Fig. 28.1
Pleural endoscopic images. INF inferior, 4R right paratracheal lymph node region according to Naruke’s classification , SVC superior vena cava, LUL left upper lobe, LLL left lower lobe. (a) Endoscopic image of the costal pleura. (b) Endoscopic image of the diaphragmatic pleura. (c) Endoscopic image of the mediastinal pleura. (d) Endoscopic image of the visceral pleura (left lung)
Visceral Pleura
The visceral pleura is intimately attached to the outer surface of the lung (Fig. 28.1d). There is no cleavage plane, so that it cannot be dissected without injuring the lungs. It covers all lung surface, penetrating and producing the lung fissures; however, on the internal lung surface (lung hilum), it reflects to continue with the mediastinal parietal pleura. Here, there is a small lung surface without pleural lining, and the pleural reflection extends down to the diaphragm, and it is called the triangular or inferior pulmonary ligament.
The hilar region is shaped as a long inverted teardrop, with a rounded superior end covering the lung pedicle and a triangular space whose base is superior that elongates downwards, and it is called triangular ligament as discussed above. This ligament helps fixing the lung not only to the mediastinum but also to the diaphragm, where it ends. Between the two pleural reflection sheets that form the triangular ligament, nodal station 9 is found (Naruke’s classification).
Pleural Recesses
The pleural space is a virtual space delimited between the parietal and the visceral pleura. This space has important anatomical accidents, and the most important of them are called sinuses or pleural recesses, which are the following:
- 1.
Pleural apex or superior pleural sinuses: they are cervical since they are situated above the clavicle, at the base of the neck. At the apex, the costal and mediastinal pleura join forming the upper cone (Fig. 28.2a). On the outer side, the three suspensor ligaments of Sebileau insert:
Transverse-pleural ligament: it goes from C7 transverse apophysis to the pleural apex and issues an expansion to the first rib. If it contains muscle fibers, it is called scalenus minimus muscle.
Costo-pleural ligament: it runs from the first rib neck to the pleural apex.
Vertebro-pleural ligament: it runs from C7 vertebral body to the pleural apex.
- 2.
Anterior costophrenic recesses or cardiophrenic: at a retrosternal level, they form an acute angle. They represent the point where the parietal costal, diaphragmatic, and mediastinal pleura intersect. In the left side the costophrenic recess is displaced by the heart 2.5–4 cm from the vertical line (Fig. 28.2b).
- 3.
Posterior costophrenic recesses: they are located posteriorly, at the level of the intersection of the diaphragmatic parietal, costal, and mediastinal pleura on the vertebral body. Those recesses represent the most dependent points in the pleural cavity.
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