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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. 2.130 Fluoroscopy and
EBUS (1)
Fig. 2.131 Fluoroscopy and
EBUS (2)
2 Actual Identication ofBronchial Branch
Fig. 2.132 Fluoroscopy and
EBUS (3)
Fig. 2.133 Fluoroscopy
cranial
caudal
Left
2 Actual Identication ofBronchial Branch
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B3b
1+2
B
c
93
cranial
1+2
a+B
1+2
b
B
B3bi
3
B
B3bii
ventral
c
dorsal
1+2
B
3
B
bii
1+2
B
c
3
3
B
b
B
a
3
bi
B
c
B3a
row in the direction from dorsal
to ventral site
caudal
B3bi b
B3bi a
1+2
1+2
a+B
B
1+2
B
c
b
3
B
c
3
biiB3bii
3
B
B
a
Fig. 2.134 CT and bronchial branch diagram
B3c
3
bi a
B
(cranial)
3
B
bi a
(caudal)
94
cranial
caudal
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2 Actual Identication ofBronchial Branch
cranial
B3b+B3c
3
a
1+2
1+2
1+2
1+2
a+B
bB
a+B
B
1+2
B
c
b
3cB3
B
c
B3bi
3aB3
a
1+2
B
c
caudal
b
B3c
1+2cB1+2
dorsal
3
B
bii
1+2
B
c
3
3
b
B
B
a
3
B
bi
B
1+2
B
a+B
B3bi b
ventral
B3bii
B
3
B
b+B3c
3
B
a
3
B
c
B3b
B3bii
3aB3
a
B3bi a
1+2cB1+2
B
B
c
B3bi b
3
bii
B
B3c
Fig. 2.135 CT, bronchial branch diagram and bronchoscopic ndings
B3bi a
3
bi
B
B3bii
3
bi
B
2 Actual Identication ofBronchial Branch
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Fig. 2.136 Fluoroscopy and EBUS (1)
95
Fig. 2.137 Fluoroscopy and EBUS (2)
each facility. When encountering a problem in the routine
procedure repeatedly, the idea is to resolve the problem.
We cannot improve the bronchoscopic procedures when
the bronchoscopic procedures change at every
examination.
5
Left B
a (Figs. 2.150, 2.151, 2.152, 2.153 and 2.154)
Follow the reversed CT images from the cranial side to the
caudal 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
direction and B5 on the caudal direction. B5 branches into
B5a into the lateral and ventral directions and B5b in the
caudal direction. The angle between B5a and B5b is the
same angle as the direction between B4 and B5. B5a is
close to B4 and B5b is far from B4. The reason to read the
bronchus that branches horizontally, such as the lingular
segment bronchus, is to consider which bronchus to
advance close to/far from the target bronchus.
B5a branches into B5ai in the dorsal and lateral directions and
B5aii in the ventral and medial directions. B5aii enters the
lesion (Fig. 2.150).
Follow the sagittal MPR images of CT from the medial side
to the lateral side while looking from the medial direction
to the lateral direction. B
1 + 2+B3
(superior segment)
advances in the cranial direction, and B4+B5 (lingular seg-
cranial
caudal
2 Actual Identication ofBronchial Branch
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96
Left B3c
superior seg.
bronchus
B
1+2
B
1+2
B3a
B3ci
3
B
cia
B3cib
B3a
B
B
B
3
3
b+B3c
3
c
B
3
cii
B
B
cranial
3
cii
B
B3ci
1+2
B
dorsal
3
B
3
b
caudal
ventral
3
b
B
B3a
a
3
B
b+B3c
B3b+B3c
3
cii
B3cia
3
B
ciax
B3ciay
B3ci ay
B3ciay
B3ci ax
B
B3c
3
cii
B
3
B
b
3
ci b
3
B
ci ay
3
B
cii
B3ci
3
B
cia
Fig. 2.138 CT, bronchial branch diagram and bronchoscopic ndings
B3ciay
B3cib
2 Actual Identication ofBronchial Branch
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Fig. 2.139 Fluorocopy (1)
97
When the bronchial branch diagram read from the sagittal
MPR images of CT is rotated about 90° counterclockwise,
it corroborates the branching angle of the bronchus on the
bronchoscopic ndings (Fig.
2.151).
When inserting the ultrasonic probe into B5aii, the probe is
located within the lesion. The internal echo of the lesion
is heterogeneous, and hyperechoic lines are scattered;
thus, it is categorized as type IIIa (Fig.2.152).
When you pull back the probe gradually, and the transducer
is completely withdrawn into the guide sheath, the ultrasonic waves emitted from the transducer are reected by
the guide sheath, and the ultrasonic waves decrease,
making the EBUS image of the lesion dark. By establishing this phenomenon repeatedly, it can be conrmed
whether the tip of the guide sheath locates in the lesion
(Fig.2.153).
The X-ray uoroscopic image is rotated 180°. The biopsy
forceps are inserted through the guide sheath in the
working channel of the 4-mm bronchoscope, and the
biopsy is performed (Fig.2.154).
Fig. 2.140 EBUS
Fig. 2.141 Fluorocopy (2)
ment) advances in the caudal direction. B4+B5 branches
into B4 in the cranial direction B5 in the caudal direction.
B5 branches into B5a in the cranial direction and B5b in the
5
caudal direction. B
a branches into B5ai in the dorsal
direction and B5aii in the ventral direction, and B5aii
reaches the lesion.
Left S6 (Figs. 2.155, 2.156, 2.157 and 2.158)
Anatomical points of left B
6
1. Left B6 branches into B6a in the cranial direction, B6b
in the caudal and lateral directions, and B6c in the caudal and medial directions.
2. Left B6a is often branched from a common trunk with
B6b, but sometimes from B6b, or B6c.
3. When left B6c is spreading largely to the caudal side,
the area occupied by B10a is, perhaps, small.
Left B6a (Figs. 2.159, 2.160, 2.161, 2.162 and 2.163)
Follow the reversed CT images from the caudal side to the cra-
nial side. B6 branches into B6b+B6c in the caudal direction
and B6a in the cranial direction. B6a branched from B6b+B6c
advances in the dorsal direction in the bronchoscopic ndings. B
6
advances far from the basal bronchus. Here, it is essential to
think about which bronchi the bronchus is close to or far
from.
B6a branches into B6aii in the medial direction and B6ai in
the lateral direction. B6ai branches into B6aiα in the cranial direction and B6aiβ in the caudal and lateral directions. B6aiα, which branches in the cranial direction,
advances in the lung eld opposite to the basal bronchus.
6
aiβ, which branches in the caudal and dorsal directions,
B
advances in the lung eld close to the truncus basalis. The
bronchial branch close to the caudal and dorsal directions
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Fig. 2.142 Bronchial
anatomy in the left lingular
segment
2 Actual Identication ofBronchial Branch
cranial
left superior segment
4
B
a
medial lateral
B4b
5
a
caudal
B
5
b
B
front view
Fig. 2.143 Typical branching of the left lingular segment bronchus
medial
cranial
superior
segment
B4b
4
B
a
5
a
B
5
b
B
cranial
4
B
5
B
a
a
dorsalventral
B4b
5
b
B
caudal
lateral view
lateral
Fig. 2.144 Typical bronchoscopic ndings in the left lingular segment
bronchus
lower lobe
bronchus
caudal
caudal
cranial
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Left B4b
99
B4bib
B4b
B4bi
5
B
4
a
B
lateral
B4bia
B4bi b
5
B
B4bii
medial
caudal
B4bi α x
cranial
B4bii
B4bi α yy
B4a
B4bii
B4bi
B4biay
B4biayx
a
B4a
B4biay
B4bi ayx
B4bi b
5
B
4
B
biax
4
B
biayy
Fig. 2.145 CT and bronchial branch diagram
100
caudal
cranial
2 Actual Identication ofBronchial Branch
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medial
5
B
cranial
B4aB4a
B4biiB4bii
4
B
4
bi aB4bi a
B
4
bi bB4bi b
B
5B5
B
a
B4b
5
B
caudal
4
bib
B
lateral
B4bii
B4b
4
B
B
4
bi αxB4bia x
bi αB4biayy
4
B
bi
B4biiB4bii
4
B
bii
B4bi
B4aB4a
5B5
B
B4bi
B4bi αyxB4bia yx
4
B
4
B
biα
bi βB4bib
B4a
B4biay
B4biay
B4biayx
4
biax
B
B4bia
B4bib
B4bia
4
B
biayy
B4bia
Fig. 2.146 CT, bronchial branch diagram and bronchoscopic ndings
medial
lateral
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2 Actual Identication ofBronchial Branch
4+5
B
5
B
4
B
B4a
b
4
B
bi
B4aB4a
101
B4a
4
B
biaB4bia
B4bibB4bi
5
B5B
4
B
biiB4bii
b
5
B
4
b
B
B4bi
B
4
B
B
biax
4
biayx
4
biayx
B4bii
B4bi
4
B
bi
B4bi
B4bi
B4biay
B4biay
B4biayy
B4biayy
4
B
bii
B4biax
B4biayy
B4a
B4bii
B4biayx
B4bi
a
B4bib
5
B
b
B4bia
B4bib
B4bia
B4biayx
B4biayx
B4biayx
Fig. 2.147 MPR (sagittal), bronchial branch diagram, and broncho-
scopic ndings
B4bia
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