Research progress on the anatomy of the right lung based on CT-based three-dimensional reconstruction_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

YOU Yuhe ^1,2 , CHEN Siqi ^1,3 , CAO Wenjun ¹ , CHEN Zhang ^1,2 , XUE Hongsheng ¹ , SHI Xiaoyu ¹ , PIAO Zhe ¹ , YOU Maoduan ¹ ,  ZHAO Zhilong ¹

1. Department of Thoracic Surgery, Affiliated Zhongshan Hospital of Dalian University, Dalian, 116601, Liaoning, P. R. China;
2. Zhongshan School of Clinical Medicine, Dalian University, Dalian, 116622, Liaoning, P. R. China;
3. Graduate School, Dalian Medical University, Dalian, 116044, Liaoning, P. R. China;

Corresponding?author：

ZHAO Zhilong, Email: zhilong509@126.com

Keywords：

Computed tomography imaging; three-dimensional reconstruction; right lung; bronchi; pulmonary arteries; pulmonary veins; anatomy; sublobar resection

DOI：

10.7507/1007-4848.202512109

Video：

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Abstract Full text Figures/Tables Video References Cited by

The detection rates of pulmonary nodules and early-stage lung cancer are rising year on year, which underscores the clinical value of sublobar resections including lung segmentectomy. CT-based three-dimensional reconstruction can intuitively visualize the anatomical courses and variants of bronchial and pulmonary vascular structures (arteries and veins), thereby providing accurate guidance for preoperative localization, surgical planning and intraoperative identification. This article systematically reviews the anatomical classification patterns of the bronchi and pulmonary vessels in the right upper, middle, and lower lobes at the segmental and subsegmental levels, and summarizes clinically significant variations, including tracheal bronchus, common arterial trunk, right top pulmonary vein, lingular-like bronchial configuration of the middle lobe, ectopic venous drainage, the subsuperior segment ("star segment") variation, and the relationship of B7/A7 to the inferior pulmonary vein, analyzing their impact on intraoperative anatomical judgment and treatment strategies for bronchial and vessels. This review aims to provide an anatomical basis and clinical reference for individualized precise segmentectomy and complex sublobar resection, so as to maximize preservation of pulmonary function while ensuring oncologic radicality and reducing the risk of surgical complications.

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1. Mazzone PJ, Silvestri GA, Souter LH, et al. Screening for lung cancer: CHEST guideline and expert panel report. Chest, 2021, 160(5): e427-e494.
2. Saji H, Okada M, Tsuboi M, et al. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. Lancet, 2022, 399(10335): 1607-1617.
3. Mimae T, Miyata Y, Kumada T, et al. The intersegmental pulmonary vein is not always located on the intersegmental plane of the lung: evaluation with 3-dimensional volume-rendering image reconstruction. JTCVS Tech, 2022, 16: 132-138.
4. Sardari Nia P, Olsthoorn JR, Heuts S, et al. Interactive 3D reconstruction of pulmonary anatomy for preoperative planning, virtual simulation, and intraoperative guiding in video-assisted thoracoscopic lung surgery. Innovations (Phila), 2019, 14(1): 17-26.
5. Shiina N, Kaga K, Hida Y, et al. Variations of pulmonary vein drainage critical for lung resection assessed by three-dimensional computed tomography angiography. Thorac Cancer, 2018, 9(5): 584-588.
6. Nilssen Y, Brustugun OT, Fjellbirkeland L, et al. Distribution and characteristics of malignant tumours by lung lobe. BMC Pulm Med, 2024, 24(1): 106.
7. Boyden EA, Scannell JG. An analysis of variations in the bronchovascular pattern of the right upper lobe of 50 lungs. Am J Anat, 1948, 82(1): 27-73.
8. Najafi H, Savoji K, Mirzaeibonehkhater M, et al. A novel method for 3D lung tumor reconstruction using generative models. Diagnostics (Basel), 2024, 14(22): 2604.
9. Jahani N, Choi S, Choi J, et al. Assessment of regional ventilation and deformation using 4D-CT imaging for healthy human lungs during tidal breathing. J Appl Physiol (1985), 2015, 119(10): 1064-1074.
10. Xiang Z, Wu B, Zhang X, et al. Preoperative three-dimensional lung simulation before thoracoscopic anatomical segmentectomy for lung cancer: a systematic review and meta-analysis. Front Surg, 2022, 9: 856293.
11. Zhai HR, Yang XN, Nie Q, et al. Different dissecting orders of the pulmonary bronchus and vessels during right upper lobectomy are associated with surgical feasibility and postoperative recovery for lung cancer patients. Chin J Cancer, 2017, 36(1): 53.
12. Javed S, Mei Y, Zhang Y, et al. Multi-slice CT analysis and identification of anatomical types of segmental bronchi in right superior lobe. Curr Med Imaging, 2023. [Epub ahead of print].
13. 李志凱. 右肺上葉和左肺上葉的支氣管血管模式的分析及變異相關的肺葉及肺段切除的研究. 河北醫科大學, 2023.Li ZK. The analysis of the bronchovascular pattern of the right upper lobe and the left upper lobe and the study of variant-associated lobectomy and segmentectomy. Hebei Medical University, 2023.
14. Nagashima T, Shimizu K, Ohtaki Y, et al. An analysis of variations in the bronchovascular pattern of the right upper lobe using three-dimensional CT angiography and bronchography. Gen Thorac Cardiovasc Surg, 2015, 63(6): 354-360.
15. Zhang M, Mao N, Wang SH, et al. The B1 defective type of bifurcated right upper lobe bronchus. J Thorac Dis, 2019, 11(10): 4218-4223.
16. Zhong X, Huang Y, Yang M, et al. Elucidating the anatomy of the quadrivial pattern of the right upper lobe bronchus using 3D-CT images. Ann Transl Med, 2022, 10(2): 46.
17. 范坤, 馮錦騰, 王泓懿, 等. 基于三維重建的肺小結節患者右上肺葉解剖研究. 中華胸心血管外科雜志, 2020, 36(9): 557-561.Fan K, Feng JT, Wang HY, et al. Anatomy of upper lung lobes of patients with small pulmonary nodules based on three-dimensional reconstruction of PC. Chin J Thoracic Cardiovasc Surg, 2020, 36(9): 557-561.
18. Wooten C, Patel S, Cassidy L, et al. Variations of the tracheobronchial tree: anatomical and clinical significance. Clin Anat, 2014, 27(8): 1223-1233.
19. Chen Y, Guo Y, Mi W, et al. Anatomy of the right upper lobe revisited and clinical considerations in Chinese population. PLoS One, 2020, 15(11): e0242178.
20. Levin E, Bowling MR. Malignancy in the tracheal bronchus: a case series and review of the literature. Clin Respir J, 2018, 12(9): 2441-2445.
21. Cheng L, Liu S, Qi W, et al. The incidence of tracheal bronchus in thoracic surgery patients and its implication for lung isolation: a retrospective cohort study. J Cardiothorac Vasc Anesth, 2020, 34(11): 3068-3072.
22. 劉治利, 張敏, 劉興元, 等. 右上肺B2下移變異: 一種特殊類型的氣管支氣管. 中國胸心血管外科臨床雜志, 2024, 31(12): 1759-1766.Liu ZL, Zhang M, Liu XY, et al. Variation of right B2 downwards-shift: a special type of tracheal bronchus. Chin J Clinic Thorac Cardiovasc Surg, 2024, 31(12): 1759-1766.
23. Wong LM, Cheruiyot I, de Oliveira MHS, et al. Congenital anomalies of the tracheobronchial tree: a meta-analysis and clinical considerations. Ann Thorac Surg, 2021, 112(1): 315-325.
24. Mishra M, Kumar A. Tracheal bronchus: a rare cause of recurrent pneumonia in adults. BMJ Case Rep, 2022, 15(7): e250715.
25. Yaginuma H. Investigation of displaced bronchi using multidetector computed tomography: associated abnormalities of lung lobulations, pulmonary arteries and veins. Gen Thorac Cardiovasc Surg, 2020, 68(4): 342-349.
26. 劉杜娟, 任冉, 朱銘飛, 等. 氣管性支氣管的流行病學與CT影像特征. 中華解剖與臨床雜志, 2024, 29(11): 722-727.Liu DJ, Ren R, Zhu MF, et al. Epidemiological and CT imagine adiologic characteristics of tracheal bronchus. Chin J Anat Clin, 2024, 29(11): 722-727.
27. Nomori H. Segmental anatomy of the right upper lobe. In: Nomori H, ed. Anatomical Segmentectomy for Lung Cancer: Illustration and Videos. Singapore: Springer Nature, 2024: 73.
28. Li Z, Kong Y, Li B, et al. The detailed classification of the interlobar artery and the artery crossing intersegmental planes in the right upper lobe. Front Oncol, 2023, 13: 1195726.
29. Xu H, Zhao H, Jin J, et al. An atlas of anatomical variants of subsegmental pulmonary arteries and recognition error analysis. Front Oncol, 2023, 13: 1127138.
30. Ma X, Lu T, Qin D, et al. Analysis of pulmonary artery variation based on 3D reconstruction of CT angiography. Front Physiol, 2023, 14: 1156513.
31. Xie Z, Zhu X, Li F, et al. Pulmonary arterial anatomical patterns: a classification scheme based on lobectomy and 3D-CTBA. Thorac Cardiovasc Surg, 2024, 72(7): 557-567.
32. Li Z, Chen S, Ren D, et al. Right upper lobe segmentectomy and subsegmentectomy guided by classification pattern of peripheral segmental veins. Front Oncol, 2023, 13: 1179570.
33. Chen ZH, Chu XP, Zhang JT, et al. The regularity of anatomical variations of dominant pulmonary segments in the right upper lobe. Thorac Cancer, 2023, 14(5): 462-469.
34. Xu W, Li Z, He Z, et al. Anatomical distribution and clinical significance of translobar bronchi, arteries, and veins hidden in the interlobar fissure. J Thorac Dis, 2024, 16(2): 901-910.
35. Shimizu K, Nagashima T, Ohtaki Y, et al. Analysis of the variation pattern in right upper pulmonary veins and establishment of simplified vein models for anatomical segmentectomy. Gen Thorac Cardiovasc Surg, 2016, 64(10): 604-611.
36. Sato Y, Tanaka Y, Ohno S, et al. Right top pulmonary vein is a venous anomaly of which surgeons should be aware in subcarinal dissection for thoracoscopic esophagectomy: a case report and literature review. World J Surg Oncol, 2022, 20(1): 160.
37. Hiroshi Y, Ken-Ichiro T, Masashi U. Right top pulmonary veins associated with lung incomplete fissure and displaced bronchus: a retrospective study using multidetector computed tomography. Gen Thorac Cardiovasc Surg, 2021, 69(2): 290-296.
38. 徐海迪. 應用三維計算機斷層掃描血管成像和支氣管成像分析右上葉 B1 缺陷型兩分叉支氣管的血管分支模式及血管變異類型. 河北醫科大學, 2023.Xu HD. Three-dimensional computed tomography angiography and bronchography were used to analyze the vascular branching pattern and vascular variation types of B1 defective bifurcated bronchi in the right upper lobe. Hebei Medical University, 2023.
39. Nagashima T, Shimizu K, Ohtaki Y, et al. Analysis of variation in bronchovascular pattern of the right middle and lower lobes of the lung using three-dimensional CT angiography and bronchography. Gen Thorac Cardiovasc Surg, 2017, 65(6): 343-349.
40. Zhao B, Wu W, Duan G. Observation of bronchial anatomy and variation of the middle lobe of the right lung based on three-dimensional reconstruction of lung CT. J Cardiothorac Surg, 2025, 20(1): 172.
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Latest ArticlesResearch progress on the anatomy of the right lung based on CT-based three-dimensional reconstruction

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