108 Chapter 1 • Thorax

• A central mediastinum, a compartment intervening between the horizontal and oblique fissures (Figs. 1.30B & C and

and completely separating the two pulmonary cavities, 1.31A). In cadaver dissection, the visceral pleura cannot usu-

which contains essentially all other thoracic structures— ally be dissected from the surface of the lung. It provides the

the heart, thoracic parts of the great vessels, thoracic part lung with a smooth slippery surface, enabling it to move

of the trachea, esophagus, thymus, and other structures freely on the parietal pleura. The visceral pleura is continu-

(e.g., lymph nodes). It extends vertically from the superior ous with the parietal pleura at the hilum of the lung, where

Th
thoracic aperture to the diaphragm and anteroposteriorly
from the sternum to the thoracic vertebral bodies.
structures making up the root of the lung (e.g., bronchus and
pulmonary vessels) enter and leave the lung (Fig. 1.30C).

ieLungs, and
Pleurae,
The parietal pleura lines the pulmonary cavities, thereby
adhering to the thoracic wall, mediastinum, and diaphragm.

Tracheobronchial Tree p It is thicker than the visceral pleura, and in surgery and in
cadaver dissections, it may be separated from the surfaces it

Each pulmonary cavity Teru

(right and left) is lined by a pleural covers. The parietal pleura consists of three parts—costal,

mediastinal, and diaphragmatic—and the cervical pleura.

IIruary
membrane (pleura) that also reflects onto and covers the

external surface of the lungs occupying the cavities (Fig. The costal part of the parietal pleura (costovertebral

1.30B & C). To visualize the relationship of the pleurae and or costal pleura) covers the internal surfaces of the thoracic
a

lungs, push your fistvijuvelaiz

into an underinflated balloon (Fig. wall (Figs. 1.30B & C and 1.32). It is separated from the

1.30C). The inner part of the balloon wall (adjacent to your internal surface of the thoracic wall (sternum, ribs and costal
fist, which represents the lung), is comparable to the visceral cartilages, intercostal muscles and membranes, and sides of

É
pleura; the remaining outer wall of the balloon represents the thoracic vertebrae) by endothoracic fascia. This thin, extra-

D
parietal pleura. The cavity between the layers of the balloon,
here filled with air, is analogous to the pleural cavity, although
pleural layer of loose connective tissue forms a natural cleav-
age plane for surgical separation of the costal pleura from the

Dananlougous
the pleural cavity contains only a thin film of fluid. At your thoracic wall (see the blue box “Extrapleural Intrathoracic

raistche the root of the lung), the inner and outer

wrist (representing Surgical Access,” p. 96).

walls of the balloon are continuous, as are the visceral and The mediastinal part of the parietal pleura (medias-

gets

parietal layers of pleura, together forming a pleural sac. Note tinal pleura) covers the lateral aspects of the mediastinum,

that the lung is outside of but surrounded by the pleural sac, the partition of tissues and organs separating the pulmonary

just as your fist is surrounded by but outside of the balloon. cavities and their pleural sacs. It continues superiorly into the
The inset in Figure 1.30C is also helpful in understanding root of the neck as cervical pleura. It is continuous with costal

pleura anteriorly and posteriorly and with the diaphragmatic

the development of the lungs and pleurae. During the embry-

pleura inferiorly. Superior to the root of the lung, the medi-

onic period, the developing lungs Ivajinairy
invaginate (grow into) the

pericardioperitoneal canals, the precursors Osient

of the pleural astinal pleura is a continuous sheet passing anteroposteriorly

Kemoshesh
cavities. The invaginated coelomic epithelium covers the pri- between the sternum and the vertebral column. At the hilum

Gotilamik
mordia of the lungs and becomes the visceral pleura in the of the lung, it is the mediastinal pleura that reflects laterally

same way that the balloon covers your fist. The epithelium onto the root of the lung to become continuous with the vis-

lining the walls of the pericardioperitoneal canals forms the ceral pleura.

Oi

parietal pleura. During embryogenesis, the pleural cavities The diaphragmatic part of the parietal pleura (dia-
become separated from the pericardial and peritoneal cavities. phragmatic pleura) covers the superior (thoracic) surface of

the diaphragm on each side of the mediastinum, except along

its costal attachments (origins) and where the diaphragm is

PLEURAE

fused to the pericardium, the fibroserous membrane sur-

Each lung is invested by and enclosed in a serous pleural rounding the heart (Figs. 1.30B & C and 1.32). A thin, more

sac that consists of two continuous membranes: the visceral elastic layer of endothoracic fascia, the phrenicopleural

pleura, which invests all surfaces of the lungs forming their fascia, connects the diaphragmatic pleura with the muscular

shiny outer surface, and the parietal pleura, which lines the fibers of the diaphragm (Fig. 1.30C).
pulmonary cavities (Fig. 1.30B & C). The cervical pleura covers the apex of the lung (the part

The pleural cavity—the potential space between the lay- of the lung extending superiorly through the superior tho-

ers of pleura—contains a capillary layer of serous pleural racic aperture into the root of the neck—Figs. 1.30B & C

fluid, which lubricates the pleural surfaces and allows the and 1.31A). It is a superior continuation of the costal and

layers of pleura to slide smoothly over each other during res- mediastinal parts of the parietal pleura. The cervical pleura

piration. The surface tension of the pleural fluid provides the forms a cup-like dome (pleural cupula) over the apex that

cohesion that keeps the lung surface in contact with the tho- reaches its summit 2–3 cm superior to the level of the medial

racic wall; consequently, the lung expands and fills with air third of the clavicle at the level of the neck of the 1st rib. The

when the thorax expands while still allowing sliding to occur, cervical pleura is reinforced by a fibrous extension of the

much like a film of water between two glass plates. endothoracic fascia, the suprapleural membrane (Sibson
The visceral pleura (pulmonary pleura) closely covers fascia). The membrane attaches to the internal border of the

the lung and adheres to all its surfaces, including those within 1st rib and the transverse process of C7 vertebra (Fig. 1.30C).

Chapter 1 • Thorax 109

Common carotid artery

Apex of left lung

Internal jugular vein covered by cervical pleura

(pleural cupula)
Subclavian artery

Right and left

Subclavian vein sternal lines of

pleural reflection

1st rib

Left lung (covered

4th rib with visceral pleura)

Horizontal fissure

Cardiac notch

Right lung of left lung

(covered with

visceral pleura)
Oblique fissure

Bare area of
6th rib

pericardium
Oblique fissure

Apex of

Right vertebral heart

line of pleural

reflection Lingula (of superior

lobe)
Costal

attachment Left costal line

of pleural reflection

of diaphragm

10th rib Vertebra (T12)

Vertebral attachment

(A) Anterior view of diaphragm Lines of (parietal) pleural reflection

Outline of heart (pericardium)

Costomediastinal

recesses

2 2

4 4

6 6
10 8

8 8
10 12

Visceral pleura 12

10 10 (lungs)

Costodiaphragmatic Parietal pleura Costodiaphragmatic Costodiaphragmatic

recesses recesses recesses

(B) Anterior view (C) Posterior view (D) Lateral view

FIGURE 1.31. Relationship of thoracic contents and linings of thoracic cage. A. The apices of the lungs and cervical pleura extend into the neck. The left
sternal reflection of parietal pleura and anterior border of the left lung deviate from the median plane, circumventing the area where the heart is, lies adja-

cent to the anterior thoracic wall. In this “bare area” the pericardial sac is accessible for needle puncture with less risk of puncturing pleural cavity or lung.

B–D. The shapes of the lungs and the larger pleural sacs that surround them during quiet respiration are demonstrated. The costodiaphragmatic recesses,

not occupied by lung, are where pleural exudate accumulates when the body is erect. The outline of the horizontal fissure of the right lung clearly parallels
the 4th rib. The ribs are identified by number.

The relatively abrupt lines along which the parietal pleura pulmonary cavities are asymmetrical (i.e., are not mirror

changes direction as it passes (reflects) from one wall of the images of each other) because the heart is turned and extends

pleural cavity to another are the lines of pleural reflection toward the left side, imposing on the left cavity more markedly

(Figs. 1.31 and 1.32). Three lines of pleural reflection outline than on the right.
the extent of the pulmonary cavities on each side: sternal, Deviation of the heart to the left side primarily affects the

costal, and diaphragmatic. The outlines of the right and left right and left sternal lines of pleural reflection, which are

110 Chapter 1 • Thorax

Sternal reflection of right pleura

Bare area of pericardium

Internal thoracic vessels

Sternal reflection of left pleura

Costomediastinal recess Transversus thoracis muscle

Fat pad Diaphragmatic part*

External oblique

Left phrenic nerve

Right phrenic nerve

Pericardial sac fused

with central tendon

Inferior vena cava

Central tendon

Central tendon
of diaphragm

Thoracic duct

Esophagus
Azygos vein

Aorta
Splanchnic

nerve
Diaphragmatic

part* Sympathetic

trunk

Costodiaphragmatic

recess Latissimus dorsi m.

Costal part*

* of parietal pleura Serratus posterior inferior m.

Superior view

FIGURE 1.32. Diaphragm, base of pulmonary cavities and mediastinum, and costodiaphragmatic recesses. Most of the diaphragmatic pleura has been

removed. At this level, the mediastinum consists of the pericardial sac (middle mediastinum) and the posterior mediastinum, mainly containing the esoph-

agus and aorta. The deep groove surrounding the convexity of the diaphragm is the costodiaphragmatic recess, lined with parietal pleura. Anteriorly at this

level, the pericardium and costomediastinal recesses and, between the sternal reflections of pleura, an area of pericardium only (the bare area) lie between

the heart and the thoracic wall.

asymmetrical. The sternal lines are sharp or abrupt and left costal line begins at the midclavicular line; otherwise,

occur where the costal pleura is continuous with the medi- the right and left costal lines are symmetrical as they proceed

astinal pleura anteriorly. Starting superiorly from the cupulae laterally, posteriorly, and then medially, passing obliquely
(Fig. 1.31A), the right and left lines of sternal reflection run across the 8th rib in the midclavicular line (MCL) and the

inferomedially, passing posterior to the sternoclavicular joints 10th rib in the midaxillary line (MAL), becoming continuous

to meet at the anterior median line (AML), posterior to the posteriorly with the vertebral lines at the necks of the 12th ribs

sternum at the level of its sternal angle. Between the levels of inferior to them.

costal cartilages 2–4, the right and left lines descend in con- The vertebral lines of pleural reflection are much

tact. The pleural sacs may even slightly overlap each other. rounder, gradual reflections and occur where the costal pleura

The sternal line of pleural reflection on the right side contin- becomes continuous with the mediastinal pleura posteriorly.

ues to pass inferiorly in the AML to the posterior aspect of the The vertebral lines of pleural reflection parallel the vertebral

xiphoid process (level of the 6th costal cartilage), where it turns column, running in the paravertebral planes from vertebral

laterally (Fig. 1.31). The sternal line of reflection on the left side, level T1 through T12, where they become continuous with

however, descends in the AML only to the level of the 4th the costal lines.
costal cartilage. Here it passes to the left margin of the ster- The lungs do not fully occupy the pulmonary cavities during

num and continues inferiorly to the 6th costal cartilage, cre- expiration; thus the peripheral diaphragmatic pleura is in con-

ating a shallow notch as it runs lateral to an area of direct tact with the lowermost parts of the costal pleura. The potential

contact between the pericardium (heart sac) and the anterior pleural spaces here are the costodiaphragmatic recesses,

thoracic wall. This shallow notch in the pleural sac, and the pleura-lined s“gutters,” which surround the upward convexity of

“bare area” of pericardial contact with the anterior wall, are the diaphragm inside the thoracic wall (Figs. 1.30B and 1.32).

important for pericardiocentesis (see blue box, “Pericardio- Similar but smaller pleural recesses are located posterior to

centesis,” in this chapter). the sternum where the costal pleura is in contact with the

The costal lines of pleural reflection are sharp contin- mediastinal pleura. The potential pleural spaces here are the

uations of the sternal lines, occurring where the costal pleura costomediastinal recesses. The left recess is larger (less

becomes continuous with diaphragmatic pleura inferiorly. The occupied) because the cardiac notch in the left lung is more
right costal line proceeds laterally from the AML. However, pronounced than the corresponding notch in the pleural sac.

because of the bare area of pericardium on the left side, the The inferior borders of the lungs move farther into the pleu-

Chapter 1 • Thorax 111

ral recesses during deep inspiration and retreat from them monary cavities. They are also elastic and recoil to approxi-

during expiration. mately one third their size when the thoracic cavity is opened

(Fig. 1.30C). The lungs are separated from each other by the

LUNGS mediastinum. Each lung has (Figs. 1.33 and 1.34)

The lungs are the vital organs of respiration. Their main • An apex, the blunt superior end of the lung ascending
function is to oxygenate the blood by bringing inspired air above the level of the 1st rib into the root of the neck that

into close relation with the venous blood in the pulmonary is covered by cervical pleura.

capillaries. Although cadaveric lungs may be shrunken, firm • A base, the concave inferior surface of the lung, opposite

or hard, and discolored, healthy lungs in living people are the apex, resting on and accommodating the ipsilateral

normally light, soft, and spongy, and fully occupy the pul- dome of the diaphragm.

Apex Apex

Oblique

Horizontal
fissure
Superior lobe Anterior border

fissure
Superior

Superior
Oblique
lobe
Superior fissure

lobe
lobe
Oblique
Horizontal fissure

fissure

Middle Middle
Inferior
Cardiac lobe

lobe notch
lobe

Inferior Inferior Cardiac

Inferior lobe notch

lobe
lobe Inferior border
Oblique Lingula

fissure

RIGHT LUNG LEFT LUNG

(A) Anterior view (B) Lateral views

Right vagus nerve Trachea

Apex of left lung

Left vagus nerve

Superior lobe Phrenic nerve

of right lung
Origin of left recurrent

laryngeal nerve

Costal surface Superior lobe of left lung

of right lung
Root of lung

Horizontal
Parietal layer of
serous pericardium

fissure

Middle lobe Fibrous pericardium

of right lung

Oblique fissure
Oblique fissure

Mediastinal surface

Inferior lobe
of lung
of right lung

Inferior lobe of left lung

Costal part of
Costodiaphragmatic

parietal pleura
recess

Diaphragm

(C) Anterior view

FIGURE 1.33. Costal surfaces of lungs. The lungs are shown in isolation in anterior (A) and lateral views (B), demonstrating lobes and fissures. C. The

heart and lungs are shown in situ. The left lung is retracted from the heart (covered by fibrous pericardium) revealing the phrenic nerve as it passes anterior

to the root of the lung, while the vagus nerve (CN X) passes posterior to the root. The superior lobes of the left lungs in B and C are variations that have nei-
ther a marked cardiac notches nor lingulae.