultrasonic probe
Intrabronchial observation
Insertion of the bronchoscope into the leading bronchus
Intrabronchial injection of physiological saline
Scan by the ultrasonic probe
Leave the guide sheath in situ
Brushing and biopsy
At every step, I try to stick to the standardized technique. The
standardization of these procedures should be decided at
caudal
cranial
Left
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B3a
91
B
3
B
B
B
3
ai b y
B
A3aiβ yx
1+2
B3a
B3ai
ai a
3
ai b
3
ai b
B
B3ai b
3
ai b y
B
3
b+B3c
B3aii
B3aii
cranial
3
B
B3c
3
b
B
3
aii(ventral)
B
ventral
dorsal
1+2
B
3
B
ai(dorsal)
caudal
3
B
3
B
aiby
aibx
3
aii
B
1+2
3
B
B
5
4
B
B
1+2
B
B
3
b+B3c
3
B
B3a
B3aia
3
aii
B
3
aib
B
3
ai
B
3
aib y
3
B
aib yy
B
3
ai b
B
B3ai b x
3
ai b yy
B
B3ai b yy
Fig. 2.129 CT, bronchial branch diagram and bronchoscopic ndings
B
B
3
ai a
3
ai b x
3
B
B
ai b y
3
ai b y
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