A composite medical figure illustrating surgical management of a horseshoe lung with extralobular sequestration. Panel A is an anatomical diagram showing bilateral posterolateral thoracotomy incision lines (red) on the left and right posterior thoracic wall. Panel B is an intraoperative clinical photograph during a left thoracotomy, distinguishing the native left lung from the abnormal 'protruding lung' tissue crossing the mediastinum. Panel C shows the surgical field identifying the descending aorta and a systemic abnormal blood vessel supplying the sequestered lung segment. Panel D displays the gross pathology specimen of the resected horseshoe lung, consisting of the right lower lobe and the continuous protruding lung tissue. The specimen appears dark and congested, consistent with chronic infection or aspergillosis. This content serves as an educational resource for thoracic surgery and congenital pulmonary malformations.

Educational composite figure demonstrating surgical planning and intraoperative execution for Robotic-Assisted Thoracic Surgery (RATS). Panel A is a schematic anatomical diagram of the left posterolateral chest wall. Red circles indicate specific port placements at the 6th, 8th, and 10th intercostal spaces (ICS), with the 8th ICS marked 'C' to denote the camera port. A curved red line indicates the site for a posterior skin incision required for chest wall resection. Panel B is a clinical photograph of the intraoperative field with the da Vinci surgical system docked. The surgical site is prepared with povidone-iodine and bordered by blue sterile drapes. Robotic arms encased in sterile plastic draping are positioned over the patient. A surgeon's hand is seen manipulating a clear suction/irrigation tube near the thoracotomy opening, which is illuminated by a red light source. A metal retractor is visible at the edge of the incision, which exposes the underlying muscle and rib tissue involved in the resection of a posterior mediastinal mass.

A clinical photograph of a fresh intraoperative surgical site on the posterolateral hemithorax. The image demonstrates a long, oblique incision approximately starting 2 cm lateral to the spinous process and extending inferiorly and laterally toward the midpoint of the XIIth rib. The incision edges are sharp and exhibit minor active bleeding from the dermal and subcutaneous layers. The surrounding skin is prepped for surgery, covered by a clear adhesive surgical drape (incise drape), showing a slightly reflective surface. This visual illustrates a standard posterolateral thoracotomy or retroperitoneal approach, commonly utilized in thoracic or urological surgeries. The anatomical landmarks and orientation are critical for understanding surgical access to the thoracic cavity or kidney.

This clinical photograph demonstrates the preoperative surgical positioning and skin marking for a posterolateral thoracotomy in a patient with spontaneous pneumothorax. The patient is placed in the lateral decubitus position on an operating table, lying on their healthy side with the upper arm extended anteriorly toward the head to facilitate surgical access. A surgical marker has been used to delineate the incision site. The marking consists of a solid angled line, where one branch follows the line of the spinous processes and the other aligns with the spinal edge of the scapula. A dotted line bisects this angle, representing the planned cutaneous incision path. The positioning is designed to provide optimal exposure of the thoracic cavity while minimizing muscle sectioning, specifically targeting the planes between the latissimus dorsi, trapezius, serratus anterior, and rhomboid muscles. Visible equipment includes surgical drapes, a surgical cap, and anesthesia tubing.

Anatomical diagram and surgical illustration of a 'clamshell' thoracotomy approach (bilateral anterolateral thoracotomy with transverse sternotomy). The diagram depicts a wide surgical field across the anterior chest wall, extending laterally toward the axillary lines. Key mediastinal and thoracic structures are exposed and labeled, including the heart centrally with the right ventricle (RV) prominently visible, and the ascending aorta (Ao) superior to it. The hilum is visible bilaterally, providing access to the pulmonary structures. The image demonstrates the extensive exposure of the anterior and posterior mediastinum provided by this incision, which is commonly utilized in complex cardiothoracic procedures, such as unifocalization of major aortopulmonary collateral arteries (MAPCAs) or lung transplantation, particularly in cases involving significant scarring from previous median sternotomies.

A clinical photograph of a male patient's torso in a supine position, serving as an anatomical diagram for surgical planning. A dashed red line is superimposed across the anterior chest to illustrate the approximate incision site for a bilateral clamshell thoracotomy. The line follows a transverse, slightly curved path through the fourth or fifth intercostal spaces, extending from the left anterior axillary line, passing inferior to the nipples/inframammary creases, and crossing the sternum to the right anterior axillary line. Anatomical landmarks visible include the pectoralis major muscles, sternum, and axillary regions. The image demonstrates the extensive surgical access required for emergency thoracic trauma management, such as hemorrhage control or cardiac procedures. The educational focus is on the surface anatomy and topographical mapping necessary for emergent surgical interventions in a trauma setting.

This composite of clinical photographs illustrates the surgical incision and exposure techniques for a clamshell incision (bilateral antero-lateral thoracotomy) during a lung transplant or major thoracic procedure. Panel A shows the initial bilateral thoracotomies with a Wilson rib retractor positioned to widen the intercostal spaces, viewed from the head end. Panel B provides a detailed view of the right internal mammary vessels, which have been ligated with surgical clips (indicated by a yellow arrow) to prevent hemorrhage. Panel C demonstrates the performance of a midline sternotomy using a surgical power drill to divide the sternum, connecting the bilateral thoracotomies. Panel D displays the final surgical exposure with Tuffier retractors in place, providing a wide field of view that reveals the underlying thoracic structures and an elevated right diaphragmatic dome. The sequence highlights the progression from intercostal dissection to full sternal division and wide retraction for optimal hilar access.

This composite educational graphic features a side-by-side presentation of an intraoperative photograph (left) and a corresponding anatomical line drawing (right) detailing the surgical dissection of the median arcuate ligament. The clinical photograph displays a high-magnification view of the upper abdominal surgical field. Key vascular structures are clearly labeled at the inferior margin, including the common hepatic artery (CHA) and splenic artery bifurcating from the celiac axis, and a ligated left gastric artery (LGA) stump. Superior to these vessels, the esophageal hiatus is shown, flanked by the right and left crus of the diaphragm. The diaphragm's muscular fibers are visible as they form the aortic and esophageal openings. The diagram replicates these relationships, emphasizing the spatial orientation of the celiac trunk branches relative to the diaphragmatic crura. This material is designed to demonstrate surgical anatomy during lymph node dissection and the release of median arcuate ligament syndrome (MALS), providing visual clarity on vascular and diaphragmatic landmarks essential for upper gastrointestinal surgery and esophageal cancer resection.

This anatomical diagram provides an anterior view of the human thoracic cage and upper abdominal musculature. The skeletal framework consists of the sternum (manubrium, body, and xiphoid process), articulating ribs with prominent costal cartilages, and components of the shoulder girdle, including the clavicles and glenoid cavities. Two intersecting red lines represent the long and short axes used for cardiac surface projection and surgical landmarks: the 'Long axis' extends from the right shoulder toward the left epigastrium, and the 'Short axis' extends from the left mid-clavicular region toward the right chondrocostal ramp. Inferiorly, the muscular diaphragm is depicted with its dome-like morphology and central tendon, alongside the superior attachments of the rectus abdominis muscle. The diagram serves as a clinical reference for surface anatomy, illustrating the spatial relationships between the thoracic wall and the underlying mediastinal structures, specifically for identifying cardiac chambers and valve locations in medical and osteopathic education.

Anatomical diagram of the human diaphragm in a transverse section, viewed from below (inferior aspect from the abdominal cavity). The illustration demonstrates the dual composition of the diaphragm: a peripheral muscular region (appearing as a dark, striated band) and a central, trefoil-shaped non-muscular central tendon. Key hiatal structures are labeled to show their relative positions. The vena cava (caval opening) is located anteriorly and slightly to the right within the central tendon. The esophagus (esophageal hiatus) is situated posteriorly and to the left of the vena cava, surrounded by the muscular fibers of the right crus. The aorta (aortic hiatus) is positioned most posteriorly, passing behind the diaphragm adjacent to the vertebral column. Anatomical landmarks include the spinal column at the posterior margin and the ribs and costal margins laterally and anteriorly. This diagram illustrates the gross structural arrangement and spatial orientation of the major diaphragmatic apertures essential for understanding thoracoabdominal transit and surgical anatomy.

This medical anatomical diagram illustrates a complex surgical and pathological scenario involving the upper gastrointestinal and biliary systems. The image is divided by the diaphragm, showing a large hiatal hernia of the 'upside-down stomach' type, where the majority of the stomach has prolapsed into the thoracic cavity. Below the diaphragm, the abdominal anatomy includes the liver, gallbladder, and pancreas. A significant pathological finding is a purple, nodular mass located in the head of the pancreas, which is shown causing extrinsic compression of the distal common bile duct and the second portion of the duodenum. Additionally, the main pancreatic duct is depicted as dilated (highlighted in blue), indicating obstructive changes proximal to the tumor. The diagram provides clinical context for managing biliary and duodenal obstruction in the presence of severe anatomical distortion. This visual is suitable for gastroenterology and surgical oncology education, focusing on pancreatic malignancy and hiatal hernia complications.

This anatomical diagram provides a superior view of the thoracic surface of the human diaphragm, illustrating its key structural components and apertures. The central area features the trefoil-shaped central tendon (8), a white aponeurotic region where muscular fibers insert. To the right of the midline within the central tendon is the caval opening (3 or 4 in metadata), which transmits the inferior vena cava. Posteriorly, the muscular part of the diaphragm forms the esophageal hiatus (10) for the passage of the esophagus and the aortic hiatus (9) for the descending aorta, the latter located between the crura in the lumbar area (5). A dotted line on the superior surface demarcates the area of contact and support for the heart. The diagram highlights the radiating muscular fibers (4) originating from the sternal (1), costal (7, 11), and lumbar (5) attachments. Surrounding structures include cross-sections of the ribs and the vertebral column, providing anatomical context for the diaphragm's position at the thoracoabdominal interface. This illustration is used for teaching respiratory anatomy and the spatial relationships of major retroperitoneal and thoracic structures.

This medical illustration depicts a cross-sectional anatomical diagram of the trunk, specifically highlighting a surgical repair of a posterolateral diaphragmatic defect (likely a Bochdalek hernia). The central focus is on a prosthetic mesh patch, shown as a grid-like structure, positioned to close the opening in the diaphragm. The mesh is secured to the surrounding diaphragmatic tissue and adjacent thoracic wall structures using several non-absorbable spiral tacks, which are visible around the perimeter of the patch. A laparoscopic fixation device is illustrated in the act of applying or positioning the mesh. The surrounding anatomy includes the vertebral column, major vessels such as the aorta, and the musculature of the abdominal and thoracic walls. This educational diagram demonstrates the technique of tension-free prosthetic repair in cases where primary suture closure is insufficient, illustrating a common approach in pediatric or adult thoracic surgery.

This endoscopic clinical photograph depicts an intraoperative view of a hiatal hernia repair procedure. The surgical field highlights the dissection and preparation of the esophageal hiatus. Two white arrows indicate the right and left crura of the diaphragm, which have been prepared in their ventral aspect, revealing the striated muscular texture of the diaphragmatic tissue. Centrally located between the crura is a dark, smooth-textured mass representing the hiatal sac being mobilized. Metallic laparoscopic surgical instruments are visible in the upper quadrants, manipulating the surrounding tissues. The surrounding anatomical structures show signs of active surgical dissection, including exposed tissue planes and minor localized hemorrhage. The view demonstrates the necessary anatomical exposure of the mediastinal opening required for reduction of hernia contents and subsequent hiatoplasty.

This clinical photograph captures an intraoperative view during a laparoscopic hiatal hernia repair (hiatoplasty). The image shows the application of Gore Bio-A Tissue Reinforcement, a synthetic absorbable mesh, over the diaphragmatic crura. The surgical field includes the exposed muscular pillars of the diaphragm, which have been primarily closed with sutures to reduce the esophageal hiatus. The white, translucent, 'U'-shaped mesh is seen positioned over the crura to provide structural reinforcement to the repair. The material is flexible, conforming to the anatomical contours of the retroesophageal space. Darker areas along the mesh edges indicate fixation points where absorbable sutures or tacks are used to secure the material to the underlying muscle, preventing migration. This procedure is performed to treat large hiatal hernias and gastroesophageal reflux disease (GERD) by strengthening the crural closure and reducing the risk of recurrence while avoiding the complications associated with non-absorbable permanent meshes.

This clinical photograph captures a laparoscopic surgical field during a cruroplasty for hiatal hernia repair. The central focus is the intraoperative placement of a bioabsorbable surgical mesh (biological prosthesis) for reinforcement of the diaphragmatic crura. The mesh appears as a rectangular, opaque white, flexible sheet positioned at the base of the esophageal hiatus. A laparoscopic grasper with a silver metallic tip and black shaft is visible at the bottom right, used to manipulate the mesh and underlying tissue. Adjacent to the mesh is the reddish-brown muscular tissue of the diaphragm and the gastroesophageal junction. A blue braided suture is visible near the top right, and clear medical adhesive (cyanoacrylate) has been applied to fix the mesh in place. The image demonstrates the anatomical relationship between the prosthetic reinforcement and the esophageal hiatus, highlighting surgical techniques for strengthening hiatal closure in foregut surgery.

This intraoperative clinical photograph shows an open abdominal surgical field focused on the upper gastrointestinal region. The image demonstrates a pathologically enlarged esophageal hiatus, serving as a hernial orifice. Visible anatomical structures include the liver (smooth, reddish-brown organ on the left), the diaphragm, and the esophagus/stomach junction area. The operative field is characterized by moist, glistening visceral surfaces with exposed reddish muscular tissue and yellow adipose (fatty) tissue. The esophageal hiatus appears as a distinct, abnormally wide opening formed by the diaphragmatic crura. There is evidence of surgical dissection and manipulation of the surrounding tissues to expose the hiatal defect. This image illustrates a case of esophageal hiatal hernia where the orifice is sufficiently large to allow the herniation of abdominal viscera, such as the small intestine, into the thoracic cavity. The pathology is clinically relevant for understanding diaphragmatic hernia repair and the anatomical landmarks involved in cruroplasty.

A composite medical illustration and intraoperative image detailing the surgical management of a Bochdalek hernia. The upper panel displays a laparoscopy frame showing the diaphragm with a 'pendulum-shaped incision' made to facilitate the reduction of herniated viscera. A surgical instrument is seen manipulating the vascularized, pink diaphragmatic tissue. An inset anatomical diagram clarifies the orientation, showing the relationship between the central tendon, the esophageal hiatus, the Bochdalek hernia defect, and the relief incision. The lower panel is a clinical diagram of thoracoscopic port placement on the left lateral chest wall. It illustrates the positioning of a 10 mm camera port at the 5th intercostal space (ICS) along the midaxillary line (MAL), flanked by two 5 mm working ports at the 7th ICS. Key anatomical landmarks are labeled, including the anterior axillary line (AAL), midaxillary line (MAL), and posterior axillary line (PAL), providing a guide for surgical access in thoracic surgery.

This diagnostic image is a contrast-enhanced fluoroscopic radiograph (barium study) of the upper abdomen and lower thorax, demonstrating a diaphragmatic hernia. The primary finding is the herniation of the transverse colon through a defect in the right dome of the diaphragm into the thoracic cavity. The contrast-filled colon shows a distinct superior deviation from the abdominal cavity. Specifically, the ascending limb of the herniated loop (marked by a white arrow) appears moderately dilated, while the descending portion of the loop passing through the diaphragmatic hiatus (marked by a black arrow) shows relative focal constriction, suggesting the site of the hernia neck. The image illustrates the radiological appearance of a Bochdalek or Morgagni hernia involving the large bowel. This clinical study is essential for visualizing gastrointestinal displacement and assessing the patency of herniated loops in patients presenting with atypical abdominal or respiratory symptoms.

A multi-panel medical figure illustrating a Morgagni diaphragmatic hernia through diagnostic imaging, anatomical diagrams, and surgical photography. Panel A displays a 3D pre-operative angio-CT scan reconstruction, where a voluminous hernial sac containing omentum is color-coded red, positioned anterior to the yellow-coded pericardium. White markers indicate the diaphragmatic defect edges. Panel B is an anatomical illustration showing the superior view of the diaphragm, highlighting the anterior Morgagni foramen and the posterolateral Bochdalek foramen for comparative diagnosis. Panel C is an intraoperative photograph during a median sternotomy. Retractors expose the mediastinum, showing the physical relationship between the hernial sac and the pericardium, separated by a dashed white line indicating the boundary for dissection. This figure demonstrates the clinical presentation, anatomical basis, and surgical appearance of a rare adult Morgagni hernia causing significant cardiac compression.

An anatomical diagram illustrating the classification and frequency of congenital diaphragmatic hernias (CDH) based on anatomical location. The illustration presents an axial view of the diaphragm, highlighting three primary defect sites: 1) Postero-lateral (Bochdalek) hernias, which are the most common at 75% of cases; 2) Anterior (Morgagni) hernias located retrosternally, accounting for 23%; and 3) Central hernias, representing 2%. The diagram further specifies the lateralization for Bochdalek hernias, indicating that 85% occur on the left side, 13% on the right side, and 2% are bilateral. Anatomical landmarks such as the vertebral column, esophagus, and major vessels are visible to provide orientation. This educational graphic is used to teach the epidemiology and spatial distribution of diaphragmatic defects in neonatology and pediatric surgery.

This composite of diagnostic images illustrates a Bochdalek diaphragmatic hernia in the left hemithorax through multiple modalities. (a) A frontal chest radiograph displays an obscure soft tissue opacity above the left hemidiaphragm (indicated by a yellow arrow), suggesting a protrusion into the thoracic cavity. (b, c, d) Contrast-enhanced Computed Tomography (CT) images in axial, coronal, and sagittal planes provide definitive characterization. The CT images reveal a well-defined, approximately 6 x 6 cm mass of retroperitoneal fat and omental tissue herniating through a defect in the posterolateral aspect of the left diaphragm. The axial view shows the rounded protrusion displacing lung parenchyma, while the coronal and sagittal reformats highlight the superior migration of abdominal contents through the diaphragmatic hiatus. Contrast enhancement aids in differentiating the low-density adipose tissue within the hernia from the surrounding pleura, chest wall, and vascular structures, demonstrating the clinical utility of cross-sectional imaging for surgical planning in diaphragmatic defects.

**Imaging Modality:** Lateral chest radiograph (X-ray). **Anatomical Region:** Thoracic cavity, specifically focusing on the posterior costophrenic angle and the right hemidiaphragm. **Observed Pathology:** Bochdalek hernia. **Characteristic Visual Features:** The image demonstrates a localized, well-circumscribed, small round soft-tissue opacity situated in the posterior aspect of the chest. The lesion is in direct contact with the posterior portion of the right hemidiaphragm, near the retrocardiac space and the vertebral column. A red arrow highlights the specific location of the protrusion. **Key Diagnostic Features:** The posterior location of the diaphragmatic defect is characteristic of a Bochdalek-type congenital diaphragmatic hernia. The lack of pulmonary parenchymal infiltration and the distinct margins of the opacity suggest a herniation of abdominal contents (typically omental fat or viscera) through a pleuroperitoneal hiatus. This presentation is a key differentiating feature from anterior Morgagni hernias or intrapulmonary nodules.

This diagnostic image is a coronal view of a Computed Tomography (CT) scan of the chest and upper abdomen, demonstrating a complex gastric volvulus associated with a large paraesophageal hiatus hernia. Red arrows indicate the rolling paraesophageal hiatus hernia, where a portion of the stomach has herniated through the esophageal hiatus into the thoracic cavity. The stomach exhibits significant distension and abnormal rotation (volvulus), leading to a distortion of normal gastrointestinal anatomy. Yellow arrows point to visible fluid accumulation (perigastric fluid) surrounding the gastric component within the intra-abdominal and lower thoracic space, which may suggest inflammation or venous congestion. The CT scan highlights the relationship between the anatomical displacement of the stomach and the potential for obstructive pathology. This material serves as a clinical reference for identifying surgical emergencies involving the upper gastrointestinal tract, specifically the coexistence of hiatal herniation and organoaxial or mesenteroaxial twisting of the stomach.

**Imaging Modality:** Axial computed tomography (CT) of the chest with intravenous and oral contrast. **Anatomical Region:** Lower thorax at the level of the retrocardiac space and esophageal hiatus. **Observed Pathology:** Sliding hiatal hernia (Type I). **Characteristic Visual Features:** The image demonstrates a soft tissue mass containing an internal air-fluid level located in the posterior mediastinum, situated directly behind the heart and anterior to the descending thoracic aorta. This represents the cranial displacement of the gastroesophageal junction and a portion of the proximal stomach through the esophageal hiatus into the thoracic cavity. The azygoesophageal recess is distorted by the herniated gastric contents. **Relevant Landmarks:** Key structures visualized include the cardiac silhouette (ventricles), the descending aorta, the vertebral body, and the liver dome (right). The oral contrast facilitates identification of the gastric lumen within the mediastinal herniation. **Differentiating Features:** The superior migration of the gastroesophageal junction above the diaphragmatic crus distinguishes this sliding hiatal hernia from a paraesophageal hernia, where the gastroesophageal junction typically remains in its normal anatomical position. No acute cardiopulmonary complications are visualized in this section.

**Imaging Modality:** Axial computed tomography (CT) of the chest/upper abdomen with intravenous contrast. **Anatomical Region:** Lower mediastinum and diaphragmatic hiatus. **Observed Pathology:** Sliding hiatal hernia. The image demonstrates the superior migration of the gastroesophageal junction and a portion of the proximal stomach into the posterior mediastinum, located posterior to the heart and anterior to the descending aorta. **Characteristic Visual Features:** - A soft tissue mass containing an internal air-fluid level and heterogeneous contents (oral contrast and gas) is visible within the retrocardiac space. - The gastric herniation causes a focal widening of the diaphragmatic hiatus. - The descending thoracic aorta shows mild atherosclerotic calcification. - The liver, spleen, and visible portions of the lung parenchyma appear unremarkable at this level. **Differentiating Features:** The central location of the stomach within the hiatus, rather than adjacent to a normally positioned gastroesophageal junction, is characteristic of a sliding hiatal hernia (Type I) rather than a paraesophageal hernia. **Clinical Significance:** This finding is a common cause of retrocardiac masses on chest radiography and can correlate with symptoms of gastroesophageal reflux or mechanical compression.

**Imaging Modality:** Contrast-enhanced Computed Tomography (CT), axial section. **Anatomical Region:** Lower thorax/upper abdomen at the level of the diaphragmatic hiatus. **Observed Pathology:** Sliding hiatal hernia. **Characteristic Visual Features:** The image demonstrates a portion of the stomach herniating superiorly through the esophageal hiatus into the posterior mediastinum. Key landmarks include the liver (right), spleen (left), and the descending aorta. Centrally, a retrocardiac soft tissue mass representing the displaced gastric cardia is visible adjacent to the esophagus. **Key Diagnostic Features:** - Widening of the diaphragmatic hiatus. - Intrathoracic displacement of the gastroesophageal junction. - Presence of a gas-filled or contrast-containing gastric pouch above the level of the diaphragm, posterior to the heart. - Absence of a distinct paraesophageal component, consistent with a Type I (sliding) hiatal hernia. **Clinical Context:** This finding is typically associated with gastroesophageal reflux disease (GERD) and is a common incidental finding on cross-sectional imaging of the chest and abdomen.