폐엽과 폐구역의 형태 및 기관지와 폐혈관의 분포에 대한 국소해부학적 연구

Abstract

[한글]

폐엽의 경계를 이루는 폐틈새의 형태는 전산화단층사진에서 병변의 위치를 정확히 파악하는데 있어서 중요한 지표로 이용되는 관계로 이에 대한 관심이 점차 높아지고 있다. 폐구역의 형태 변이와 기관지, 폐혈관의 분지 양상 및 국소해부학적 위치관계는 폐질환을 진단하고 치료할 때 중요한 자료이나 아직 체계적인 연구가 부족한 실정이다. 따라서 이 연구에서는 한국 성인 시체의 폐 172개를 대상으로 폐문과 페틈새의 형태 변이를 관찰하였고, 폐를 해부하여 기관지와 폐혈관의 분포 및 위치관계를 조사하였으며, 구역기관지에 gelatin 용액과 섬유물감을 섞어서 만든 색소를 주입하여 폐구역의 형태를 살펴보았다.

그 결과를 간추리면 아래와 같다.

1. 폐문을 통과하는 기관지와 폐혈관이 폐뿌리에서 미리 갈라지는 경우는 오른폐가 왼폐보다 많았다. 폐틈새의 모양을 관찰한 결과, 오른폐 위엽이 중간엽과 아래엽을 외측에서 덮는 모양이 많았으며, 중간엽은 대체로 늑골면에서 좁고, 종격면에서 넓었다. 경사틈새와 수평틈새가 불완전하게 형성된 폐의 빈도는 각각 57.1∼59.4%와 58.5%였으며, 불완전한 부분은 대부분 폐문에 닿아있었다. 덧틈새의 빈도는 오른폐가 33.3%, 왼폐가 54.3%였으며, 오른폐는 폐구역 속에 있는 것이 많았고, 왼폐는 두개의 폐구역 사이에 있는 것이 많았다.

2. 기관지가 구역기관지로 분지되는 양상은 일반적으로 알려진 것과 크게 다르지 않았으며, 다음과 같은 변이가 관찰되었다. 중간엽기관지와 혀구역기관지의 곁가지는 각각 3.4%와 18.8%의 빈도로 나타났으며, 오른폐 아래엽의 꼭대기구역기관지와 중간엽기관지가

같이 일어나는 경우는7.4%였다. 꼭대기밑기관지의 출현 빈도는 오른폐 20.0%, 왼폐 65.477였으며, 외측바닥구역기관지와 뒤바닥구역기관지의 공통줄기에서 일어나는 경우가 많았다. 구역기관지에서 갈라지는 가지의 방향은 이미 알려진 것(Hoyden이 정한 구역기관지가지의 이름)과 대체로 비슷하였으나, 그렇지 않은 경우도 있었다.

3. 폐표면에 나타나는 폐구역의 특징은 다음과 같았다. 일반적으로 앞구역은 수평틈새에 닿았고, 뒤구역은 수평틈새와 경사틈새에 닿았으나, 오른폐 앞구역이 경사틈새에 닿은 경우(27.0%)와 왼폐 꼭대기구역이 경사틈새에 닿은 경우(30.3%)도 관찰되었다. 중간엽이

위구역과 아래구역으로 나뉘고, 혀구역이 외측구역과 내측구역으로 나뉘는 경우는 각각 13% 안팎이었다. 횡격막면에서 오른폐는 내측바닥구역과 외측바닥구역이 맞닿은 유형과 앞바닥구역과 뒤바닥구역이 맞닿은 유형이 비슷한 빈도로 나타났으나, 왼폐는 내측바닥구역과 외측바닥구역이 맞닿은 한가지 유형만 나타났다.

4. 오른폐동맥은 위엽가지, 중간엽가지, 아래엽위가지, 바닥가지의 순으로 갈라지는 경우가 많았고(44.3%), 왼폐동맥은 위엽가지, 아래엽위가지, 폐혀가지, 바닥가지의 순으로 갈라지는 경우가 많았다(50.0%). 폐동맥의 위엽가지와 중간엽가지는 주로 기관지의 내측을 지났고, 폐혀가지와 아래엽위가지, 바닥가지는 주로 기관지의 외측을 지났으며, 폐정맥의 가지들은 오른폐 뒤가지를 제외하고 대부분 기관지의 내측을 지났다. 오른폐 중간엽의 폐정맥이 아래폐정맥으로 유입되는 경우(6.777)와 왼폐 위엽의 폐정맥이 아래폐정맥으로 유입되는 경우(4.3%)가 발견되었다.

이와 같이 본 연구에서 조사한 폐틈새의 모양과 기관지의 분지 양상은 질병을 이해하고 방사선사진을 판독할 때 도움을 줄 것이며, 폐구역의 형태 및 기관지와 폐혈관의 국소해부학적 관계는 폐구역을 절제할 때 응용할 수 있다. 또한 폐엽을 절제할 때에는 폐틈새가 불완전한 빈도와 그 위치, 그리고 이곳을 통하여 혈판이 지날 수 있다는 점에 유의하여 수술에 따르는 합병증을 줄일 수 있을 것으로 생각된다.

Studies on the morphology of the pulmonary robes and segments, and the

topographical anatomy of the distribution of bronchi and pulmonary vasculatures

Min Suk Chung

Department of Medicine, The Graduate School, Yonsei University

(Directed by Professor In Hyuk Chung)

The morphological variations of pulmonary hila and fissures, and the distribution

and vocational relationships of the bronchi and pulmonary vasculatures were

examined by dissecting 172 lungs from Korean adult cadavers. To clarify the

morphology of pulmonary segments, coloring solutions composed of gelatin and fabric

dye were injected into the segmental bronchi.

The findings were as follows:

1. The incidence of the main bronchus and pulmonary vessels branching in the lung

root was higher in the right than in the left side. The interlobar surface of the

right superior lobes inclined inferolaterally, and the middle lobes were narrower

at the costal surface than at the mediastinal surface. The oblique and horizontal

fissures were found to be incomplete in more than half of the lungs examined, with

the fissures discontinuing as they approached the hilum. The incidence of accessory

fissures was 33.3% for the right side and 54.3% for the left. Their main location

was within one segment for the right part and between two segments for the left.

2. The branching patterns of the bronchus were net much different from those

found in previous studies, but some variations were found. The incidence of

accessory branches in the middle lobar bronchus and lingular bronchus was 3.4% and

18.8%, respectively. These accessory branches were distributed to the lateral and

posterior surface. Occasionally(7.4%), the middle bronchus and superior segmental

bronchus divided at the same place. The incidence of a subsuperior bronchus was

20.0%(right) and 65.4%(left), and the most common source was the common trunk of

the lateral basal segment and posterior basal segment. The direction of the

subsegmental bronchus did not always correspond with Boyden's nomenclature.

3. Characteristics of the bronchopulmonary segments on the lung surface were as

follows. Generally, the anterior segment was in contact with the horizontal

fissure, and the posterior segment was in contact with the oblique and horizontal

fissures. In some instances, the right anterior segment was in contact with the

oblique and horizontal fissures(27.0%), and the left apical segment was in contact

with the oblique fissure(37.3% ). Atypically, the middle lobe divided into superior

and inferior segments(13.8% ), and the lingular segment divided into lateral and

medial segments(12.5%). At the diaphragmatic surface of the right lung, the

incidence of the medial and lateral basal segments being in contact was 58.3%, and

the incidence of the anterior and posterior basal segments being in contact was

41.7%. At the diaphragmatic surface 7f the left lung, the medial and lateral basal

segments were always in contact.

4. The right pulmonary artery was commonly sequentially divided into the superior

lobar branch, middle lobar branch, superior branch of inferior lobe, and basal

part(44.3% ), while the left pulmonary artery divided into the superior lobar

branch, superior branch of inferior lobe, singular branch, and basal Part(57.7%).

The superior lobar and middle lobar branches passed medially to the bronchi, and

the lingular and inferior lobar branches passed laterally. Most tributaries of the

pulmonary vein, with the exception of the right posterior branch, passed medially

to the bronchi. In some instances, the veins of the right superior and middle lobe

drained into the right inferior pulmonary vein(6.7%), and the veins of the left

superior lobe drained into the left inferior pulmonary vein(4.3%) .

This study contributes to the literature on the morphology of fissures, and on

bronchial distribution, knowledge of which can help us understand lung diseases.

The findings on variations in bronchopulmonary segmentation and locational

relationships of the bronchus and pulmonary vessels may facilitate segmentectomy.

Moreover, attention to the incidence and location of incomplete fissures, and the

possible existence of vessels passing through those, may reduce complications from

lobectomy.

[영문]

The morphological variations of pulmonary hila and fissures, and the distribution and vocational relationships of the bronchi and pulmonary vasculatures were examined by dissecting 172 lungs from Korean adult cadavers. To clarify the morphology of pulmonary segments, coloring solutions composed of gelatin and fabric dye were injected into the segmental bronchi.

The findings were as follows:

1. The incidence of the main bronchus and pulmonary vessels branching in the lung root was higher in the right than in the left side. The interlobar surface of the right superior lobes inclined inferolaterally, and the middle lobes were narrower

at the costal surface than at the mediastinal surface. The oblique and horizontal fissures were found to be incomplete in more than half of the lungs examined, with the fissures discontinuing as they approached the hilum. The incidence of accessory fissures was 33.3% for the right side and 54.3% for the left. Their main location was within one segment for the right part and between two segments for the left.

2. The branching patterns of the bronchus were net much different from those found in previous studies, but some variations were found. The incidence of accessory branches in the middle lobar bronchus and lingular bronchus was 3.4% and 18.8%, respectively. These accessory branches were distributed to the lateral and posterior surface. Occasionally(7.4%), the middle bronchus and superior segmental bronchus divided at the same place. The incidence of a subsuperior bronchus was 20.0%(right) and 65.4%(left), and the most common source was the common trunk of the lateral basal segment and posterior basal segment. The direction of the subsegmental bronchus did not always correspond with Boyden's nomenclature.

3. Characteristics of the bronchopulmonary segments on the lung surface were as follows. Generally, the anterior segment was in contact with the horizontal fissure, and the posterior segment was in contact with the oblique and horizontal fissures. In some instances, the right anterior segment was in contact with the

oblique and horizontal fissures(27.0%), and the left apical segment was in contact with the oblique fissure(37.3% ). Atypically, the middle lobe divided into superior and inferior segments(13.8% ), and the lingular segment divided into lateral and medial segments(12.5%). At the diaphragmatic surface of the right lung, the incidence of the medial and lateral basal segments being in contact was 58.3%, and the incidence of the anterior and posterior basal segments being in contact was

41.7%. At the diaphragmatic surface 7f the left lung, the medial and lateral basal segments were always in contact.

4. The right pulmonary artery was commonly sequentially divided into the superior lobar branch, middle lobar branch, superior branch of inferior lobe, and basal part(44.3% ), while the left pulmonary artery divided into the superior lobar branch, superior branch of inferior lobe, singular branch, and basal Part(57.7%).

The superior lobar and middle lobar branches passed medially to the bronchi, and the lingular and inferior lobar branches passed laterally. Most tributaries of the pulmonary vein, with the exception of the right posterior branch, passed medially to the bronchi. In some instances, the veins of the right superior and middle lobe drained into the right inferior pulmonary vein(6.7%), and the veins of the left superior lobe drained into the left inferior pulmonary vein(4.3%) .

This study contributes to the literature on the morphology of fissures, and on bronchial distribution, knowledge of which can help us understand lung diseases.

The findings on variations in bronchopulmonary segmentation and locational relationships of the bronchus and pulmonary vessels may facilitate segmentectomy.

Moreover, attention to the incidence and location of incomplete fissures, and the possible existence of vessels passing through those, may reduce complications from lobectomy.