Department of Human Anatomy, Operative

surgery and Topographic Anatomy

YHU
 The Thorax (Chest)

It Is the region of the body between the neck and the abdomen.
The framework of the walls of the thorax (thoracic cage) is formed:

Posteriorly by the thoracic part of the vertebral column;

Anteriorly by the sternum and costal cartilages;

Laterally by the ribs and intercostal spaces;

Superiorly by the suprapleural membrane;

Interiorly by the diaphragm which separates the thoracic cavity from the
abdominal cavity
 Borders and orientation lines of the thorax:
Superior aperture:
- Anterior: Upper border of the manubrium sterni.
- Posterior: Superior surface of the body of the 1st thoracic vertebra.
- Bilateral: 1st rib with its cartilage.
· Inferior aperture:
- Anterior: Infrasternal angle between the 2 costal margins.
- Posterior: Inferior surface of the 12th thoracic vertebra.
- Bilateral:
- Costal margin formed by cartilages of the 7th to 10th ribs.
- 11th and 12th ribs.
The thorax (or chest)
 Orientation lines:
It is necessary for description of wound and organs which are
situated in the thorax

Anterior median line (linea mediana anterior) - Directed on the middle of the sternum.
- Right and left sternal lines (linea sternalis dextra et sinistra) - Directed along the edge of
the sternum.
- Right and left parasternal lines (linea parasternalis dextra et sinistra) - Directed on the
middle between the sternum and midclavicular line.
- Right and left midclavicular lines (linea mediaclavicularis dextra et sinistra) - Directed on
the middle of the clavicle and through the nipple.
- Right and left anterior axillary lines (linea axillaris anterior dextra et sinistra) - Directed
on the anterior edge of the axillary cavity.
- Right and left midaxillary lines (linea axillaris media dextra et sinistra) - Directed through
the middle of the axillary cavity.
- Right and left posterior axillary lines (linea axillaris posterior dextra et sinistra) - Directed
on posterior edge of the axillary cavity.
- Right and left scapular lines (linea scapularis dextra et sinistra) - Directed through the
scapular angle.
- Right and left paravertebral lines (linea paravertebralis dextra et sinistra) - Directed between
the scapular and posterior median lines.
- Posterior median line (linea mediana posterior) - Directed along the vertebral spinal processes
Orientation lines:
Thoracic Cavity
 Layers and intercostal spaces of the thoracic wall
Conventionally there are three layers of the thoracic wall:
- Superficial layer (skin; subcutaneous fatty tissue with the superficial
blood vessels and nerves; superficial fascia with the mammary glands);
- Medium layer (investing, or pectoral, fascia; muscles);
- Deep layer (bones of the thoracic cage; intercostal spaces; internal
thoracic vessels; transverses thoracic muscles; visceral, or endothoracic,
fascia;
Superficial layer of the thoracic wall:
- The skin of the anterior thoracic areas is thin and mobile, but behind it is thicken.
- The superficial fascia is composed of loose connective tissue.
- The hypodermis contains a variable amount of fat, sweat glands, blood and lymphatic vessels
and nerves. Some blood vessels and nerves are forms the neurovascular fascicles,
which provide the blood supply of the superficial soft tissues:
- lateral thoracic artery and veins, long thoracic nerve;
- superior thoracic artery and veins, supraclavicular nerves;
- thoracoacromial artery and veins, lateral pectoral nerve;
- cutaneous branches from the intercostal nerves and vessels.
Medium layer of the thoracic wall:
- The investing, or pectoral fascia is thin but is usually dense and loosely attached to the
superficial fascia.
- It forms an envelope, deep to the superficial fascia, which is adherent to the underlying
muscles and constitutes their covering, called epimysium.
- The pectoral fascia can be separated only by sharp dissection because the epimysium sends
septa into the muscles.
- This fascia covers the muscles up to their attachment to bone (e g., the sternum and ribs)
and is itself attached to the periosteum of bones.
- The part of investing fascia between the clavicle and the upper edge of pectoralis minor
muscle is named clavipectoral.
 Muscles:

The muscles of the may be divided into the extrinsic and intrinsic
groups.
- : They have either their origins or insertions on the bony thorax.
- Pectoralis major, trapezius, serratus anterior, latissimus
dorsi, levator scapulae, rhomboideus major, rhomboideus minor, serratus posterior
superior, serratus posterior inferior muscles
- : Rectus abdominis and external oblique muscles.
- : Erector spinae muscle In addition to the muscles listed above,
a number of other muscles (of the abdomen and of the head and neck) are attached
to the margins of the 2 apertures of the thorax.
- They have both their origins and insertions on the thoracic wall
and are innervated by the thoracic nerves.
- External layer: External intercostal muscles.
- Middle layer: Internal intercostal muscles.
- Internal layer: Transverse-thoracic and innermost intercostal muscles.
Muscles:
 Intercostal spaces (Deep layer of the Thorax) and their
contents:

There are 11 intercostal spaces.

- They are wider above than below; anteriorly than posteriorly.
- The innermost intercostal muscle is lined internally by the endothoracic fascia, which
is lined internally by the parietal pleura.
Each intercostal space contains the intrinsic thoracic muscles and intercostals veins,
arteries and nerves
Intercostal spaces (Deep layer of the Thorax) and their
contents:
 Topography of the mammary gland
The breast containing mammary gland are located in the superficial fascia of the anterior thoracic wall.
Boundaries:
Superiorly-the 3-d rib
Inferiorly-the 6-7-th ribs
Medialy—the lateral border of the sternum
Lateral—Linea axillaris anterior.
Topography of the mammary gland
 Topography of the mammary gland
Function:
- Lactation.
Skeletopy:
- 3rd - 6th ribs.
Syntopy:
- Posterior: Fatty tissue, pectoralis major
- and minor muscles, intercostal muscles and ribs.
Arterial supply:
- Lateral thoracic artery.
Perforating cutaneous branches of the internal mammary artery.
- Lateral branches of the 2nd and 4th intercostal arteries.
Venous drainage:
- Axillary vein Internal mammary vein.
-Intercostal veins.
Nerve supply:
- 2nd to 5th intercostal nerves.
-Nervi pectorales medialis et lateralis
(from the brachial plexus).
-Nervi supraclaviculares (from the cervical plexus).
- Sympathetic nerves
Topography of the mammary gland
Arterial supply:
 Lymphatic drainage:
Lymphatic drainage:
Most lymph passes from the mammary gland along interlobular lymphatic vessels to a
subareolar plexus. From here and other parts of the breast, most lymph vessels follow the veins
of the breast to the axilla. Most of the lymphatic drainage (about 75%) is to the axillary lymph
nodes, mainly the pectoral group of nodes. They are located along the inferior border of the
triangular pectoralis minor muscle, which lies deep to the pectoralis major.

Groups of lymphatic nodes:

- Superficial groups: Transmammar nodes, infraclavicular nodes, Grossman s pathway to the
superior axillary nodes and Gerota’s epigastric pathway.
- Deep groups: Axillary (5 groups), pectoral, parasternal, substernal and inguinal lymph
nodes.
- The largest lymph node is called the Zorgius’ lymph node
Lymphatic drainage:
 Topography of the diaphragm
- The diaphragm is a dome-shaped muscle forming the partition between the thoracic and abdominal
cavities
- It is the chief muscle of respiration.
- The muscle fibres form the periphery of the partition.
- They arise from the circumference of the thoracic outlet and are inserted into the central
tendon (centrum tendineum).
- 3 parts (according to origin of the muscular fibres) are distinguished:
- Sternal part.
- Costal part.
- Lumbar part.

Foramen venae cavae - It transmits the inferior vena cava and right phrenic nerve.
- Hiatus esophagus - It transmits the oesophagus, vagus nerve and lower oesophageal blood
vessels.
- Hiatus aorticus - It transmits the aorta, thoracic duct and azygos vein.
- Sternocostal triangle (Morgagni’s foramen, trigonum sternocostale) - It transmits the superior
epigastric vessels.
 Topography of the diaphragm

- Acting as a respiratory 7 muscle.

- Assisting in moving lymph along the thoracic duct - “Passive lymphatic heart".

- Inferior phrenic artery.

- Superior phrenic artery.
- Branches from the superior epigastric artery.
- Lower intercostal arteries.

- Inferior phrenic vein.

- Phrenic lymph nodes.

- Mediastinal lymph nodes.
- Parasternal lymph nodes.

- Phrenic nerve.
- 7th to 12th intercostal nerves.
The diaphragm
The diaphragm
 Topographic anatomy of the chest cavity
- It contains the right and left pleural cavities which are completely invaginated and
occupied by the lungs.
- The right and left pleural cavities are separated by a thick median partition called the
mediastinum.
- The heart lies in the mediastinum.
 Pleural cavity, pericardial cavity, interpleural areas and sinuses

- The lungs are each encased in a serous sac, the pleura.

- The two sacs are separated by the mediastinum.
- The pleura consist of a parietal and a visceral layer, between which is a potential capillary
space, the pleural cavity containing a small amount of serous fluid.
Two pleural cavities-rigth and left are situated within the thoracic cavity and mediastinum
located between them.
The parietal layer of pleura can topographically subdivided into four portion: the cupola of
pleura(cupula pleurae), the costal pleura(pleura costalis), the diaphragmatic pleura(pleura
diaphragmatica), and mediastinal pleura(pleura mediastenalis).

- Costodiphragmatic triangle (the largest sinus).

- Mediastinodiaphragmatic triangle.
- Anterior and posterior costomediastinal triangles.

- 2 triangular spaces in front and behind the sternum.

Pleural cavity
 Topography of the mediastinum
- Mediastinum refers to a complex of organs situated between the mediastinal pleura. The
organs are surrounded by mediastinal fat, in which the neurovascular structure is located.
- It is divided into the anterior and posterior departments by the frontal plane drawn
posteriorly to the root of the lung.
Borders:
- Superior: Thoracic inlet.
- Inferior Diaphragm.
- Anterior: Sternum.
- Posterior: Vertebra column.
- Bilateral: Mediastinal pleura.
Classification:
- The mediastinum is divided into superior and inferior parts by an imaginary plane passing
from the sternal angle anteriorly to the lower border of the body of the 4th thoracic vertebra
posteriorly
 mediastinum
Superior Mediastinum:
- (1) Thymus, (2) large veins, (3) large arteries, (4) trachea, (5) esophagus and thoracic duct, and (6)
sympathetic trunks.

Inferior Mediastinum:
- (1) Thymus, (2) heart within the pericardium with the phrenic nerves on each side, (3) esophagus and
thoracic duct, (4) descending aorta, and (5) sympathetic trunks.

Posterior mediastinum (mediastinum posterius)

- From the anterior to posterior, (1)inferior vena cava, (2)oesophagus, (3)vagus nerve, (4)thoracic
(descending) aorta, (5)thoracic duct, (6)lymph nodes, (7)azygos and hemiazygos veins, (8)splanchnic
nerves
Topography of the mediastinum
Topography of the mediastinum
Topography of the heart
 Topography of the heart

Functions:
- Acting as a muscular pump sending blood to the arteries and receiving blood from the veins.
- Production of atrial natriuretic hormone in the right atrium.
Holotopy:
- Chest: anterior department.
Skeletopy:
- Superior and iferior: 3rd costal cartilage (or 3rd intercostal space) to 6th costal cartilage.
- Right: 1- 2.5 cm lateral to the right sternal line.
- Left: 1 cm medial to the left midclavicular line.
Syntopy:
-Superior: Superior vena cava, ascending aorta, pericardium, mam vessels, pulmonary trunk, thymus.
trachea, fatty tissue and anterior mediastinal lymph nodes .
- Inferior: Pericardium, diaphragm and interior vena cava.
- Anterior: Pericardium, lungs, pleura, sternum, retrosternal fatty space, retrosternal and
parasternal lymph nodes.
- Posterior: Pericardium, descending aorta, oesophagus, vagus nerve, thoracic duct, azygos
and hemiazygos veins, sympathetic trunk, vertebral column, fatty tissue and posterior mediastinal
lymph nodes.
- Bilateral: Pericardium, lungs, pleura and phrenic nerves.
 Topography of the heart

Arterial supply:
- Right and left coronary arteries.
Venous drainage:
- Sinus coronarius cordis.
- Venae cordis anteriores.
- Venae cordis minimae.
Lymphatic drainage:
- Anterior mediastinal nodes.
- Left tracheal nodes.
- Tracheobronchial nodes.
Nerve supply:
- Superficial cardiac plexus (from the sympathetic trunk and vagus nerve).
- Deep cardiac plexus (from the sympathetic trunk and vagus nerve).
 Topography of the pericardium
- It is
closed serous sac, which is composed of an outer fibrous layer (pericardium fibrosum)
and an inner serous layer (pericardium serosum).
- The serous layer is divided into the visceral and parietal layers.
 Topography of the pericardium
- Transverse sinus of the pericardium (sinus transversus pericardii) - It is a passage behind
the aorta and pulmonary trunk.
- Oblique sinus of the pericardium (sinus obliquus pericardii) - It is a space bounded below
and to the right by the inferior vena cava; above and to the left by the left pulmonary vein.
 Topography of the pericardium
Function:
- Producing fluid to reduce friction during the heart contraction
Holotopy:
- Chest: anterior department.
Skeletopy:
- 4th - 9th thoracic vertebrae.
- 3rd- 5th intercostal spaces.
Syntopy:
- Superior: Main vessels.
- Inferior: Diaphragm.
- Anterior: Sternum.
- Posterior: Oesophagus and descending aorta.
- Lateral: Lung and pleura.
Arterial supply:
- Pericardiophrenic artery (from the internal thoracic artery).
- Musculophrenic artery (from the internal thoracic artery).
- Pericardial branch of the bronchial artery.
- Pericardial branch of the oesophageal artery.
- Pericardial branch of the superior phrenic artery.
- Coronary artery - It supplies the visceral layer of the pericardium serosum.
Nerve supply:
- Vagus nerve.
- Phrenic nerve.
- Sympathetic trunk.
Topography of the pericardium
Topography of the lung
 Topography of the lung
Morphology:
3 surfaces:
- Diaphragmatic surface (facies diaphragmatica).
- Costal surface (facies costalis).
- Medial surface (facies medialis).
Lobes and segments:
• Right:
1. Upper lobe (lobus superior):
2. Middle lobe (lobus medius):
3. Lower lobe (lobus inferior):
•Left:
1. Upper lobe (lobus superior),
2. Lower lobe (lobus inferior).
Functions:
- Respiratory function: Gaseous exchange.
- Nun-respiratory functions:
- Participating in metabolism (water, lipid and salt with regulation of chlorine balance).
- Excretion of waste products.
- Maintaining acid-base balance in the organism.
- Participating in phagocytosis by alveolar macrophages (dust cells).
- Conversion of the angiotensinogen into the angiotensin I.
 Topography of the lung
Holotopy:
- Chest: anterior department; thoracic, pleural and pectoral cavities, covered by the pleura.
Skeletopy:
- Superior: 3-4 cm above the 1st rib (or 2-3 cm above the clavicle or 7th cervical vertebra).
-Inferior: 5th intercostal space (right), 6th rib (left).

Syntopy:
- Superior: Pleura, subclavian artery and vein.
- Inferior: Pleura, diaphragm, liver (right) and stomach (left).
-Anterior: Pleura, ribs, intercostal muscles,
- internal thoracic arteries and veins.
-Posterior:
Pleura, ribs and posterior thoracic wall.
-Medial: Pleura, root of the lung, pericardium, heart,
- mediastinum, thymus, trachea, oesophagus,
azygos and hemiazygos veins, phrenic nerve, thoracic duct,
superior vena cava, ascending
aorta, aortic arch, descending aorta,
pericardiacophrenic artery and vein.
- Lateral: Pleura, ribs and lateral thoracic wall.
Skeletopy: Topography of the root of the lung
- 5th thoracic vertebra.
Syntopy:
- Superior: Pulmonary artery.
- Inferior: Pulmonary vein.
- Middle: Bronchus.
Contents:
- Bronchi, pulmonary artery and nerves enter the lungs through this root.
- 2 pulmonary veins and lymphatic vessels leave the lungs through this root.
Topography of the root of the lung
 Operation on the Thorax
Suppurative mastitis.
Purulent processes in the breast can be located under the skin, between the lobules of the gland,
between the fascial capsule of the gland and the fascia pectoralis (retrommary mastitis).
Mastitis
 Mastitis
Surgical treatment
Respective surgical treatment depends on the depth, location and spread. Mostly radial incisions
are preferred.
Position-lies on her back
Anaesthesia-local or general
Technigue of the operation.
•When there is a superficial single abscess, the incision should be made over the area of
maximum tenderness. Incission passes through the skin and superficial fascia, the pus will well-
up. A finger is the insinuated through the incision, for broken all septa, which forming recesses.

•When the abscess cavity is quite deep, it require a containcision (contrapperture) at the most
dependent area, in the radial direction. The cavity is washed with 3% solution oh H2O2.
The wound is dried, drained by pads with hypertonic saline.

•When the abscess is in the deep layers of the inferior half of the in breast or there is a
retromammary abscess. The incision is made along the submammary fold. The pass is
evacuated, examined by a finger ,the cavityis drained.
 Mastitis
Surgical treatment
Breast examination
 Puncture of the Pleural Cavity
Indication-Patological fluid(effusion, blood, pus), or air (pneumothorax) in the pleural cavity.

Position of the patient. Sitting, the head is flexed anteriorly, the hand on the side of the
puncture is elevated.
When there is pathological fluid in the pleural cavity, the puncture is made in the VII-VIII
intercostals space between middle axillary and scapular lines.
When there is air in the pleural cavity, the puncture is made in the II-III intercostals space on
the midclavicular line.

Technique of the operation.

The side of the puncture is infiltrated with local anaesthetic solution(lidocain). The skin of the
intercostals space is elevated forming a fold by the fingers of the left hand and a large needle is
introduced along the superior margin of the inferior rib to prevent injury of the intercostals
nervs and vessels. A rubber tube is connected to the large needle. The end of the tube is
connected to the 20 ml injector by means of the a metallic cannula. When there is a lot of fluid,
not more than 1 litre can be drained at a time,in order to prevent vasomotor collapse.
Puncture of the Pleural Cavity
Puncture of the Pleural Cavity
Puncture of the Pleural Cavity
 Treatment of the Pneumothorax.
Pneumothorax is a condition when the air enters the pleural cavity.
Types of Pneumothorax-closed, open, valvular.
Treatment of the Pneumothorax
 Treatment of the Pneumothorax

Closed Pneumothorax. This condition occurs when either thoracic wall or lungs
parenchyma are injured. In both cases the are enters the pleural cavity only once- at
the time of the trauma. A small amount of the air is absorbed in 2-3 weeks and the
lung subsequently re-expand. When the lung is pressed more than in ¼ of its volume,
the air should be evacuated by pleural puncture.

Open pneumothorax. This condition occurs when the air enters the pleural cavity
through the penetrating wound in the chest wall. During the inspiration the air freely
enters the pleural cavity goes out during the expiration. The lung usually is
completely collapsed and is out of ventilation. Treatment as soon as possible
Hermetication of the chest cavity(bandage).
 Treatment of the Pneumothorax

Valvular pneumothorax. The condition is a fatal. This tipe of pneumothorax occurs as a result
of an injure either to the chest wall or to the lung. I both cases a “valve” is formed either by
the chest wall or by the lung tissue , which allows the air to pass in one direction. The air
enters the pleural cavity during inspiration, but its exit is prevented during the expiration due
to the closure of the valve. The volume of the air in the pleural cavity gradually increases with
each inspiration, thus transforming the valvular pneumothorax into the tension one. The lung
is completely collapsed and mediastinuum shifted to the opposite side.

Treatment- requires immediate intervention to save the patient life. Puncture of the chest wall
by a wide bore needle is performed to evacuation the air from the pleural cavity. Later an
occlusion bahdage is put (external valve) or dranage of the pleural cavity is
performed(internal valve). The drainage is made in the II-III intercostals space through the
midclavicular line.
Treatment of the Pneumothorax
Damage of the Chest Wall