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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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62
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B
B6bii
2 Actual Identication ofBronchial Branch
Right B7b (Figs.2.87, 2.88, 2.89 and 2.90)
B6a+B6c
The CT images reversed horizontally are traced from the cra-
nial side to the caudal side. B7 runs on the ventral side of
the inferior pulmonary vein, branching into B7a in the lat-
6
b
B
eral direction and B7b in the medial direction.
B7b branches into B7bi in the dorsal and lateral directions
and B7bii in the ventral and medial directions. Two
branches of B7bi∗ considered to be the lateral branch
(daughter branch) are branched from the dorsal side and
dorsal lateral side of B7bi, respectively (see side page 19
and 20 for “lateral branch”).
6
bi
After branching B7bi∗, which is considered the lateral branch
from B7bi, B7bi branches into B7biα in the lateral and ventral directions and B7biβ in the medial and dorsal direc-
6
bii
B
tions. A probe is inserted into B7biβ.
The ultrasonic probe is inserted into B7biβ and reaches within
the lesion. Hyperechoic points and open vessels are noted,
and this EBUS image is classied as type IIb (Fig.
2.88).
The X-ray uoroscopic image is rotated 180°. The probe
reaches within the lesion, and the position (←) of the
6
B
bii
transducer at the tip of the probe is memorized on the
uoroscopic screen (Fig.2.89).
Subsequently, the biopsy forceps are inserted into the guide
sheath, and the cups of the biopsy forceps are opened and
closed at the position (←) where the transducer scans on
the X-ray uoroscopic screen (Fig.2.90).
6
bii x
B
Fig. 2.76 Bronchoscopic ndings
B
6
bii
B6bii y
Right B9a (Figs.2.91, 2.92, 2.93 and 2.94)
On the horizontally reversed CT images, the bronchi are
traced from the cranial side to the caudal side. The
right truncus basalis branches into B7, B8, and B9+B10.
B7 is running on the ventral side of the inferior pulmonary vein.
B9 branches into B9a in the dorsal and lateral directions and
B9b distributed on the ventral–medial direction.
B9a branches into B9aii in the medial direction, B9aii branches
into B9aiiα in the lateral direction, and B9aiiα branches
into B9aiiαx in the lateral direction. B9aiiαx reaches the
lesion. A 4-mm bronchoscope could be guided up to the
bifurcation between B9ai and B9aii, and a probe was
inserted into B9aii (Fig.2.91).
The ultrasonic probe is inserted into B9aii. Hyperechoic
points (→) are noted around the entire circumference of
the probe, which reaches within the lesion, and the biopsy
is performed. Hyperechoic points are observed without
2 Actual Identication ofBronchial Branch
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63
Fig. 2.77 Bronchial branch
diagram
Fig. 2.78 EBUS and
uroscopy
lateral
B6bii
B6bi
cranial
caudal
B
6
a+B6c
B
6
bii x
medial
B6bii y
open vessels, and then EBUS image is classied as type
IIa (Fig.2.92).
The probe, inserted into B9aii, reaches within the lesion, and
the position (→) of the transducer is memorized on the
X-ray uoroscopy screen. Then, a brush is inserted into
the guide sheath, and brushing cytology is performed at
the position where the transducer is rotating on the X-ray
uoroscopic screen (Fig.2.93).
Subsequently, the biopsy forceps are inserted into the guide
sheath, and a biopsy is performed, while the cups of the
biopsy forceps are opened and closed at the memorized
position (→) on the X-ray uoroscopic screen (Fig.2.94).
Right B9b (Figs. 2.95, 2.96, 2.97, 2.98, 2.99 and 2.100)
On the horizontally reversed CT images, the bronchi are
traced from the cranial side to the caudal side. The right
truncus basalis branches into B7, B8, and B9+B10. B∗ (subsuperior bronchus) branches from B9+B10 on the dorsal
side. B9 branches into B9a in the dorsal direction and B9b
in the ventral direction. B∗ is a bronchus distributed in the
area between S6 and the basal segment (details on page
71).
B9b branches further into B9bi in the lateral direction and
B9bii in the medial direction, and B9bii is followed
(Fig.2.95).
64
cranial
caudal
Right
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2 Actual Identication ofBronchial Branch
B6c
B6a
B6a
B6c
B6b
B
6
ci
6
cii
B
B6cii
caudal
B6ci
6
B
cii
6
B
medial lateral
6
a
B
b
cranial
B6cii
B6cii
B6cii
B6cii
Fig. 2.79 CT and bronchial branch diagram
B6cii
B6ci
6
B
cii
B6b
6
a
B
2 Actual Identication ofBronchial Branch
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6
B
B
B
a+B6c
6
cii
6
cii
B6cii
B6b
6
B
c
6
a
B
6
B
ci
B6cii
B6cii
65
The peripheral branch of B9bii becomes invisible, and the
accompanying pulmonary artery is traced. The pulmonary artery accompanying B9bii branches into A9biiα in
the dorsal direction and A9biiβ in the ventral direction
(Fig. 2.96). The probe is inserted into B9biiα, which
should be accompanied by A9biiα that advances in the
dorsal direction on the CT images. The tip of the bronchoscope could be inserted up to B9bii (fourth-generation
bronchus). At this situation, the bronchoscope is rotated
so that B9biiα is positioned on the orice of the working
channel of the bronchoscope, and then the probe is
inserted into B9biiα (Fig.2.96).
When the probe is inserted into B9biiα, which is branched in
the dorsal side on the CT images, the probe is adjacent to
the lesion margin. In the EBUS image, the internal echo is
uniform (homogeneous), hyperechoic points are scattered
in the lesion, and the blood vessels are recognized; thus, it
is classied as type IIb, and well-differentiated adenocarcinoma is suspected (Fig.
2.97).
While bending the tip of the bronchoscope with the up-/
down-angle lever of the bronchoscope, you might change
the position of the probe by pulling back and inserting the
probe. When the up-/down-angle lever of the bronchoscope controlled with the left hand is applied to the up
angle, the tip of the bronchoscope moves to the cranial
side on the uoroscopic image. On the X-ray uoroscopic
image rotated 180°, it is easy to operate because applying
the angle lever and movement of the tip of the bronchoscope coincides (Fig.2.98).
On the X-ray uoroscopic image, the brush inserted into
the guide sheath is extruded from the tip of the guide
sheath and brushes to recover cells. Notably, you feel
resistance when pushing the brush into the lesion for the
rst time and brush it between the same distances. In the
case of the hard lesion, such as cancer, the assistant
often feels the hard resistance while pushing out the
brush (Fig.2.99).
On the X-ray uoroscopic image, the biopsy forceps inserted
into the guide sheath are extruded from the tip of the
guide sheath. The bronchoscopist can grasp the biopsy
forceps from the surface of the guide sheath around the
opening of the working channel and open the biopsy forceps by pulling back and pushing approximately 2–3cm.
The bronchoscopist presses the opened biopsy forceps
through the working channel against the lesion. By closing the biopsy forceps slowly over about 5s, the assistant
could bite the relatively large tissue in the cups while feeling the hardness of the lesion (Fig.2.100).
Fig. 2.80 Bronchoscopic ndings
66
B
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Fig. 2.81 Bronchial branch
diagram
6
cii
medial
B6cii
2 Actual Identication ofBronchial Branch
caudal
B6ci
B6b
6
a
B
cranial
lateral
echo is homogeneous, the blood vessels are patent (→),
and the EBUS image is judged as type Ia (Fig.2.102).
The probe is inserted into B10aii, and the guide sheath is
placed at the position where the probe locates within the
lesion (→). I perform brushing cytology and biopsy at
that same place on the X-ray uoroscopic screen
(Fig.2.103).
Right B10b (Figs. 2.104, 2.105 and 2.106)
The bronchus is traced on the horizontally reversed CT
Fig. 2.82 EBUS and uoroscopy
images from the cranial side to the caudal side. B6 is
branched from the lower lobe bronchus in 5 o’clock direc-
Right B10a (Figs.2.101, 2.102 and 2.103)
The bronchus is traced on the horizontally reversed CT
images from the cranial side to the caudal side. The right
truncus basalis branches into B7, B8+B9+B10+B∗ (subsuperior segment), and B∗, which is diverged from B9+ B10
dorsally (see page 61).
B10 branches into B10a in the dorsal and lateral directions and
B10b+B10c in the ventral and medial directions, and B10a is
followed.
B10a branches into B10aii in the caudal and lateral directions
and B10ai in the cranial and medial direction. The probe is
inserted into B10aii leading to the lesion (Fig.2.101).
tion. The right truncus basalis branches into B7, B8, and
B9+B10. B10 branches into B10a in the dorsal and lateral
directions and B10b + B10c in the ventral and medial directions. B10b+B10c∗ (refer to page 19) is considered the lateral branch because the narrow branch branched off near
the right angle from B10b+B10c and the distributed area is
small.
I follow B10b, which is branched from B10b+B10c, and B10b∗
because it is a narrow branch diverging dorsally and laterally at a right angle from B10b, and its distributed area is
also small; thus, it is judged as the lateral branch. B10b
branches into B10bi in the dorsal direction and B10bii in
the ventral direction. B10bi branches into B10biα in the
10
The probe is inserted into B
10
aii, and the probe is located
dorsal direction and B
this B10biβ enters the lesion (Fig.2.104).
biβ in the caudal direction, and
within the lesion, close to the lesion margin. The internal
front view lateral view
2 Actual Identication ofBronchial Branch
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Fig. 2.83 Bronchial anatomy
in the right basal segment
B6a
67
6
a
B
6
B
b
6
B
c
7
B
10
B
a
7
b
B
c
B8b
8
B
8
B
a
9
B
a
10
b
B
9
b
B
10
B
Fig. 2.84 Typical branching of the right basal segment bronchus
ventral
B8b
B8a
B7b
B10b
B9b
B9a
medial lateral
B7a
B10c
B10a
dorsal
6
B
6
b
B
6
c
B
10
B
a
9
B
a
10
c
B
10
B
B
b
8
a
B
7
b
B
B7a
9
b
8
b
B
The bronchoscope with the outer diameter of 4mm reaches
B10b+B10c, and a probe is inserted toward B10bi. As the
probe is in contact with the lesion (adjacent to), the probe
could be guided within the lesion by inserting the probe
again. Hyperechoic points (→) are scattered, thin blood
vessels are also opened, and this EBUS image is classied
as type IIb (Fig.2.105).
The guide sheath was placed in the position within the lesion.
Brushing cytology and biopsy are performed at that site
(→) (Fig.2.106).
Fig. 2.85 Bronchial branching of the right basal segment bronchus
observed from the right lower lobe bronchus
68
1.9
I. Single stem
B
II
B
III
B
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2 Actual Identication ofBronchial Branch
8+(9+10)
, B
9+10
type
right
left
3.8
10.5
6.7
20.0
9.5
10
B
4.3
10.8
6.5
11.8
8
B
9
B
7
B
8
9
B
B
10
B
22.6
. Single stem
8+9
type
2.7
7
B
right
left
8
B
9
B
2.7
9
B
10
B
5.1
1.3
3.8
10
B
8
B
. Two stems
8+(9+10)
, B
9+10
type
right
left
7
B
8
B
10
B
1.6
3.8
2.2
1.6
9
B
5.4
B
10
B
0.6
1.3
8
B
9
Fig. 2.86 Subsuperior bronchus (Quoted from “Yamashita
H:Roentgenologic the Lung. p98, Igaku-shoin, 1978”)
Right B10c (Figs. 2.107, 2.108, 2.109 and 2.110)
The bronchus is traced on the horizontally reversed CT
images from the cranial side to the caudal side. The right
truncus basalis branches into B7, B8, B9, and B10. B10
branches into B10a in the dorsal and lateral directions and
B10b+B10c in the ventral and medial directions.
B10b+B10c branches into B10b and B10c. A narrow branch
(B10ci) branched off from B10c in the dorsal direction at
the right angle. From B10cii, the lateral branch (B10cii∗)
branched off in the 10 o’clock direction entered in the
center of the lesion (see side page 19).
From B10cii, the probe is inserted into the lateral branch
(B10cii∗) in 10 o’clock direction, which locates in the
lesion (the branching angle of B10cii∗ is 60°). By injecting
saline into B10cii, the narrow entrance of B10cii∗ could be
observed.
The bronchoscope with an outer diameter of 4mm reaches
B10cii, and a probe is inserted into the branch (B10cii∗)
considered to be the lateral branch in the 10 o’clock
direction. The probe could be guided within the lesion.
Heterogeneous internal echo, scattered hyperechoic
points, and narrow blood vessels are observed, and
then the EBUS image is classied as type IIb
(Fig.2.108).
While scanning the probe, x the probe/GS to the position
slightly proximal from the center of the lesion (the
biopsy forceps open and bite tissue 4mm ahead from the
tip of the guide sheath). Leave the guide sheath at this
position, and withdraw the probe gradually to the proximal direction. The transducer is entirely covered by the
guide sheath, the ultrasound attenuates because of the
reection of the guide sheath, and the EBUS image of
the lesion gets dark (Fig. 2.109, right gure).
Subsequently, when the probe is pushed, and the transducer of the probe exits the guide sheath, the EBUS of
the lesion becomes bright originally (Fig. 2.108, right
gure). Repeating this phenomenon establishes that the
tip of the guide sheath is located in a good position for
biopsy (Fig.2.109).
Biopsy forceps are inserted from the guide sheath left in the
lesion, and biopsy is performed (Fig.2.110).
Left superior segment (Fig.2.111)
The typical branching of the left superior segment
bronchus.
Points of the anatomy of the left superior segment bronchus
1. The left superior segmental bronchus branches into
1 + 2
B
in the dorsal direction and B3 in the ventral
direction.
cranial
caudal
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2 Actual Identication ofBronchial Branch
Right B7b
7
B
7
B
medial
B7b
69
7
a
central
B
8+B9+B10
B
lateral
7
B
7
B
B7bi
B
bii
B7bi
B7bi
7
b
B
B7bi
B7a
7
b
B
B7a
dorsal
7
bii
B
B7bi
B7bii
7
a
7
bi
B
B7bi
B7bi
B7bi
7
bi
B
B7bi
B7bi
B7bi
B7bi
B7bi
Fig. 2.87 CT, bronchial branch diagram and bronchoscopic ndings
B7bi
B7bi
B7bi
B7a
7
bi
B
B7bi
B7bi
B7bi
B7bi
B7bi
B7bi
70
2 Actual Identication ofBronchial Branch
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Fig. 2.88 EBUS
Fig. 2.89 Fluoroscopy (1)
1 + 2
2. B
c rst branches laterally and horizontally from
1 + 2
B
, and the remaining branch branches into B
heading toward the apex of the lung and B
1 + 2
1 + 2
b heading
a
toward the apex and dorsal side of the lung.
3. Similarly to the right side, left B3 branches into B3a in
the lateral and horizontal directions and B3b in the ventral and horizontal directions.
4. The difference from the right B3 is that left B3c
branches in the ventral and cranial directions
(Fig.2.112).
CT images and bronchoscopic ndings in the left superior
segment bronchus (Figs. 2.113 and 2.114)
The procedure for the reading branch of the left superior seg-
ment bronchus on the axial CT images is as follows:
1. In the left superior segment, rotate the CT images
clockwise 90° (so that the lateral chest wall is
downward).
2. Follow the bronchi to nd in which subsegment the
lesion is approximately located.
3. Trace the bronchi from the slice at the entrance of the
superior segmental bronchus to the slice in which the
lesion is located.
4. In the left B
1 + 2
a, left B
1 + 2
b, and left B3c, most bronchi
are orthogonal to the axial CT section; then, we draw
the angle of the spur at the bifurcation on the bronchial branch diagram similar to that on the axial CT
images.
5. In the left B
1 + 2
c, left B3a, and left B3b, most bronchi
are parallel to the axial CT section. We should consider whether the horizontal bronchus approaches or
leaves from the other bronchi.
Fig. 2.90 Fluoroscopy (2)
1 + 2
Left B
a (Figs. 2.115, 2.116, 2.117 and 2.118)
Because of the lesion in the left superior segment, rotate the
CT images 90° in the clockwise direction, and follow the
CT images from the caudal side to the cranial side. The
left superior segmental bronchus branches into B3 in the
ventral direction and B
Typically, B
1 + 2
branches into B
in the cranial direction. B
of the lungs and B
1 + 2
B
a had the three branches of B
1 + 2
apex, B
lateral. B
aii heading slightly lateral, and B
1 + 2
1 + 2
aiii, running in the cranial and lateral
directions, branches into B
1 + 2
and B
aiiiβ in the ventral direction.
1 + 2
in the dorsal direction.
1 + 2
1 + 2
c rst and B
a advanced toward the apex
1 + 2
a+B
1 + 2
b advanced in the dorsal direction.
1 + 2
ai toward the lung
1 + 2
aiii heading
1 + 2
aiiiα in the dorsal direction
b
B9aii x
cranial
caudal
B9aiia x
Right
2 Actual Identication ofBronchial Branch
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B9a
71
7
B
8-10
B
B8b
B8a
B
medial lateral
9B10
B
9
B
B9b
9
B
a
B9aiB9aii
ventral
8-10
B8b
8
B
7
10
B
a
7
9
B
B
B
dorsal
8
B
9
B
10
B
B9a
9
B
B9b
9
B
ai
b
B9aii
B9aii B9aii
B9aii B9aii
B9aii
9
B
B9aii y
aii x
B9aiib
Fig. 2.91 CT, bronchial branch diagram and bronchoscopic ndings
B9b
B
9
aiia
9
B
a
9
aii
B
9
B
ai
B9ai
9
B
aii
B9aii
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