Lymphatic Drainage by Faisal Azmi

2. ‫فیصل‬ ‫محمد‬
‫جراحیات‬ ‫شعبہ‬
‫میڈیس‬ ‫یونی‬ ‫ٓف‬‫ا‬ ‫انسٹیٹیوٹ‬ ‫نیشنل‬‫بنگلور‬ ‫ن‬

3. Introduction
 Lymphatic System
 Development
 Lymphatic- less Areas
 Components
 Functions
 Flow Of Lymph
 Collecting Ducts
 Lymphatic Water sheds of Skin
Drainage Areas & Examinations

4. The lymphatic system was first described by ‫ایراسسطراطوس‬ in Alexandria more
than 2000 years ago.
William Hunter, in the late eighteenth century, was the first to describe the
function of the lymphatic system.
Starling’s pioneering work on the hydrostatic and haemodynamic forces
controlling the movement of fluid across the capillary provided further insights into
the function of the lymphatics.
‫ہیں‬ ‫ی‬ ‫ہ‬ ‫میں‬ ‫از‬‫ر‬ ‫صیغہ‬ ‫عوامل‬ ‫سے‬ ‫بہت‬ ‫متعلق‬‫سے‬ ‫اس‬ ‫بھی‬ ‫اب‬ ‫لیکن‬

5. The lymphatic system represents an accessory route through which fluid can
flow from the interstitial spaces into the blood.
(Guyton)
Primordial lymphatic system begins to develop during 6th week of
development adjacent to jugular vein as lymph sacs
Srb’s manual of surgery

6. Internal
jugular vein
Subclavian vein
Inferior vena cava
Jugular lymph sac
Thoracic duct
Cisterna chyli
Retroperitoneal lymph
sac
Posterior lymph sac

7. Brain, Choroid, Internal Ear, Epidermis,cornea,CNS,Cartilage,Tendon &
muscles
ROAMS & srb’ of manual surgery
There are about total 600-800 lymph nodes in the body.
Around 200-300 in the neck; around 100 in the thorax; around 50-60 in the axilla;
around 250 in the abdomen and pelvis; around 50 in the groin area.

8. Terminal lymphatic capillaries, which have high porosity absorb lymph,
macromolecules, cells and microbes from tissues into the system.
lymphatic vessels which collect and transport lymph;
lymph nodes which are interposed in the lymphatic pathway filter lymph and
maintain immunity of the body
Capillaries Vessels Node

9. It is mostly water and usually contains, albumin, globulin, salt, urea, neutral
fats, glucose and cells like monocytes and lymphocytes.
The lymphatics of intestine contain chyle rich in fat.
Tissue drainage
An "overflow mechanism" carry proteins and large particles away
from the tissue spaces, neither of which can be removed by
absorption directly into the blood capillaries.
(Guyton)

10. In the small intestine, special lymphatic vessels called lacteals absorb
dietary lipids that are not absorbed by the blood capillaries.
Defense. helps defend the body against disease by the WBCs of lymphatics

11. Lymph takes the following route from the tissues back to the
bloodstream:
lymphatic
capillaries
collecting
vessels
6
lymphatic
trunks
2
Collecting
ducts
Subclavian
veins
Thus, there is a continual recycling of fluid from blood to tissue fluid to lymph
and back to the blood.
1. Subclavian
2. Bronchomediastinal
3. Jugular
Thoracic duct—single;
Right lymph duct—single

12. Lymphatic duct
SYSTEMIC CIRCULATION PULMONARY CIRCULATION
Subclavian vein
Lymphatic vessel
Valve
Lymph node
Lymphatic capillaries
Systemic blood capillaries
Arteries
Lymphatic capillaries
Pulmonary blood
capillaries
Lymph node
Veins
Heart

13. This duct begins at the , cisterna chyli(is formed by joining of right and left
lumbar lymphatic trunks and intestinal lymphatic duct.) which is a dilated
lymph channel situated in front of the bodies of the first two lumbar
vertebrae. The duct is about 45cm long and opens into the left subclavian
vein in the root of the neck.
Both legs
 The pelvic
 Abdominal cavities
 Left half of the thorax
Head and neck
 Left arm

15. Right lymph duct
is 2.5 cm in
length, formed
by right jugular,
right subclavian
and right
bronchomediasti
nal trunks; runs
on the scalenus
anterior joining
the junction of
right internal
jugular vein and
subclavian vein.
(a) Anterior view of principal
components of lymphatic system
Palatine tonsil
Submandibular node
Cervical node
Right internal jugular vein
Right subclavian vein
Lymphatic vessel
Thoracic duct
Cisterna chyli
Intestinal node
Large intestine
Appendix
Red bone marrow
Lymphatic vessel
Left internal jugular vein
Left subclavian vein
Thoracic duct
Axillary node
Spleen
Aggregated lymphatic
follicle (Peyer’s patch)
Small intestine
Iliac node
Inguinal node

16. Area drained byright lymphatic duct
Area drained by thoracic duct

17. Lymph from the dermis and appendages drain into a plexus in deep fascia which
in turn drains into respective lymph nodes.
There are six watershed areas in the body for lymphatic drainage.
One vertical midline divides into right and left.
Two horizontal lines on each side divide the area into three zones.
First lies above the line of clavicle.
second between line of clavicle and line at umbilical level.
third below the level of umbilical line.

18. First drains into
head and neck
lymph nodes.
Second drains
into axillary nodes.
Third drains into
inguinal groin
nodes

19. It suggests the origin of the disease in the lymph node (secondaries from carcinoma or
melanoma/tuberculosis/ lymphadenitis) from a primary focus in the drainage area.

20. They are divided into superficial and deep Lymph nodes
Deep is called as Cloquet’s node. It drains from glans penis or clitoris.
Superficial lymph nodes are divided into
Vertical
Horizontal groups.
Vertical drains from lower limb.
Horizontal chains are divided into medial and lateral

24. In carcinoma penis inguinal nodes are divided into five zones (zones of
Rouviere) by a vertical and horizontal line centering at saphenous opening.
Zone 1-superolateral;
zone 2-superomedial;
zone 3-inferomedial;
zone 4-inferolateral;
zone 5 is central.
Superomedial zone 2 contains sentinel saphenoepigastric node of Cabanas.

25. They are palpated in
supine position in relation to inguinal ligament inrelaxed position
Inguinal lymph node palpation.

26. Drain (from umbilicus to toes)
Entire lower limb,perineum, penis, scrotum, vulva, anus, buttock, lower anal
canal, lower urethra, vagina, skin over lower below the umbilicus.

27. They drain entire upper limb, trunks, breast, and chest wall from the clavicle
to umbilicus.
Axillary lymph nodes are divided into three levels in relation to pectoralis
minor muscle. Berg’s levels—
Level I:Below the pectoralis minor;
Level II: behind the pectoralis minor;
Level III: above the pectoralis minor.
Berg’s levels

28. Anterior group (pectoral group) is situated behind the anterior axillary
fold
Central group (medial group) is over the lateral thoracic wall.
Lateral/brachial axillary nodes are situated over the axillary vein
Subscapular lymph nodes are located in the posterior axillary fold in relation
to latissimus dorsi muscle.
Apical group of lymph nodes

29. Axilla should be inspected with arm raised
above in sitting position

30. Examination of pectoral nodes. Examination of medial/central group of lymph
nodes.
Examination of subscapular group
of lymph nodes.

32. Lymph nodes in the head and neck are arranged in two horizontal rings and two
vertical chains on either side of the neck .
The outer, superficial, ring consists of the occipital, preauricular (parotid),
submandibular and submental nodes,
The inner, deep, ring is formed by clumps of mucosa associated lymphoid tissue
(MALT) located primarily in the naso- and oro-pharynx (Waldeyer's ring).
The vertical chain consists of superior and inferior groups of nodes related to the
carotid sheath. All lymph vessels of the head and neck drain into the deep cervical
nodes, either directly from the tissues or indirectly via nodes in outlying groups.
Lymph is returned to the systemic venous circulation via either the right lymphatic
duct or the thoracic duct.

34. Cervical lymph nodes drain from lymphatics of head, neck, face, oral cavity, nasal
cavity, paranasal sinuses, pharynx, larynx and thyroid. Left supraclavicular nodes
receive from left upper limb, left side chest wall, left breast, abdomen and both testes.
Cervical lymph nodes
can be superficial or deep.

35. levels—Level I to level VI. Level VII is mediastinal node.
Level I—submental and submandibular nodes;
level II is upper deep cervical;
level III is middle deep cervical;(Mid Jugular)
level IV is lower deep cervical; (Supra clavicular)
level V is posterior triangle nodes;
level VI is central nodes (paratracheal and laryngeal).

37. A to D: Palpation of submental and submandibular lymph nodes on both sides.

38. Level 11 Level iii Level iv
Level v
supraclavicular nodes in the neck.

39. Opposite side neck also should be always
examined for any enlargement of lymph nodes
Epitrochlear lymph node
palpation—2 cm above the
medial epicondyle.

41. Lymphatic drainage
Lymph from the upper half of the anal canal flows upwards to drain into
the post rectal lymph nodes and from there goes to the para-aortic
nodes via the inferior mesenteric chain.
Lymph from the lower half of the anal canal drains on each side first
into the superficial and then into the deep inguinal group of lymph
glands.