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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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52
2 Actual Identication ofBronchial Branch
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Fig. 2.54 Fluoroscopy (1)
Fig. 2.56 Fluoroscopy (2)
Fig. 2.55 EBUS
B4b branches into B4bi in the ventral and lateral directions
and B4bii in the caudal direction.
B4bi branches into B4biβ in the medial direction and B4biα in
the lateral direction.
B4biβ further branches into B4biβx in the cranial direction
and B4biβy in the caudal direction, and a probe is inserted
4
into the cranial branch (B
biβx) (Fig. 2.53).
The ultrasonic probe is inserted into B4biβx (Fig. 2.54).
The probe could reach within the lesion, hyperechoic points
(→) are observed, and there are patent blood vessels (→),
which is classied to type IIb and suspected of a lesion
with air in alveoli (Fig. 2.55).
A brush (left upper gure) and biopsy forceps (left bottom
gure) are inserted into the guide sheath that could reach
within the lesion, and cells and tissues are collected (Fig.
2.56).
Procedure for the reading CT anatomy of right B5 from the
axial CT images:
1. For the lesion on right B5, the CT images are reversed
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 middle lobe bron-
chus to the slice where the lesion exists, follow the
bronchus gradually.
4. Identify the bifurcation between B4 and B5 and between
B5a and B5b.
5. As B5a advances horizontally in the ventral direction
on the axial CT images, we determine in which direction the branch of B5a advances and which other bronchi are approaching/departing to the bronchus.
6. As B5b advances in the caudal direction on the axial
CT images, we think and draw the angle of the spur at
the bifurcation of bronchoscopic images, which is
similar to the angle of the spur on CT images.
Furthermore, we consider which other bronchi are
approaching/departing from the bronchus.
cranial
caudal
2 Actual Identication ofBronchial Branch
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53
One-point advice
The typical appearance of branches of right B5a and B5b on
CT images (Fig. 2.57).
B5 advanced in the medial direction branches into B5a in the
ventral and horizontal direction and B5b in the ventral and
caudal directions (Fig. 2.58).
Right B5b (Figs. 2.59, 2.60, 2.61, 2.62, 2.63, 2.64 and 2.65)
For B5b, the CT images are traced from the cranial side to the
caudal side. The right middle lobe bronchus branches into
B4 in the lateral direction and B5 in the medial direction.
B5 branches into B5a in the ventral/horizontal direction and
B5b in the caudal direction.
B5b branches into B5bi in the lateral, ventral, and caudal
directions and B5bii in the medial and caudal directions.
A probe is inserted into the caudal branch (B5biβ) of B5bi
(Fig. 2.59).
B5a
B5b
Fig. 2.57 Typical branching of the right B5a and B5b on CT images
B5a
4
B
5
B
b
a
4
b
B
The probe is inserted into B5biβ, which is the caudal branch
from B5bi, but the probe is adjacent to the lesion. I move
the tip of the bronchoscope with the up-/down-angle
lever. The probe approaches the lesion when applying the
down angle. Then, while I continue to apply the down
angle, I pull back and insert the probe. I try changing the
bronchus (Figs.
2.60, 2.61 and 2.62).
Inserting and withdrawing the probe while applying the
down angle facilitate inserting the probe into the caudal
branch and guide it within the lesion (“within”). The
guide sheath was placed at the lesion, a brush and a biopsy
forceps are inserted into the guide sheath, and brushing
cytology and transbronchial biopsy are performed at the
lesion (Figs. 2.63, 2.64 and 2.65).
The typical branching of right B6 (Figs. 2.66, 2.67, 2.68 and
2.69)
Anatomical points of right B
6
1. Right B6 branches into B6a in the cranial direction, B6b
in the caudal and lateral directions, and B6c in the caudal medial direction.
2. The right B6a often branches from the common trunk
with the B6c but could branch from either B6b or B6c.
3. When the right B6c extensively extends to the caudal side,
it is expected that the area occupied by B10a is small.
Fig. 2.58 Typical bronchoscopic branching of the right B5a and B5b
54
cranial
cranial
Right
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2 Actual Identication ofBronchial Branch
B5b
cranial
B
B5a
B5a
5
medial lateral
4
B
B5a
B
4
B
5
b
middle lobe
bronchus
caudal
B5a
4
B
B5b
5
B
b
B5a
B5b
5
B
bii
5
bi
B
4
B
5
bii
B
B5bi
B5bi
B5bii
B5bi
B5bii
B5bi
B5bi b
B5bia
B5bi b
Fig. 2.59 CT, bronchial branch diagram and bronchoscopic ndings
B5bi
B5a
4
B
B5bi b
5
B
bi a
5
B
bi b
5
bi a
B
Rotate the bronchoscope
clockwise 90º
B5bi b
2 Actual Identication ofBronchial Branch
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55
Fig. 2.60 Fluoroscopy (1): Applying the up angle
Fig. 2.61 Fluoroscopy (2): Applying the down angle
Fig. 2.63 Fluoroscopy (3): Applying the down angle
Fig. 2.64 EBUS (2): The probe is “within” the lesion
Fig. 2.62 EBUS (1): The probe is “adjacent to” the lesion
Fig. 2.65 Fluoroscopy (4): Performing a biopsy
56
Right
front view lateral view
truncus basalis
truncus basalis
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2 Actual Identication ofBronchial Branch
Fig. 2.66 Bronchial anatomy
in the right S
6
8
B
a
6
S
B6a
6
a
B
6
6
B
b
8
B
9
B
a
B
6
B
c
7
B
9
10
B
B
10
B
a
B7a
6
c
B
6
b
B
10
B
a
9
B
a
8
a
B
B8b
B
10
b
B
9
b
Fig. 2.67 Typical branching of the right B6
caudal
B6c
medial lateral
B
6
B
a
7
b
7
a
7
b
B
10
B
c
10
B
c
10
B
B
b
B
9
b
B
8
b
B
cranial
6
a
B
6
B
6
b
b
B6c
mediallateral
caudal
Fig. 2.68 Bronchial branching of right B6 looked down from the trun-
cus intermedius
cranial
Fig. 2.69 Bronchial branching of right B6 looked up from the truncus
basalis
Watching from the truncus
2 Actual Identication ofBronchial Branch
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57
intermedius using the
down-angle lever
bifurcation between
6
a + B6c and B6b
B
B6c
B6a
CT
6
ai
B
6
aii
B
6
ai
B
cranial (ventral)
medial a little
6
B
aii
caudal (dorsal)
lateral a little
B
.
.
6
b, B6c
medial
bronchoscope
6
B
ai
6
aii
B
caudal
6
B
c
cranial
6
b, B6c
B
6
B
b
lateral
Fig. 2.70 Attention on the reading CT anatomy
Bronchial branching of right B6 looked down from the trun-
cus intermedius.
Bronchial branching of right B6 looked up from the truncus
basalis.
Attention on the reading CT anatomy in the bronchi that
change the direction of the route curvedly (from the caudal direction to the cranial direction), B6a as an example
(Fig. 2.70).
1. Reverse the CT images right to left.
2. Bronchoscope advances at the entrance of B6 toward the
caudal direction and B6a toward the cranial direction.
Then, focus on the reading CT anatomy is necessary.
3. On the CT images reversed horizontally, for example,
right B6a might branch into the ventral branch and the
dorsal branch while heading toward the cranial direction
(①). B6aii (the bronchus distributed in the lung eld on
the caudal and dorsal sides of S6a) locates close to S6b
and S6c (②). B6aii is close to B6b and B6c inside B6a in the
bronchial branch diagram (④). In the bronchial branch
diagram, B6aii is adjacent to B6b and B6c inside the caudal side of B6a. B6ai (the bronchus distributed in the lung
eld on the cranial side of S6a) locates at the ventral and
cranial sides and B6aii at the dorsal and caudal sides
when observed from the cranial side on the reversed CT
images. Moreover, in the bronchoscopic view, B6ai
locates at the cranial and dorsal sides and B6aii at the
caudal and ventral sides oppositely (①, ②). Furthermore,
B6ai (the bronchi distributed in the lung eld on the cranial side of S6a) branching in the ventral side on the
reversed CT images is positioned on the cranial side
apart from B6b and B6c in the bronchial branch diagram
inside B6a (Fig.2.70).
For elucidation, we draw the bronchial branch diagram
from the cranial side (②) on the reversed CT images, and
the bronchoscope is observed from the caudal side (③).
The bronchi that branch in the ventral and cranial sides
of B6a on the reversed CT images are heading toward the
58
cranial
Right
2 Actual Identication ofBronchial Branch
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caudal
B6a
6
c
B
B6b
caudal
B6c
B6a
B6ai
6
B
B6aii
aii
medial
B6aii
(dorsal.horizontal
lateral a little)
6
c
B
6
a
B
cranial
6
c
B
.
B6b
lateral
B6b
Fig. 2.71 CT and bronchial branch diagram
cranial direction. The angle of branching in the lateral
and medial directions is drawn in the bronchial branch
diagram in the same angle as the direction in the reversed
CT images horizontally. In the example (below), B6ai,
which is marginally medial compared with B6aii on
horizontally reversed CT images, is drawn somewhat
medial from B6aii on the bronchial branch diagram (①,
④).
B6aii
B6ai
.
(cranial
medial a little)
Right B6a (Figs.2.71, 2.72, 2.73 and 2.74)
The reversed CT images horizontally are tracked from the
6
caudal side to the cranial side. B
branches into B6b in the
lateral direction, B6c in the medial and caudal directions,
and B6a in the cranial direction.
B6a branches into B6ai (a branch in a direction far from B6c)
in the cranial and slightly medial direction and B6aii (a
2 Actual Identication ofBronchial Branch
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59
B6b+B6c
6
a
B
scope. B6aii in the lesion is located lateral (near B6b and
B6c) in B6a (Figs.2.72 and 2.73).
Approximately 8mL of physiological saline is administered
into the bronchus (B6a) from the working channel, and the
probe is inserted into B6aii, while the sputum is removed,
and the bronchus is widened to some extent (Fig.2.72).
The probe could be guided within the lesion and perform
several biopsies. The internal echo of the lesion is heterogeneous without hyperechoic points and lines, and it is
classied as type IIIb (Fig.2.74).
6
B
ai
Right B6b (Figs.2.75, 2.76, 2.77 and 2.78)
The reversed CT images horizontally are traced from the cra-
nial side to the caudal side. B6 branches into B6b in the
6
B
aii
lateral direction and B6a + B6c in the medial direction.
B6b branches into B6bi (far from the basal bronchus) in the
cranial and slightly lateral direction and B6bii (close to
the basal bronchus) in the caudal and slightly medial
direction (horizontal–oblique pattern). B6bii branches
into B6biiα in the lateral and slightly caudal direction
and B6biiβ in the medial and slightly cranial direction,
and B6biiβ branches into B6biiβx in the lateral and
slightly cranial direction, and B6biiβx is in the center of
the lesion.
6
B
aii
Fig. 2.72 Bronchoscopic ndings
branch close to B6c) in the dorsal, horizontal, and the
slightly lateral directions. B6aii in the lesion is located
somewhat lateral (near B6b and B6c) in B6a (the alignment
of B6aii and B6ai on the reversed CT images is reversed on
the bronchial branching diagram looked down from the
intermediate trunk in the dorsal–ventral direction). In the
branch of B6a heading from the caudal side toward the
cranial side, the alignment in the ventral–dorsal direction
of the bronchi on the bronchial branch diagram is reversed
on those on the reversed CT images (a reference to the
previous page).
The bronchial branch diagram is rotated nearly 180° to
enable comparing the bronchoscopic ndings with the
bronchial branch diagram when inserting the broncho-
The ultrasonic probe is inserted into B6biiβx going into the
lesion while rotating the hand-drawn bronchial branch
diagram 180° and comparing it with bronchoscopic ndings. As bronchoscopic ndings are observed by rotating
the bronchoscope 180°, in this case, we compared the
bronchoscopic ndings with the bronchial branch diagram rotated 180° (Figs.2.76 and 2.77).
Approximately 8mL of physiological saline is injected into
the bronchus (B6bii) from the working channel, and the
ultrasonic probe is inserted into the B6biiβx, while the
sputum is moved off. The probe could be inserted within
the lesion, and a biopsy is performed. Notably, the internal echo of the lesion is heterogeneous with hyperechoic
lines; the EBUS image of this lesion is classied as type
IIIa (Fig.2.78).
Right B6c (Figs. 2.79, 2.80, 2.81 and 2.82)
The horizontally reversed CT images were traced from the
cranial side to the caudal side. B6 branched away to B6b in
the lateral direction and B6a+B6c (common trunk) in the
medial direction. B6c branched away to B6ci (4 o’clock
direction) in the cranial and slightly lateral direction and
to B6cii (10 o’clock direction) on the caudal and slightly
medial direction (horizontal–oblique pattern) (Fig.2.79).
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2 Actual Identication ofBronchial Branch
Fig. 2.73 Bronchial branch
diagram
lateral
B6b
caudal
cranial
6
B
ai
6
aii
B
6
B
c
medial
Fig. 2.74 EBUS and
uoroscopy
B6cii branched away to B6ciiα (2 o’clock direction, close to
the truncus basalis) and B6ciiβ (8 o’clock direction, away
from the truncus basalis) in the medial and slightly cranial
direction. B
6
ciiβ was going into the lesion.
The ultrasound probe is inserted into B6ciiβ, and it reaches
the lesion (Figs.2.79 and 2.80).
Approximately 8mL of physiological saline is injected into
the bronchus (B6cii) from the working channel, and the
ultrasonic probe is inserted into the B6ciiβ, while the sputum is moved off (Figs. 2.80 and 2.81).
The probe could be induced within the lesion, and the biopsy
is performed. The internal echo of the lesion is homogeneous with patent blood vessels, and the EBUS image is
classied as type Ia (Fig. 2.82).
Right basal segment (Figs.2.83 and 2.84)
The typical branching of the right basal segment bronchus
(Fig.2.85).
Procedure for the reading CT anatomy of the right basal seg-
ment bronchus from the axial CT images is as follows:
1. Reverse the CT images right to left.
2. Follow the bronchi to nd in which subsegment the
lesion is approximately located.
3. Follow the bronchus slowly from the slice at the
entrance of the lower lobe bronchus to the slice where
the lesion is located.
4. Many bronchi diverge to the dorsal side/ventral side,
the lateral side, and the medial side orthogonal to the
axial CT slices, and the angle of the spur is handdrawn in the same direction on axial CT images.
5. In the bronchi running parallel to the direction of the
axial CT images, consider and draw the bronchus that
cranial
caudal
Right
2 Actual Identication ofBronchial Branch
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B6b
B6a
61
caudal
B6bii
B6a
B6a
B6bii
B6bii x
B6bii y
B6bii x
B6b
B6bi
B6bii
B6bii
medial
B6bii y
6
bii x
B
6
B
a+B6c
truncus basalis
6
a+B6c
B
cranial
lateral
6
B
bi
B6bii
6
B
bi
Fig. 2.75 CT and bronchial branch diagram
branches to cranial/caudal, dorsal/ventral, and lateral/
medial direction and the other bronchi approaching/
departing from the bronchus.
Subsuperior segment (S∗) and bronchus (B∗)
Sometimes areas not belonging to S6, S7, S8, S9, and S10
between S6 and the basal segment in the bilateral lower
lobes are noted (Fig.2.86).
As the area is below S6 (superior segment), it is called subsu-
perior segment (S∗); the bronchi distributed in that area
are called subsuperior bronchus (B∗). In most cases, S∗ on
the right is present in the dorsal and lateral directions,
while S∗ on the left is present in the dorsal and lateral
directions. For B∗, Yamashita [1] and Arai etal. [2] have
reported in their books. The probability of the existence
of the right B∗ was 28.1% in Yamashita’s book, 46% in
Arai’s book, whereas that of left B∗ was 29.6% in
Yamashita’s book and 28% in Arai’s. In addition, B∗ had
one or two branches, and Yamashita reported the probability of just one branch of B∗ at 22.7% on the right,
27.7% on the left, and 5.4% as the probability of two
branches of B∗ on the right and 1.9% on the left. In a comprehensive study by Yamashita, B∗ were one or two bronchi from B
8+(9 + 10)
[B8+(B9+B10) in this book], B
in this book), and B
9 + 10
(B9+ B10 in this book) distal from
8 + 9
(B8+B9
the orice of the truncus basalis and B7.
(Quoted from “Yamashita H:Roentgenologic Anatomy of
the Lung. p98, Igaku-shoin, 1978”).
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