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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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102
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2 Actual Identication ofBronchial Branch
Under the X-ray uoroscopic image rotated 180°, the ultra-
sonic probe covered with the guide sheath is inserted into
6
aiβ, and scanning is performed (Fig.2.161).
B
The probe reaches within the lesion. The internal echo is het-
erogeneous, almost no hyperechoic lines are observed,
and it is diagnosed as type IIIb (Fig.2.162).
Under the X-ray uoroscopic image, the biopsy is per-
formed through a guide sheath inserted into B6aiβ
(Fig.2.163).
Fig. 2.148 Fluoroscopy
Fig. 2.149 EBUS
on the axial CT images is close to the truncus basalis in
the bronchoscopic ndings looked down from the lower
lobe bronchus (Fig.2.159).
The bronchoscope approaches to B6 by using the up-angle
lever. B6 branches into B6b+B6c in the caudal direction
and B6a in the cranial direction.
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 direction. B6aiβ
enters the lesion (Fig.2.160).
Left B6b (Figs. 2.164, 2.165, 2.166 and 2.167)
Follow the reversed CT images from the cranial side to the
caudal side. B6 branches into B6a in the cranial direction.
B6b branches into B6bi in the lateral direction and B6bii in
the medial and caudal directions (horizontal–horizontal
pattern).
B6bi branches into B6biα in the cranial and dorsal directions
6
and B
biβ in the caudal and lateral directions (horizontal–
oblique pattern, blue dotted line). B6biβ branches into
B6biβx in the cranial direction and B6biβy in the caudal
direction (horizontal–vertical pattern). B6biβy branches
into B6biβyx in the ventral direction and B6biβyy in the
lateral direction (horizontal–horizontal pattern). B6biβyy
reached the cranial side of the lesion. The ultrasonic probe
is inserted into B6biβy (Fig. 2.164).
Three to seven: bronchial generation
On the EBUS image, hyperechoic points are observed in the
hypoechoic area from 7 o’clock to 10 o’clock around the
ultrasonic probe. The probe is adjacent to the lesion. As
hyperechoic points and blood vessels (→) are visible in
the lesion, it is diagnosed as type IIb (Fig. 2.165).
When scanning the lesion with the probe, it is essential to
memorize the position of the transducer (middle part of
the intercostal space: →) on the X-ray uoroscopic
screen; this site should be biopsied (Fig. 2.166).
Cells are collected by brushing at the previously memorized
position (middle part of the intercostal space: →)
(Fig.2.167).
crania
caudal
2 Actual Identication ofBronchial Branch
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Left B5a
l
5
B4 + B
103
cranial
5
4
4
B
B
B
mediallateral
B5a
B5a
B5a
5
b
B
5
B
b
B5a
4
B
caudal
B5aii
5
B
4
B
5
B
aii
B5ai
B5b
5
b
B
5
B
ai
5
aii
B
B5aii
B5aii
Fig. 2.150 CT, bronchial branch diagram and bronchoscopic ndings
B5ai
B5aii
5
ai
B
104
medial
lateral
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B
1+2+B3
B
4+B5
2 Actual Identication ofBronchial Branch
5
4
B
5
aii
B
B
B5ai
B
4+B5
4
B
5
B
B
B5a
B
4
B
5
b
B
B5a
5
B
b
B5ai
4
B5aii
5
b
5
B
5
aii
B
ai
B5aii
5
aii
B
4
B
5
b
B
Fig. 2.151 MPR (sagittal), bronchial branch diagram, and bronchoscopic ndings
B5ai
B5aii
5
B
ai
2 Actual Identication ofBronchial Branch
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Fig. 2.152 EBUS (1)
105
Left B6c (Figs. 2.168, 2.169, 2.170 and 2.171)
Follow the reversed CT images from the cranial side to the
caudal side. B6 branches into B6a in the cranial direction.
B6 branches into B6b in the caudal direction, and the common trunk of B6a+B6c branches B6c. The branch (B6c in
this case), which branches in the caudal direction with the
axial CT images, is located close to the basal bronchus,
that is, to the ventral direction, on the bronchoscopic ndings from the left lower lobe bronchus.
B6c branches into B6cii in the medial direction and B6ci in
the lateral direction (horizontal–horizontal pattern). B6ci
branches into B6ciα in the lateral and cranial directions
(away from the basal bronchus) and B6ciβ in the medial
and caudal directions (horizontal–oblique pattern). The
pulmonary artery accompanying B6ciα enters the lesion
(Fig. 2.168).
Fig. 2.153 EBUS (2)
Fig. 2.154 Fluoroscopy
Under the X-ray uoroscopic image, the ultrasonic probe
covered with the guide sheath is inserted into B
6
ci and
scans (Fig. 2.169).
The probe could be inserted within the lesion. As hyper-
echoic points are noted inside the lesion, it is diagnosed as
type IIb (Fig.2.170).
Under the X-ray uoroscopic image, brushing cytology is
performed via the guide sheath inserted into B6ci
(Fig.2.171).
Left basal segments (Figs. 2.172, 2.173 and 2.174)
Typical branching of the left truncus basalis.
The procedure of branch reading of left B8–B10 from the
axial CT images is as follows:
1. Reverse the CT images horizontally.
2. Follow the bronchi to nd in which subsegment the
lesion is approximately located.
3. Follow the bronchus gradually from the slice at the
entrance of the left truncus basalis to the slice where
the lesion is located.
4. Many bronchi diverge orthogonal to the axial CT
images, and we draw the angle of the spur at the bifurcation similar to that on the axial CT images.
5. For the bronchus running parallel to the axial CT
images, consider which bronchus is advancing close to
or far from another bronchus.
Bronchoscopic ndings in the left lower lobe bronchus.
106
caudal
cranial
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2 Actual Identication ofBronchial Branch
Fig. 2.155 Bronchial
anatomy in the left S
6
c
B
6
10
a
B
6
a
B
6
a
B
6
B
c
B6b
8
a
B
8
9
B
a
B
9
a
a
B
6
b
B
10
a
B
8
b
B
10
B
c
B
9
b
B
10
b
front view
Fig. 2.156 Typical branching of the left B
B6b
lateral
6
a
B
cranial
Fig. 2.157 Bronchoscopic ndings of left B6 looked down from the
left lower lobe bronchus
6
truncus basalis
6
c
B
medial
8
b
B
9
b
B
10
c
B
10
b
B
lateral view
6
B
a
6
c
medial
B
B6b
truncus basalis
caudal
Fig. 2.158 Bronchoscopic ndings of left B6 looked up from the trun-
cus basalis
lateral
caudal
cranial
Left
B6a
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6
b
B
B6c
caudal
truncus
basalis
B6b+B6c
6
B
lateral
6
b
B
6
c
B
medial
B6a
cranial
6
B
truncus basalis
B6a
B6b
6
c
B6ai
b
B
B
B6aib
B6aib
B6aib
B6a
6
ai
a
B
B6aii
B6aii
6
ai
B6aia
B6aia
Fig. 2.159 CT and bronchial branch diagram
108
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cranial
B6a
2 Actual Identication ofBronchial Branch
6
B
medial
truncus basalis
lateral
6
B
c
6
B
b
B6a
caudal
B6aii
6
ai
B
cranial
B6ai
a
B6aii
B6ai
medial
6
B
c
truncus
B
caudal
6
b
basalis
Fig. 2.160 Bronchial branch diagram and bronchoscopic ndings
lateral
6
B
ai
b
B6aia
B6aib
B6aia
Rotate the bronchoscope
counterclockwise 90º
B6aib
2 Actual Identication ofBronchial Branch
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Fig. 2.161 Fluoroscopy (1)
109
Left B8a (Figs.2.175, 2.176 and 2.177)
Follow the reversed CT images from the cranial side to the
caudal side. The left lower lobe bronchus branches into B6
in the dorsal direction. The left truncus basalis branches
into B8 and B9+B10 in the caudal direction. B8 branches
into B8b in the caudal direction and B8a in the lateral
direction. B8a branches into B8aii close to B8b in the caudal direction and B8ai in the lateral direction.
Follow the reversed CT images from the caudal side to the
cranial side. B8ai branches into B8aiβ in the ventral and
caudal directions and B8aiα in the dorsal and cranial directions (horizontal–oblique pattern). B8aiα branches into
B8aiαy (close to B8aii) in the lateral direction and B8aiαx
(far from B8aii) in the cranial side (horizontal–vertical pattern). The bifurcation of B8aiαx and B8aiαy is a branch
tracking from the caudal side to the cranial side, as
described in the case of right B6a (see pages 57–59). The
positions of B8aiαx and B8aiαy on the CT and the bronchial branch diagram become opposite (blue character).
Furthermore, B
8
aiαx branches into B8aiαxy in the lateral
and ventral directions and B8aiαxx in the medial and dorsal directions. B8aiαxx is in the center of the lesion (Fig.
2.175).
Fig. 2.162 EBUS
Fig. 2.163 Fluoroscopy (2)
Under the X-ray uoroscopy, the ultrasonic probe covered
with the guide sheath is inserted into B8aiαxx and scanned
(Fig. 2.176).
The probe could be inserted within the lesion. The internal
echo is heterogeneous, and almost no hyperechoic lines
are observed; thus, it is diagnosed as type IIIb (Fig.2.177).
Left B8b (Figs. 2.178, 2.179, 2.180 and 2.181)
Follow the reversed CT images from the cranial side to the
caudal side. The left lower lobe bronchus branches into B6
in the dorsal direction. The left truncus basalis branches
into B8 and B9+ B10, and B8 branches into B8b in the caudal direction and B8a in the lateral direction.
B8b branches into B8bi in the lateral and dorsal directions
and B8bii in the medial and ventral direction. B8bi
branches into B8biα in the dorsal and lateral directions
and B8biβ in the ventral and medial directions. B8biα
branches into B8biαx in the lateral direction and B8biαy in
the medial direction. B8biαx enters the lesion (Fig.2.178).
caudal
cranial
Left
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110
B6b
B6a
B6b+c
lateral
B6bi
B
ventral
6
a
2 Actual Identication ofBronchial Branch
6
B
bii
6
B
c
medial
B6b
6
B
B6bibyy
B6bibx
6
B
bia
B6bibx
B6b
B6bi b
B6bia
B6biby x
B6bi bx
B6bi
B6c
B6bii
B6bi b yy
6
B
bi b
B6bi α
dorsal
6
B
bi b yx
6
B
bii
B
6
bi b x
6
B
bi
6
B
bib
6
B
bia
6
B
6
B
bibx
bib
B
6
bi by
6
bii
B
Fig. 2.164 CT, bronchial branch diagram and bronchoscopic ndings
B
6
B
6
bibx
biby
2 Actual Identication ofBronchial Branch
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Fig. 2.165 EBUS
111
When the ultrasonic probe is inserted into B8biαx, the probe
could be located within the lesion (“within”). As the internal echo is heterogeneous, and many hyperechoic lines
are present inside the lesion, it is diagnosed as type IIIa
(Fig.2.179).
On the uoroscopic screen, while the probe/GS is inserted
into B8biαx, the probe/GS reaches the lesion (Fig.2.180).
After the guide sheath reached the lesion on the X-ray uo-
roscopic screen, the biopsy forceps are jabbing slightly,
the cups are opened, and biopsy of the lesion is performed
by closing the cups slowly (Fig.2.181).
Left B9a (Figs. 2.182, 2.183, 2.184, 2.185, 2.186 and 2.187)
Follow the reversed CT images from the cranial side to the
caudal side. The left truncus basalis branches into B8 and
B9+ B10. B9 branches into B9b in the caudal direction and
B9a in the lateral direction. B9a branches into B9ai in the
dorsal and cranial directions (close to B
10
, and far from
B9b) and B9aii in the ventral direction (close to B9a). The
branching of B9ai and B9aii is the horizontal–oblique pattern. B9aii branches into B9aiiα in the lateral direction and
B9aiiβ in the ventral and caudal directions (close to B9b
and B8b) (horizontal–oblique pattern). B9aiiβ enters the
lesion.
To read the bronchial branch from the axial CT images, con-
sider which other bronchi the bronchus approaches or
moves away from (Fig.2.182).
Fig. 2.166 Fluoroscopy (1)
Fig. 2.167 Fluoroscopy (2)
The truncus basalis branches into B8 and B9+B10. B9 branches
into B9b in the caudal direction and B9a in the lateral
direction. B9a branches into B9ai in the dorsal and cranial
directions (close to B10, and far from B9b) and B9aii in the
ventral direction (close to B8a). B9aii branches into B9aiiα
in the lateral direction (close to B9ai) and B9aiiβ in the
ventral and caudal directions (close to B9b and B8b)
(Fig.2.183).
The rotated bronchial branch diagram corresponds to the
bronchoscopic ndings.
When inserting the ultrasonic probe into B9aiiβ, the probe
could reach at the margin of the lesion (“adjacent to”). As
the internal echo is heterogeneous, and few hyperechoic
lines exist inside the lesion, it is diagnosed as type IIIb
(Fig.2.184).
On the uoroscopic screen, the probe is inserted into B9aiiβ
and reaches the lesion (Fig.2.185).
When the probe is inserted into B9aiiβ, the probe could reach
within the lesion (“within”). As the internal echo is heterogeneous, with no hyperechoic lines inside the lesion, it
is categorized as type IIIb (Fig.2.186).
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