Endometriosis Talk

uterine fundus

The superior haemorrhoidal artery

The superior haemorrhoidal artery

This artery is the continuation of the inferior mesenteric artery and descends in the base of the pelvic mesocolon. It divides into two branches which run on either side of the rectum and supply numerous branches to it.

The pelvic veins

The veins around the bladder, uterus, vagina and rectum form plexuses which intercommunicate freely.

Venous drainage from the uterine, vaginal and vesical plexuses is chiefly into the internal iliac veins.

Venous drainage from the rectal plexus is via the superior haemorrhoidal veins to the inferior mesenteric veins, and the middle and inferior haemor- rhoidal veins to the internal pudendal veins and so to the iliac veins.

The ovarian veins on each side begin in the pampiniform plexus which lies between the layers of the broad ligament. There are at first two veins on each side which accompany the corresponding ovarian artery. Higher up the vein becomes single; that on the right ends in the inferior vena cava and that on the left in the left renal vein.

Lymph draining from the lower extremities and the vulval and perinea regions is all filtered through the inguinal and superficial femoral nodes before continuing along the deep pathways on the side wall of the pelvis. One deep chain passes upwards lateral to the major blood vessels, forming in turn the external iliac, common iliac and para-aortic groups of nodes. Medially another chain of vessels passes from the deep femoral nodes through the femoral canal to the obturator and internal iliac groups of nodes. The last nodes are interspersed among the origins of the branches of the internal iliac artery, receiving lymph directly from the organs supplied by this artery, including the upper vagina, cervix and body of the uterus. From the internal iliac and common iliac nodes afferent vessels pass up the para-aortic chains, and finally all the lymphatic drainage from the legs and pelvis flows into the lumbar lymphatic trunks and the cisterna chyli at the level of the second lumbar vertebra. From here all the lymph is carried by the thoracic duct through the thorax, with no intervening nodes, to empty into the junction of the left subclavian and internal jugular veins. Tumour cells which penetrate or bypass the pelvic and para-aortic nodes are rapidly disseminated via the great veins at the root of the neck.

The lymphatic vessels from individual parts of the genital tract drai$ into this system of pelvic lymph nodes in the following manner. 1

The vulva and the perineum medial to the labiocrural skin folds cont~ superficial lymphatics which pass upwards towards the mons pubis

then curve laterally to the superficial inguinal and femoral nodes. Drain from these is through the fossa ovalis into the deep femoral nodes. T largest of these, lying in the upper part of the femoral canal, is known the node of Cloquet.

Vagina. The lymphatics of the lower third follow the vulval drainage the superficial inguinal nodes, whereas those from the upper two-t . pass upwards to join the lymphatic vessels of the cervix.

Cervix. The lymphatics pass either laterally in the base of the br ligament or posteriorly along the uterosacral ligaments to reach the' wall of the pelvis. Most of the vessels drain to the internal iliac, obturat and external iliac nodes, but vessels also pass directly to the common" and lower para-aortic nodes, so that radical surgery for carcinoma of cervix should include removal of all these node groups on both sides of pelvis.

Corpus uteri. Nearly all the lymphatic vessels join those leaving cervix and therefore reach similar groups of nodes. A few vessels at fundus follow the ovarian channels, and there is an inconstant path along the round ligament to the inguinal nodes.

The ovary and Fallopian tube have a plexus of vessels which drain al the infundibulopelvic fold to the para-aortic nodes on both sides of midline. On the left these are around the left renal pedicle, whilst on right there may be only one node intervening before the lymph flows'

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khurram akhtar
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