toracele

generalitati
Toracele constituie partea superioara a trunchiului. Este alcatuit dintr-un schelet (osteotorax) si muschii care
invelesc cutia osoasa. Peretii osteo-mus-culari ai cutiei toracice circumscriu un spatiu, cavitatea toracica, in
care se gasesc viscerele toracice.

Forma sa este variabila in raport cu varsta, sexul, tipul constitutional si se modifica cu miscarile respiratorii, in
functie de particularitatile anatomice ale cutiei toracice diferentele in structura cutiei toracice au importanta
practica pentru alegerea cailor de acces chirurgical si ne dau indicii asupra topografiei organelor din interiorul
cutiei toracice. Toracele este mai inalt posterior avand cea. 30-35 cm de la vertebra T1 la T12, in timp ce
anterior are lungimea sternului, 15-l8 cm.

Prin cresterea organismului, sternul sufera o migratie caudala pana la nivelul vertebrei a treia toracice, se
diferentiaza curbura marginilor si curbura de torsiune a coastelor, asociate cu inclinarea acestora. in urma
acestor modificari apare respiratia de tip toracic care implica ridicarea si coborarea coastelor si excursiile
diafragmei care maresc cele trei diametre ale cutiei toracice. Se adancesc santurile pulmonare dupa ce copilul
incepe sa mearga, iar toracele se turteste in sens sagital si se largeste in sens transversal. Toracele copilului
se apropie de forma toracelui adult la 12 ani, apertura toracica superioara formand cu colona vertebrala un
unghi de 65 grade.
 The thoracic cavity enclosed by the
thoracic wall and the diaphragm is
subdivided into three major
compartments:
a left and a right pleural cavity, each
surrounding a lung;
mediastinum.

The two pleural cavities are totally separate from each

other (Fig. 2). Each pleura consists of two layers: a visceral
layer intimately related to the surface of the lung, and a
parietal layer lining the inner aspect of the chest wall, the
upper surface of the diaphragm and the sides of the
pericardium and medi- astinum. The two layers are
continuous in front and behind the root of the lung, but
below this the pleura hangs down in a loose fold, the
pulmonary ligament, which forms a dead-space for
distension of the pulmonary veins.
linii de referinta
Liniile de referinta care servesc la delimitarea regiunilor toracele ca si pentru
proiectia viscerelor toracice sunt simplificate dupa NA.

Linia mediana anterioara (linea mediosternalis) uneste incizura jugulara

cu procesul xifoid.

Linia medioclaviculara (linea medioclavicularis) coboara de la jumatatea

claviculei prin papila mamara.

Linia axilara se traseaza din varful axilei.

Linia mediana posterioara (linea mediodorsalis) trece vertical prin

procesele spinoase T1 si T12.

Linia scapulara (linea scapularis) trece prin marginea vertebrala a

omoplatului.
linii de referinta
Linii verticale - linia sternala (linea sternalis) este dusa prin marginile sternului, linia parasternala (linea
parasternalis) la jumatatea distantei dintre linia mediana anterioara si linia medioclaviculara, linia axilara
anterioara (linea axilaris ntralis) care porneste inferior din unghiul brahi pectoral si linia axilara posterioara
(linea axilaris dorsalis) care prelungeste in jos unghiul brahi-scapular, linia costortebrala (linea costortebralis)
care trece prin articulatiile costortebrale.

Linii orizontale - pe fata anterioara a toracelui linia claviculara, care trece prin cele doua clavicule, linia
bimamelonara, care uneste cele doua mame-Ioane, linia xifoidiana, care intersecteaza baza apen-dicelui xifoid
si linia subcostala prin punctele cele mai decli ale marginii inferioare a cutiei toracice. Oblic se duce linia
condro-sternala care trece prin dreptul articulatiilor dintre coaste si cartilajele acestora.

Posterior, linia cervicotoracica constituie limita inferioara a gatului si trece prin CVII. O linie orizontala care
trece prin extremitatile mediale ale spinei omoplatului (bispinoscapulara) corespunde rtebrei T3, iar alta care
trece prin unghiul inferior al scapu-lei (bianguloscapulara) corespunde rtebrei T12. Linia subcostala trece prin
marginea inferioara a ultimelor coaste corespunzand rtebrei L1.
coastele
The greater part of the thoracic cage is formed by the twelve pairs of ribs. Of these,
the first seven are connected anteriorly by way of their costal cartilages to the
sternum, the cartilages of the 8th, 9th and 10th articulate each with the cartilage of
the rib above (false ribs) and the last two ribs are free anteriorly (floating ribs).

Each typical rib has a head bearing two articular facets, for articulation with the
numerically corresponding vertebra and the vertebra above, a stout neck, which
gives attachment to the costotransverse liga- ments, a tubercle with a rough non-
articular portion and a smooth facet, for articulation with the transverse process of
the corresponding vertebra, and a long shaft flattened from side to side and
divided into two parts by the angle of the rib. The angle demarcates the lateral
limit of attachment of the erector spinae muscle.
sternul
The manubrium is roughly triangular in outline
and provides articulation for the clavicles and for
the first and upper part of the 2nd costal
cartilages on either side. It is situated opposite the
3rd and 4th thoracic vertebrae. Opposite the disc
between T4 and T5 it articulates at an oblique
angle at the manubriosternal joint (the angle of
Louis), with the body of the sternum (placed
opposite T5 to T8). This is composed of four parts
or sternebrae which fuse between puberty and
25 years of age. Its lateral border is notched to
receive part of the 2nd and the 3rd to the 7th
costal car- tilage. The xiphoid process is the
smallest part of the sternum and usually remains
cartilaginous well into adult life.
All ribs articulate with thoracic vertebrae posteriorly. Most ribs (from rib II to IX) have three articulations with the vertebral
column.
regiunea pectorala
The pectoral region is external to the anterior thoracic wall and anchors the upper
limb to the trunk. It consists of:

a superficial compartment containing skin, superficial fascia, and breasts; and

a deep compartment containing muscles and associated structures.

Nerves, vessels, and lymphatics in the superficial compartment emerge from the
thoracic wall, the axilla, and the neck.
The extrinsic muscles of the anterior thoracic wall are the pectoralis major (Fig. 2-17), the pectoralis
minor, the subclavius, and the serratus anterior.

The muscles of the posterior thoracic wall are the trapezius, latissimus dorsi, rhomboideus major
and minor, levator scapulae, serratus posterior superior, serratus posterior inferior, and levatores
costarum
The muscles of the pectoral region
form the anterior wall of the axilla, a
region between the upper limb and
the neck through which all major
structures pass.
Nerves, vessels, and lymphatics that
pass between the pectoral region
and the axilla pass through the
clavipectoral fascia between
subclavius and pectoralis minor or
pass under the inferior margins of
pectoralis major and minor.
The intrinsic muscles (also known as the
intercostal muscles) are arranged in three
layers: external, middle, and internal.
inervatia toracelui
anatomia mediastinului
Mediastinul reprezinta spatiul median intre cei doi pulmoni. Este o regiune
viscerala in care se gasesc strans legate intre ele organe ale aparatului cardio-
vascular respirator si digestiv, timusul, vase si ganglioni limfatici, nervi, toate
inconjurate de tesut conjunctiv mediastinal si tesut adipos reprezentat de corpul
adipos retrosternal si al spatiului subcardiac.

Superior: A plane passing obliquely upward from the suprasternal (jugular) notch to the upper
border of the first thoracic vertebra

Anterior: Manubrium

Posterior: First through fourth thoracic vertebrae

Lateral: Right and left cervical pleurae, from the cervical cupola to the pericardium

Inferior: Line drawn from angle of Louis to distinguish between T4 and T5 vertebrae
traheea

Este un tub fibrocartilaginos care continua in jos laringele si se intinde pana la nivelul vertebrei a IV-a, a V-a
toracala, cu o lungime de 11-13 cm si cu un diametru de circa 2 cm.

Ca structura traheea este alcatuita dintr-o tunica fibromusculocartilaginoasa, in grosimea careia se gasesc 6-
20 semiinele cartilaginoase, legate intre ele prin ligamente inelare.

Posterior, unind cele doua capete ale potcoavei cartilaginoase, se afla membrana traheeala, in grosimea careia
se afla muschiul traheal. Contractia acestuia micsoreaza calibrul traheei. Tunica interna este formata din
mucoasa ciliata, cu numeroase glande, specifice mucoaselor respiratorii.
arborele bronsic

o portiune extrapulmonara: cuprinde bronhiile principale si originea bronhiilor

lobare

o portiune intrapulmonara: cuprinde

ramificatiile de la bronhii segmentare pna la
bronhiolele respiratorii si alveole
anatomia plamanilor
Fiecare plaman are o forma conica, iar la examinare prezinta un apex, o baza, trei
marginii si doua suprafete.

Apexul

Are forma rotunjita si se intinde pana la baza gatului, ajungand pana la 2,5 si 4 cm
deasupra nivelului capatului sternului si a primei coaste. Artera subclavie formeaza un
sant la trecerea sa in fata pleurei, sant care se intinde deasupra si lateral de apex.

Baza plamanului

Este larga, concava si se afla deasupra suprafetei concave a diafragmului, care

separa plamanul drept de lobul drept al ficatului si plamanul stang de lobul stang al
ficatului, stomac si splina. Intrucat diafragmul se intinde mai sus pe partea dreapta
decat pe partea stanga, concavitatea de la baza plamanului drept este mai profunda
decat cea de pe partea stanga. Lateral si in spate, baza plamanului este limitata de o
margine subtire si ascutita care se proiecteaza pe o oarecare distanta in sinusul
frenico-costal al pleurei, intre coastele inferioare si insertiile costale ale diafragmului.
Baza plamanului coboara in inspir si urca in expir.
Plamanul drept, desi este mai scurt cu 2,5 cm decat cel stang, ca o consecinta a
ridicarii diafragmului datorita prezentei ficatului, este mai larg, datorita inclinarii spre
stanga a inimii; capacitatea sa totala este mai mare si cantareste mai mult decat
plamanul stang.
santurile si lobii
plamanilor
Plamanul stang este impartit in doi lobi, unul
superior si altul inferior, de o fisura interlobara,
care se intinde de la suprafata costala la cea
mediastinala a plamanului, atat desupra cat si sub
hil.

Plamanul drept este impartit in trei lobi, superior,

mijlociu si inferior de catre doua fisuri interlobare.
 Stg - Fisura incepe la suprafata mediastinala a plamanului
pana in partea superioara si posterioara a hilului si se
indreapta posterior si superioar pana la marginea
posterioara pe care o intalneste intr-un punct aflat la
aproximativ 6 cm sub apex. Se extinde anterior si
posterior deasupra suprafetei costale si ajunge la
marginea inferioara putin in spatele extremitatii anterioare,
iar traseul sau ulterior poate fi urmarit antero-posterior de-
a lungul suprafetei mediastinale pana la portiunea
inferioara a hilului.

Dr. - Directia sa este, totusi, mai verticala, si intalneste

marginea inferioara la aproximativ 7,5 cm in spatele
extremitatii anterioare. Cealalta fisura separa lobul superior
de cel mijlociu. Isi are originea in fisura anterioara, langa
marginea posterioara a plamanului si , avand un traseu
orizontal anterior, intretaie marginea anterioara la acelasi
nivel cu capatul sternal al cartilajului costal patru; la nivelul
suprafetei mediastinale poate fi urmarita posterior, pana la
hil. Lobul mijlociu, cel mai mic lob al plamanului drept, are
forma de pana si include partea inferiora a marginii
anterioare si partea anterioara a bazei plamanului.
structura
plamanilor
Plamanii sunt formati dintr-o membrana externa seroasa, un tesut areolar
subseros si substanta pulmonara sau parenchim.
Membrana seroasa este pleura pulmonara; este subtire, transparenta si imbraca
organul pana la radacina.

Parenchimul este compus din lobuli secundari, care, desi sunt in legatura
stransa intre ei prin tesut areolar interlobular, acestia sunt distincti unul de
altul.
Lobulii secundari variaza in marime, cei de la suprafata sunt mari, au forma
piramidala, cu baza intoarsa spre suprafata; cei din interior sunt mai mici si au
forme variate. Fiecare lobul secundar este format din mai multi lobuli primari, care
reprezinta unitatile anatomice ale plamanilor. Lobulii primari sunt formati din
canalul alveolar, spatiile aeriene conectate cu acestea si vasele de sange,
limfaticele si nervii care le deservesc.

Bronhiolele lobulare difera de bronhiile mai mari, prin faptul ca nu au cartilaj

si celulele epiteliului ciliat sunt de forma cubica. Bronhiolele lobulare au un
diametru de aproximativ 0,2 mm.
 cavitatile pleurale
The pleura lining the walls of the cavity
is the parietal pleura, whereas that
reflected from the mediastinum at the
roots and onto the surfaces of the lungs
is the visceral pleura. Only a potential
space normally exists between the
visceral pleura covering lung and the
parietal pleura lining the wall of the
thoracic cavity.
vasele
Artera pulmonara transporta sangele fara oxigen pana la plamani; se divide in mai
multe ramuri care insotesc fiecare ramificatie bronsica si care se termina intr-o
retea densa de capilare in peretele alveolelor. In plaman ramurile arterei
pulmonare se gasesc, de obicei, deasupra si in fata bronhiei, iar vena dedesubt.

Venele pulmonare isi au originea in capilarele pulmonare, se unesc apoi in

ramuri mai mari care strabat parenchimul pulmonar, independent de arterele
pulmonare si bronhii. Dupa ce comunica liber cu alte ramuri, formeaza vase
largi, care vor avea legaturi cu arterele si bronhiile si pe care le insotesc pana la
hilul organului. In final se varsa in atriul drept al inimii, sangele oxigenat fiind apoi
distribuit in tot organismul prin aorta.

Arterele bronhice transporta sange pentru nutritia plamanului; ele deriva din
aorta toracica sau din arterele intercostale superioare si, insotind bronhiile, sunt
distribuite glandelor bronsice si peretilor bronhiilor mari si a vaselor pulmonare.

Vena bronsica se formeaza la radacina plamanului, primind venele

superficiale si profunde corespunzatoare bronhiilor si arterelor bronsice.
The mediastinum is a thick,
flexible soft tissue partition
oriented longitudinally in a
median sagittal position. It
contains the heart, esophagus,
trachea, major nerves, and
major systemic blood vessels.
The mediastinum acts as a conduit for structures that pass completely through the
thorax from one body region to another and for structures that connect organs in the
thorax to other body regions.

The esophagus, vagus nerves, and thoracic duct pass through the mediastinum as
they course between the abdomen and neck.

The phrenic nerves, which originate in the neck, also pass through the mediastinum
to penetrate and supply the diaphragm.

Other structures such as the trachea, thoracic aorta, and superior vena cava course
within the mediastinum en route to and from major visceral organs in the thorax.
anatomia cordului
Este un organ musculocavitar, de forma conica, format din 4 camere: 2 atrii - atriul drept (AD) si atriul
stng (AS) si 2 ventriculi - ventriculul drept (VD) si ventriculul stng (VS). Cele 4 ncaperi sunt delimitate
prin septul interatrial si interventricular n cord drept si cord stng.

Cordul drept (AD + VD): > primeste snge n AD prin venele mari [vena cava inferioara (VCI) - dreneaza
sngele etajului inferior: viscere abdominale, pelvis, membre inferioare si vena cava superioara (VCS) -
dreneaza sngele etajului superior: membre superioare, cap si gt] si pompeaza sngele din VD n circulatia
pulmonara prin artera pulmonara, unde are loc hematoza (transferul gazelor respiratorii prin membrana
alveolocapilara cu oxigenarea hemoglobinei)

Cordul stng (AS + VS): > primeste snge oxigenat n AS prin venele pulmonare (4) si pompeaza sngele din
VS n circulatia sistemica prin artera aorta

Se realizeaza 2 circulatii: marea circulatie (circulatia sistemica): VS - aorta - ramuri arteriale - capilare
sistemice (distribuie sngele la tesuturi) - vene - VCS si VCI - AD, si mica circulatie (circulatia pulmonara):
VD - artera pulmonara - capilare pulmonare - venele pulmonare - AS.
RAPORTURI:
Este situat n mediastinul mijlociu si are raporturi cu plamnul stng, diafragmul (si prin intermediul diafragmului cu
fornixul gastric) si cu peretele toracic anterior.
The right border is formed
entirely by the right atrium, the
left border partly by the
auricular appendage of the left
atrium but mainly by the left
ventricle, and the inferior
border chiefly by the
rightventricle but also by the
lower part of the right atrium
and the apex of the left
ventricle.
The bulk of the anterior surface
is formed by the right ventricle
which is separated from the
right atrium by the vertical
atrioventricular groove, and
from the left ventricle by the
anterior interventricular groove.
camerele inimii
Inima umana are patru camere. Cele doua camere superioare, atriul (auriculul) drept si stng, sunt camerele
de primire a sngelui. Acestea colecteaza sngele adus de vene. Camerele inferioare ale inimii, ventriculul
stng si drept, au rolul unor pompe puternice. Ele mping sngele prin artere, de la inima catre corp.

Partea dreapta si cea stnga a inimii sunt separate una de cealalta printr-un perete de tesut (sept
interventricular).

Patru valve interioare mpiedica alunecarea inversa a sngelui. Ele se deschid usor n directia curgerii
sngelui si se nchid cnd acesta mpinge n sens invers.

Doua dintre valve se afla ntre atrii si ventricule, cunoscute ca valve atrioventriculare. Valva atrioventriculara
dreapta (tricuspida) este formata din trei fsii de tesut, n timp ce valva atrioventriculara stnga (bicuspida sau
mitrala) are numai doua. Celelalte doua valve sunt situate ntre ventricule si artere. Sunt numite valve
semilunare, deoarece fiecare este formata din trei fsii de tesut n forma de semiluna. Valva semilunara
dreapta, dintre atriul drept si artera pulmonara, se mai numeste si valva pulmonara. Cea stnga, dintre
ventriculul stng si aorta, se mai numeste si valva aortica.
structura cordului
Un sac dur, cu pereti dubli, cunoscut ca pericard, inconjoara inima. Stratul interior
al pericardului, epicardul, se afla direct pe miocard. Stratul exterior al pericardului
este lipit de osul pieptului si de alte structuri din cavitatea toracica si are rolul de a
fixa inima. Intre peretii pericardului se afla un spatiu ingust umplut cu un lichid
apos care impiedica frecarea acestora in timpul batailor inimii.

Suprafetele interioare ale camerelor inimii

sunt captusite cu o fasie subtire de tesut
lucios, alb - endocardul. Acelasi tip de tesut -
cunoscut si ca endoteliu - captuseste si
vasele de sange ale corpului, asigurand o
curgere usoara a sangelui si prevenind
formarea de cheaguri in sistemul circulator.
atriul drept
In the anatomic position, the right border of the heart is formed by the right atrium. This chamber also
contributes to the right portion of the heart's anterior surface.

Blood returning to the right atrium enters through one of three vessels. These are:

the superior and inferior venae cavae, which together deliver blood to the heart from the body;

the coronary sinus, which returns blood from the walls of the heart itself.

The interior of the right atrium is divided into two continuous spaces. Externally, this separation is indicated by
a shallow, vertical groove (the sulcus terminalis cordis), which extends from the right side of the opening of
the superior vena cava to the right side of the opening of the inferior vena cava. Internally, this division is
indicated by the crista terminalis (Fig. 3.63), which is a smooth, muscular ridge that begins on the roof of the
atrium just in front of the opening of the superior vena cava and extends down the lateral wall to the anterior lip
of the inferior vena cava.
ventriculul drept
In the anatomic position, the right ventricle forms most of the anterior surface of
the heart and a portion of the diaphragmatic surface. The right atrium is to the right
of the right ventricle and the right ventricle is located in front of and to the left of
the right atrioventricular orifice. Blood entering the right ventricle from the right
atrium therefore moves in a horizontal and forward direction.

The walls of the inflow portion of the right ventricle have numerous muscular,
irregular structures called trabeculae carneae (Fig. 3.64). Most of these are either
attached to the ventricular walls throughout their length, forming ridges, or
attached at both ends, forming bridges.

There are three papillary muscles in the right ventricle.

At the apex of the infundibulum, the outflow tract of the right ventricle, the opening
into the pulmonary trunk is closed by the pulmonary valve
atriul stang
The left atrium forms most of the base or posterior surface of the heart.

The interatrial septum is part of the anterior wall of the left atrium. The thin area or
depression in the septum is the valve of the foramen ovale and is opposite the floor of
the fossa ovalis in the right atrium.

During development, the valve of foramen ovale prevents blood from passing from the
left atrium to the right atrium. This valve may not be completely fused in some adults,
leaving a 'probe patent' passage between the right atrium and the left atrium.
ventriculul stang
The left ventricle lies anterior to the left atrium. It contributes to the anterior,
diaphragmatic, and left pulmonary surfaces of the heart, and forms the apex.

Blood enters the ventricle through the left atrioventricular orifice and flows in a
forward direction to the apex. The chamber itself is conical, is longer than the right
ventricle, and has the thickest layer of myocardium. The outflow tract (the aortic
vestibule) is posterior to the infundibulum of the right ventricle, has smooth walls,
and is derived from the embryonic bulbus cordis.

The trabeculae carneae in the left ventricle are fine and delicate in contrast to
those in the right ventricle.

In the anatomic position, the left ventricle is somewhat posterior to the right
ventricle. The interventricular septum therefore forms the anterior wall and some of
the wall on the right side of the left ventricle. The septum is described as having two
parts:
a muscular part, and
a membranous part.
 vascularizatia cordului

Inima nu este hranita de sngele ce

trece prin camerele sale (acesta
avnd o presiune mult prea mare) ci
de o retea specializata de vase,
cunoscute ca artere coronare, care
nvaluie inima ca o coroana. Circa
5% din sngele pompat n corp
patrunde n arterele coronare, care
se ramifica din aorta deasupra
punctului de iesire de ventriculul
stng. Trei artere coronare
principale - dreapta, stnga
circumflexa si stnga anterioara
descendenta - hranesc diferite
regiuni ale muschiului cardiac.
circulatia venoasa a inimii

The bulk of the venous drainage of the heart is achieved by veins which accompany
the coronary arteries and which open into the right atrium. The rest of the blood
drains by means of small veins (venae cordis minimae) directly into the cardiac cavity.
The coronary sinus lies in the posterior atrioventricular groove and opens into the
right atrium just to the left of the mouth of the inferior vena cava.
It receives: 1the great cardiac vein in the anterior interventricular groove; 2the
middle cardiac vein the inferior interventricular groove; 3the small cardiac vein
accompanying the marginal artery along the lower border of the heart;
sistemul conductor al
inimii

1. Sinuatrial (SA) node: a crescentic collection of specialized cardiac muscle fibers

within the superior end of the crista terminalis, at the junction of the superior vena cava
and right atrium

2. Atrioventricular (AV) node: an oval collection of specialized cardiac muscle fibers in the
inferior part of the interatrial septum, above the septal cusp of the tricuspid valve

3. Atrioventricular (AV) bundle (bundle of His)

mediastinul superior
timus

traheea

esofagul

arcul aortei

venele brahicefalice

VCI

nervii vagi si frenici

timusul

1. Lies between the manubrium of the sternum and the

aortic arch; usu- ally extends superiorly into the neck and
inferiorly into the anterior mediastinum
2. Appears pink and bilobular in the infant; begins to
involute around age 15 and is largely replaced by fat and
connective tissue in the adult
 arcul aortic
1. Commences near the second right sternocostal articulation and arches backward and to the
left, reaching its summit about midway up the manubrium (the ascending aorta is the short
segment that precedes the aortic arch and gives rise to the coronary arteries); its branches are
noted below
2. The brachiocephalic trunk arises from the aortic arch just proximal to its summit; ascends on
the right side of the trachea and, near the supe- rior thoracic aperture, bifurcates into the right
subclavian and right com- mon carotid arteries
3. The left common carotid artery and then the left subclavianartery arise from the summit of the
aortic arch; they ascend on the left side of the trachea with the common carotid artery lying
anterior to the subclavian artery
venele brahiocefalice
Brachiocephalic veins
1. Formed on the sides of the superior thoracic aperture by the union of the internal jugular
and subclavian veins; the left brachiocephalic vein crosses to the right along the summit of
the aortic arch and unites with the right brachiocephalic vein near the right border of the
manubrium to form the superior vena cava
2. The right brachiocephalic vein receives the right internal thoracic and supreme intercostal
veins; the left brachiocephalic vein receives the left internal thoracic, left superior
intercostal, and thymic veins

Superior vena cava: descends along the right border of the sternum; receives the azygos vein
posteriorly and enters the right atrium at about the level of the third right sternocostal
articulation
venele azygos si
hemiazygos

2. Azygos vein
a. Formedinferiorlybytheunionoftherightsubcostalandrightascend- ing lumbar veins; ascends posterior to
the esophagus and, superiorly, arches forward over the right principal bronchus to empty into the superior
vena cava
b. Receives the right posterior intercostal veins from the fifth to elev- enth intercostal spaces; right
posterior intercostal veins from the second to fourth intercostal spaces unite to form the right
superiorintercostal vein, which drains inferiorly into the azygos vein (the supreme intercostal vein drains
the right first intercostal space and empties into the right brachiocephalic vein)

3. Hemiazygos and accessory hemiazygos veins a. Hemiazygos vein

1. Formed inferiorly by the union of the left subcostal and left as- cendinglumbarveins;ascendsposterior
tothethoracicaortaand receives the left posterior intercostal veins from the eighth to eleventh intercostal
spaces
2. It crosses to the right, anterior to the body of the eighth thoracic vertebra, to empty into the azygos vein
b. Accessoryhemiazygosvein:descendsposteriortothethoracicaorta and receives the left posterior intercostal
veins of the fourth to sev- enth intercostal spaces; drains into the hemiazygos vein or crosses the vertebral
column to drain into the azygos vein (the left superior intercostal vein receives the left posterior intercostal
veins of the first to third intercostal spaces and ascends anterior to the aortic arch to drain into the left
brachiocephalicvein)
ductul toracic
1. Thin-walled, pale channel; ascends
between the thoracic aorta and azy- gos
vein, anterior to the right posterior
intercostal arteries and poste- rior to the
esophagus
2. In the superior mediastinum it lies to
the left of the esophagus, and in the base
of the neck it deviates to the left, anterior
to the left vertebral artery and vein
3. Empties into the angle of junction of
the left subclavian and left inter- nal
jugular veins; near its termination, it
receives the left jugular, left subclavian,
and left bronchomediastinal trunks
 diafragmul
The musculotendinous diaphragm seals the inferior thoracic aperture.

Generally, muscle fibers of the diaphragm arise radially, from the margins of the inferior
thoracic aperture, and converge into a large central tendon.

Because of the oblique angle of the inferior thoracic aperture, the posterior attachment of the
diaphragm is inferior to the anterior attachment.

The diaphragm is not flat; rather, it 'balloons' superiorly, on both the right and left sides, to
form domes. The right dome is higher than the left, reaching as far as rib V.
The muscular fibres are arranged in three parts. 1A vertebral part from the crura and from the arcuate
ligaments. The right crus arises from the front of the bodies of the upper three lumbar vertebrae and intervertebral
discs; the left crus is only attached to the first two verte- brae. The arcuate ligaments are a series of fibrous arches,
the medial being a thickening of the fascia covering psoas major and the lateral of fascia overly- ing quadratus
lumborum. The fibrous medial borders of the two crura form a median arcuate ligament over the front of the aorta.
2A costal part is attached to the inner aspect of the lower six ribs and costal cartilages. 3A sternal portion
consists of two small slips from the deep surface of the xiphisternum.
The diaphragm is innervated by two
phrenic nerves that originate, one on
each side, as branches of the cervical
plexus in the neck (Fig. 3.15). They
arise from the anterior rami of cervical
nerves C3, C4, and C5, with the major
contribution coming from C4.

The arterial supply to the diaphragm is

from vessels that arise superiorly and
inferiorly to it. From above,
pericardiacophrenic and
musculophrenic arteries supply the
diaphragm. These vessels are
branches of the internal thoracic
arteries.