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Skandalakis’ Surgical Anatomy > Chapter 29. Lymphatic System >


The anatomic and surgical history of the lymphatic system is shown in Table 29-1.

Table 29-1. Anatomic and Surgical History of the Lymphatic System

Hippocrates (ca. 460-ca. 360 B.C.)   Described axillary lymph nodes and “white blood” in the nodes
Aristotle (384-322 B.C.)   Described “fibers which take position between blood vessels and nerves and which contain colorless liquid”
Herophilus of Chalcedon 300 B.C. Probably knew about the “milk-bearing vessels” of the mesentery
Erasistratus (310-250 B.C.)   Described lymphatics of small bowel
Marinus (fl. A.D. 50)   Described mesenteric lymph nodes
Galen (A.D. 129-199)   Described mesenteric lymph nodes and lacteal veins
Paul of Aegina (A.D. 607-690)   Most likely described infected lymph nodes at the lower neck (scrofulae)
Nicola Massa 1532 By dissecting human cadavers, saw renal lymphatic vessels
Gabriello Falloppio (1523-1562)   Described mesenteric “vein” containing yellow matter in dissection on human cadavers
Bartholomeus Eustachius 1563 From dissecting a horse, described thoracic duct (“vena alba thoracica”)
Marco Aurelio Severino (1580-1656)   Performed radical mastectomy with axillary dissections
Nicolas Claude Fabrice de Peirsc (1580-1637)   Saw chyliferous vessels in dissection of a criminal fed a rich meal before execution
Gaspare Aselli 1622 Based on vivisection of well-fed dog and dissection of mammals, described white cords (the lacteals) containing milky-appearing liquid
Francis Glisson (1597-1677)   Theory of absorbent function of lymphatics
Johann Vesling 1634 Based on cadaver studies, produced earliest illustrations of human lymphatics; described thoracic duct
Thomas Bartholin 1643 First to use the word “lymphatics”
George Joliff (ca. 1618-1658)   Recognized that lymphatic vessels are throughout the body carrying “aqueous humor”
Jean Pecquet 1647 Based on human and animal dissection, and injection studies, described thoracic duct and cisterna chyli
Johannes van Horne of Leyden 1651 During autopsy, accidentally discovered the thoracic duct in man without knowing the work of others
Marcello Malpighi (1628-1694)   Described conglobate glands along course of lymphatics
Olof Rudbeck 1651-1652 Based on human and animal dissection, described course of lymphatics from liver and other organs to thoracic duct and venous system
Jan Swammerdam (1637-1680)   Using suet and wax injections, discovered valves of the lymphatics
Frederick Ruysch 1665 Based on intravascular (intra-lymphatic?) injections, described morphology and function of lymphatic valves
Niels Stensen (1638-1686)   Discovered right lymphatic duct
Anton Nuck 1692 Based on mercury injection, described fine lymphatic vessels
Johann Conrad Peyer (1653-1712)   Described areas of lymph nodules in mucous membrane of small intestine (Peyer’s patches)
Antonio Pacchioni 1705 “Glandulae” (glands) secrete lymph
Jean Louis Petit (1674-1760)   First to show the spread of mammary cancer to axillary lymph nodes; advocated radical removal of the breast muscle and lymph nodes but not the nipple
Henri Francois LeDran (1685-1770)   First description of spread of cancer along lymphatics
Johann Nathanael Lieberkuhn 1745 Using microscopic injections and corrosion preparations, demonstrated origin of lymphatics in intestinal villi
Angelo Nannoni (1715-1790)   Removed malignant breast tumors by excision of wide margin, underlying fascia, large muscle, and nearby lymph nodes
William Hunter 1746 Based on dissection of birds, fish, and amphibians, and using mercury injection, stated that the lymphatic vessels “constitute one great and general system”
Johann Friedrich Meckel 1772 Described lymphovenous connections
John Hunter (1728-1793)   Discovered lymphatics in the neck of the swan and in the crocodile. Theorized cancer spread via lymphatic route: “The red veins do not absorb in the human body” (experimental studies of intestinal veins in dogs).
Alexander Monro the Second (1733-1817)   Based on injection with quicksilver, described lymph nodes
William Hewson (1739-1774)   Complete account of mercury-injected lymphatic system in the human subject, and description of lacteals and lymphatic vessels in other species. Divided the lymphatic system into deep and superficial lymphatics. Noted the occurrence of lymphocytes in lymph. Performed controlled experiments with blood and lymph to study coagulation. Lymphatics involved in absorption of poisonous substances and progress of wound inflammation and cancer. Published, in 1774, important treatise, The Lymphatic System in the Human Subject and in Other Animals. 
William C. Cruikshank (1745-1800)   Via clinical observation and injection of mercury into the subdermal lymphatic channels through very thin glass catheters, traced lymph vessels from the periosteum to the cortex of the bone. Continued classification of lymphatics, regional lymph drainage, and lymphatic topography. Stated that lymphatics is involved in defense against infection and the formation of edema.
Benjamin Bell (1749-1806)   First in England to advise radical mastectomy
Thomas Pole (1754-1829)   Described techniques (injection and corrosion studies) for lymphatic system dissection
Paolo Mascagni 1787 Based on mercury injection, said all the lymphatics pass through one or more lymph nodes during their course; published elegant atlas with detailed anatomy of the lymphatics in human body, as well as copper engravings 
Guillaume Dupuytren (1777-1835)   First to identify fibrin in chyle
Vincenz Fohmann 1821 Comparative anatomic study of direct communications between lymphatics and peripheral veins
Gabriel Andral 1824 or 1829 First report of lymphangitis carcinomatosa (based on autopsy results)
Astley Paston Cooper 1825 Using mercury injection, investigated lymphatics of the breast
Thomas Hodgkin 1832 Described diseases of the lymph nodes and spleen; Hodgkin’s lymphoma was one of his discoveries
Johannes Peter Müller (1801-1858)   By microscopic analysis and experimentation, studied chemical and physical properties of blood, lymph, and chyle
Karl Langer 1868 Based on observations of tadpoles, suggested that the endothelium of the lymphatics is of venous origin
Marie Philibert, Constant Sappey 1870s Based on mercury injection of cutaneous and deeper lymphatic trunks, described valves, counted up to 80 valves along the length of the human arm; very accurate drawings
Carl F. Ludwig (1816-1895)   Isolated and cannulated lymphatics in animals; analyzed lymph and believed it was formed by a process of filtration
Albert von Koelliker (1817-1905)   Studied capillary lymphatics, comparing amphibians, mammals, and humans
Charles Phillippe Robin (1821-1885)   Described small spaces in the external coat of arteries communicating with lymphatics
Rudolf Virchow (1821-1902)   “Barrier theory” of defensive role of lymph glands
Friedrich Daniel von Recklinghausen (1833-1910)   Using silver nitrate to stain black the epithelium of the lymphatics, identified fine lymphatic vessels within their surrounding tissue  
Dimitru Gerota 1896 Injected Prussian blue in turpentine and ether to visualize lymphatics; contributed to understanding of collecting lymph vessels; described the lymphatic route from the mammary glands to the liver or subdiaphragmatic nodes by which cancer of the breast may be spread
Louis Antoine Ranvier 1897 Based on microscopic studies of lymphocyte histology, hypothesized that terminal lymphatics are closed
Joseph Coats (1846-1899)   Studied lymphatic and extralymphatic cancer metastasis
Berkeley George 1904 Emphasized that the glands must be sought and removed in gastric resections for cancer
Andrew Moynihan
Ernest H. Starling (1866-1927)   Discovered that colloid osmotic pressure of protein in plasma acts to retain fluid in the blood stream and balances the hydrostatic pressure in the capillaries. Capillaries are impermeable to protein; lymphatics absorb protein molecules and return them to the circulation.
Florence Rena Sabin 1911 Based on vertebrate embryos, said lymphatic sacs have venous origin and lymphatic vessels spring from sacs; emphasized that lymphatic and blood capillaries have the same relationship to tissue space
Karl Sternberg (1872-1935)   Based on pathology studies, identified multinuclear giant cells in lymph nodes and spleen in Hodgkin’s disease (Reed-Sternberg cells)
Dorothy Reed (1874-1964)
James Bumgardner Murphy (1884-1950)   First experimental proof that lymphocytes are involved in immunity to grafted tissue, tuberculosis, and cancer (based on grafting tumor fragments onto bird embryos)
Cecil K. Drinker, Joseph Mendel Yoffey, Frederick Colin Courtice 1940s Demonstrated that the principal function of the lymphatic system is the absorption of protein from the interstitial tissues
Marceau Servelle 1943 By injecting thorium dioxide (Thorotrast), visualized lymphatics in patients with elephantiasis
J. Deysson
J.A. Weinberg 1951 Performed vital staining of lymphatics of the lung; mapped lymph nodes to minimize unnecessary dissection
John Bernard Kinmonth 1952 Developed a clinically applicable lymphangiogram
Denis Parsons Burkitt 1958 Noted that a tumor of the jaw followed unrecognized lymphoma
Peter Carey Nowell 1960 Noted mitotic activity of mononuclear leukocytes from human peripheral blood 48 to 72 hours after stimulation with a red kidney bean extract
R.J.V. Pulvertaft 1964 Described characteristics of cells from Burkitt lymphoma tumor. Later identified the morphology of the Burkitt lymphoma cell with the phytohemagglutinin-transformed lymphocyte.
Michael Antony Epstein (1921-?)   Studied microscopic biopsy specimens and grew cells from Burkitt tumor
Yvonne M. Barr (?-?)
Sayegh et al. 1966 Used term “sentinel node” to mean the node first visualized following injection of dye (lymphangiography)
R.M. Cabanas 1977 Stated sentinel node concept; demonstrated that sentinel node biopsy could precede lymphadenectomy
Alex & Krag 1993 Reported on ability of radioactive tracers to identify sentinel node

Source: History table adapted from Skandalakis JE. I wish I had been there: highlights in the history of lymphatics. Am Surg 61(9):799-808, 1995; with permission.


Alex JC, Krag DN. Gamma-probe guided localization of lymph nodes. Surg Oncol 1993;2:137-143.

Cabanas RM. An approach for the treatment of penile carcinoma. Cancer 1977;39:456-466.

DePalma RG. Disorders of the lymphatic system. In: Sabiston DC Jr. (ed). Textbook of Surgery, 14th Ed. Philadelphia: WB Sauders, 1991.

Gans H. On the discovery of the lymphatic circulation. Angiology 13:530-536, 1962.

Kanter MA. The lymphatic system: an historical perspective. Plast Reconstr Surg 79(1):131-139, 1987.

Knight B. Discovering the Human Body. New York: Lippincott & Crowell, 1980.

Leeds SE. Three centuries of history of the lymphatic system. Surg Gynecol Obstet 144:927-934, 1977.

McGrew RE. Encyclopedia of Medical History. New York: McGraw-Hill, 1985.

Mayerson HS. The lymphatic system with particular reference to the kidney. Surg Gynecol Obstet 116(3):259-272.

Sayegh E, Brooks J, Sacher E, Busch F. Lymphangiography of the retroperitoneal lymph nodes through the inguinal route. J Urol 1966;95:102-107.

Schmidt JE. Medical Discoveries: Who and When. Springfield IL: CC Thomas, 1959.

Weinberg JA. Identification of regional lymph nodes in the treatment of bronchiogenic carcinoma. J Thorac Surg 1951;22:517-526.


Normal Development

In spite of the important role that the lymphatic system plays in human physiology and disease, much concerning its genesis remains an enigma. During the 5th week of gestation, two paired and two unpaired endothelial sacs arise as outgrowths from the venous channels. These sacs form the primordia of the lymphatic system.

The first primordial lymph sacs to appear are the paired jugular sacs in the neck. They are located bilaterally at the junction of the subclavian and internal jugular (precardinal) veins. Soon thereafter, extensions from these sacs are visible in the upper limbs. The next sac to appear is unpaired and located at the mesenteric root in the retroperitoneal space. Later the unpaired cisterna chyli develops dorsal to the mesenteric sac. The final paired sacs, two posterior (iliac) sacs, appear at the junction of the sciatic and femoral veins. In short, it may be said that embryologically the lymph system originates and terminates in the venous system.

By the end of the ninth week, these six lymphatic sacs are linked together by multiple endothelial channels to form a complicated network of lymphatic vessels (Fig. 29-1). During early fetal development mesenchymal cells invade these sacs, converting them into groups of lymph nodes. True lymph nodes, however, do not appear until the system of vessels is well established.

Fig. 29-1.

Development of the lymphatic vessels. A. Human embryo at nine weeks, showing the primitive lymph sacs and the developing vessels. B. Ventral view of the formation of the single thoracic duct from the primitive paired lymphatic plexus. (Modified from Arey LB. Developmental Anatomy. Rev. 7th Ed. Philadelphia: WB Saunders, 1974. A, after Sabin FR. The development of the lymphatic system. In: Keibel F, Mall FP, eds. Manual of Human Embryology, vol. 2. Philadelphia: JP Lippincott, 1912. Used with permission.)

The earliest nodes appear in the places occupied by the primary sacs and confluences of capillary plexuses. At first, the nodes are represented by unencapsulated lymphoid tissue located within the meshwork of lymphatic channels. Later, the lymphoid mass separates into smaller portions allowing the inward growth of blood vessels and the lymphatic network. Each mass, together with portions of the surrounding network, becomes enclosed by a capsule of connective tissue. Original lymphoid tissue transforms into the medullary cords and cortical nodules of the node; the enclosed lymphatic capillaries form the peripheral lymph sinus. Cervical lymph nodes appear around the 9th week. Later, several other groups of lymph nodes are formed in various areas of the body.

The right and left thoracic ducts are channels connecting the right and left jugular lymph sacs with the cisterna chyli. The cisterna chyli also connects to the lower intercostal trunks, intestinal trunk, and lumbar trunks. The adult thoracic duct forms between weeks 6 and 8. It develops from the anastomosis of the right and left thoracic ducts at the level of the 4th to 6th thoracic segments, the distal (caudal) part of the right thoracic duct, and the proximal (cranial) part of the left thoracic duct. The right thoracic (lymphatic) duct is formed from the proximal part of the right thoracic duct. It must be noted, however, that the development presented here is speculative. The reader will find more detailed information in Embryology for Surgeons.2

Embryologically, lymphocytes are derived from the primitive stem cells in the mesenchyme of the yolk sac. From a functional standpoint, there are two types of lymphocytes: T cells and B cells. The progeny of the lymphopoietic stem cells found in the bone marrow that are destined to become T cells exit the marrow and settle in the thymus where their differentiation is completed. Ultimately T cells enter the circulation as the long-lived small lymphocytes. B cells originate in marrow, gut-associated lymphatic tissue, and the spleen. T cells are responsible for cellular immunity; B cells are responsible for the synthesis of antibodies.

Congenital Anomalies

It is not within the scope of this chapter to discuss lymphatic anomalies in detail. Table 29-2 presents an overview of some of the more common variations.

Table 29-2. Anomalies of the Lymphatic System

Anomaly Prenatal Age at Onset First Appearance (or Other Diagnostic Clues) Sex Chiefly Affected Relative Frequency Remarks
Variations in the course of the thoracic duct 2nd month No pathologic structures Equal Common  
Cystic hygroma (cystic lymphangioma) 6th to 9th weeks? At birth or in infancy Equal (neck); male (groin) Uncommon Invasive growth; may be a neoplasm
Primary lymphedema: Milroy’s disease 3rd month? At birth Equal? Rare Familial tendency
Lymphedema precox 3rd month? At any age Equal? Rare  
Mesenteric, omental and retroperitoneal lymphatic cysts ? In infancy to middle age Male (children); female (adults) Uncommon  

Source: Skandalakis JE, Gray SW. Embryology for Surgeons, 2nd Ed. Baltimore: Williams & Wilkins, 1994; with permission.

Congenital anomalies of the lymphatic system are relatively rare. One condition is seen as diffuse swelling of some portion(s) of the body called “congenital lymphedema.” Whether this is due to congenital hypoplasia of the lymphatic vessels or from dilatation of the primitive lymphatic vessels is still to be established. Less commonly, there are cases of diffuse cystic dilations of the lymph vessels which exist widely throughout the body.

We quote from Musone et al.3:

Cystic hygroma is a malformation of the lymphatic system that is diagnosed by ultrasound very well from the first quarter of pregnancy. It is frequently associated with chromosomal and non-chromosomal abnormalities. The presence of septae in it and amniotic fluid alpha-fetoprotein levels are prognostic indicators.

Hygromas (cystic lymphangiomas) develop as large swellings in the lower neck. Hygromas are large cavities filled with fluid which may appear at birth and frequently grow and make their presence known in the infant. Riquet et al.4 distinguish between tissular lymphangiomas of the neck and mediastinum found in childhood through young adulthood, and the purely liquid cysts of the posterior or middle mediastinum of older adults. The former are congenital, the latter suggest an acquired origin. Hygromas, according to Moore and Persaud,5 apparently are derived from abnormalities in the jugular lymph sacs. Hygromas may be pinched off parts of the lymph sacs or may be lymphatic spaces which never established connections with lymph channels.

Pulmonary lymphangiectasia, a rare disease characterized by abnormal pulmonary lymphatics, was studied by Bouchard et al.6 They reported that although it is fatal in the neonatal period, survival is possible and symptomatology decreases with age.

Surgical Anatomy

The various elements of the lymphatic system, such as the ring of Waldeyer (tonsillar ring), thymus gland, spleen, bone marrow, and lymphatic follicles of the respiratory, genitourinary, and alimentary systems are discussed in other chapters. In addition, the lymphatic drainage of each organ and region of the trunk is discussed in chapters pertinent to them. The primary purpose of this chapter is to present anatomic information which is related to surgery, rather than describing the lymphatic system in toto.

The lymphatic system can be divided into two broad categories: the lymphatic network at large and the lymphatic organs.

The lymphatic network at large includes:


The complicated network of irregular capillaries, consisting of minute lymph vessels that drain the lymph of the body (with the exception of hyaline cartilages, epidermis, and the eye’s cornea)

Larger lymph vessels which drain the capillaries

Lymph glands which accept lymph from the lymph vessels and filter the lymph

Large lymph vessels which are responsible for draining the lymph into the veins

The lymphatic entities to be studied in this chapter are:


Cisterna chyli

Thoracic duct

Right lymphatic duct

Cisterna Chyli

Is the cisterna chyli a typical and constant anatomic entity? Anatomists disagree. An illustration in Gray’s Anatomy7 designates the cisterna chyli as “atypical” and “unusual.” Woodburne and Burkel,8 quoting Nelson, indicate that the cisterna chyli is present in 25 percent of individuals as a dilatation of the thoracic duct. In only 35 percent of Rouvière’s9 dissections was a true cisterna chyli demonstrated. Lee McGregor’s Synopsis of Surgical Anatomy10 describes it as being present in 50 percent of cases. The authors of this chapter will designate as “cisterna chyli” a dilatation of the proximal thoracic duct or perhaps confluence of lymphatic trunks that may form a sac.

The cisterna chyli is an elongated and sometimes dilated sac about 5 cm in length. It is located in the shadow of the right side of the aorta and behind the right diaphragmatic crus at the surface of L2 (variably, T12-L2). It receives the right and left lumbar trunks, the intestinal trunk, and the lowest intercostal vessels (Figs. 29-2 and 29-3).

Fig. 29-2.

The general plan of the lymphatic system. (Modified from Woodburne RT, Burkel WE. Essentials of Human Anatomy (9th ed). New York: Oxford University Press, 1994; used with permission.)

Fig. 29-3.

Formation of the cisterna chyli by several trunks and proximal thoracic duct. (Modified from Brantigan OC. Clinical Anatomy. New York: McGraw-Hill Book Co., 1963; used with permission.)

Multiple sacculations may be present as a result of the contributing vessels. However, sacculations are not present after the convergence of the contributing vessels with the cisterna chyli. Alternatively, the meeting place of the principal vessels may be thoracic rather than abdominal. Because of the relative infrequency of a distinctly dilated cisterna, the term should be understood to be of topographic convenience but not necessarily related to the degree of distension. To diagnose such a giant cisterna chyli, MRI with gadolinium-DTPA enhancement has been used.11

The right and left lumbar trunks transmit lymph from the abdominal wall below the level of the navel, pelvis, kidneys, and adrenal glands. The intestinal trunk, which receives the lymph and chyle from the parts of the gastrointestinal tract supplied by the celiac and superior mesenteric arteries, occasionally empties directly into the so-called cisterna chyli. However, in most cases, the intestinal trunk is a tributary of the left lumbar trunk. The intercostal trunks enter the upper part of the cisterna chyli or empty into the beginning of the thoracic duct.

Thoracic Duct

The thoracic duct is approximately 45 cm long and 2-5 mm in diameter. The lower end of the duct receives descending, paired, posterior intercostal lymph vessels that drain the lower six or seven intercostal spaces. As it ascends, the duct receives additional tributaries from posterior mediastinal nodes and the upper intercostal spaces. Its terminal tributaries are the left jugular, subclavian, and bronchomediastinal trunks.

The duct can be subdivided into three parts: abdominal, thoracic, and cervical. The abdominal part of the thoracic duct originates from the cranial part of the cisterna chyli. With the aorta on its left and the azygos vein on its right, the thoracic duct passes through the “aortic hiatus” of the diaphragm to form the thoracic part. It maintains this relationship as it passes through the posterior mediastinum. During its ascent, the thoracic vertebrae, right intercostal arteries, and terminal portions of the hemiazygos and accessory hemiazygos veins are posterior to the thoracic duct; the esophagus, diaphragm and pericardium are anterior to it.

At the level of T7 (Fig. 29-4), the thoracic duct travels obliquely behind the esophagus to the level of the fifth thoracic vertebra. At T5, it reappears from behind the esophagus to continue its upward journey on the left of the esophagus and medial to the pleura. In the base of the neck, the thoracic duct passes posterior to the common carotid artery, internal jugular vein, vagus nerve, left anterior scalene muscle, and left phrenic nerve. It passes anterior to the vertebral artery and vein and the sympathetic trunk. The duct proceeds upward to the level of C7, whereupon it descends across the subclavian artery. It ends in the junction of the left subclavian vein and left internal jugular vein, thus forming the cervical part of the thoracic duct. A rare large thoracic duct cyst that expanded into the anterior cervico-thoracic junction has been reported by Karajiannis et al.12

Fig. 29-4.

The oblique thoracic course of the definitive thoracic duct, resulting from the anastomosis of the right and left thoracic ducts. The definitive duct represents the retention of the proximal part of the right thoracic duct and the distal segment of the left thoracic duct.

The thoracic duct is the largest lymphatic channel in the body. It collects lymph from the entire body except the right hemithorax (thoracic wall, right lung, right side of the heart, part of the diaphragmatic surface of the liver, lower area of the right lower lobe of the liver), right head and neck, and right upper extremity. The volume of flow through the thoracic duct is between 60 and 190 cc/hr; consequently, large quantities of plasma proteins can be lost quickly from the blood in the event of trauma to the duct or in association with malignant tumors. Simple ligation of the vessel is followed by gradual restoration of normal levels of blood fat over a period of about two weeks, as collateral channels reroute the flow.13

Regurgitation of blood from the jugulosubclavian confluence into the thoracic duct is not possible in life because the opening of the thoracic duct into the subclavian vein is protected by valves. In cadaveric specimens, backflow of blood into the thoracic duct from the jugulosubclavian venous junction is often apparent, causing the duct to resemble a vein.

There are several variations in the termination of the thoracic duct (Figs. 29-5 and 29-6). In 1959 Jdanov14 reported termination in the following sites:


Internal jugular vein 48%

Subclavian vein 9%

At the junction of the internal jugular and subclavian veins 35%

Left brachiocephalic (innominate) vein 8%

Fig. 29-5.

Variations of the entry of the thoracic duct into the venous system. a. A single thoracic duct and a simple junction. b. Plexiform ramification of the final segment of a thoracic duct, but with a simple junction. c. Delta-like entry of the thoracic duct. d. Duplication of the final segment of the thoracic duct and two separate junctions. e. Ampullary enlargement of the thoracic duct with multiple terminal branches. (From Heberer G, van Dongen RJAM (eds). Vascular Surgery. Berlin, Heidelberg: Springer-Verlag, 1989; used with permission.)

Fig. 29-6.

Photographs of the various types of endings of the trunk of the thoracic duct. A. Type A-1. The duct is directly inserted into the venous angle. B. Type A-2. The duct separates into two trunks before and after running below the left brachiocephalic vein. C. Type A-3. The duct has two trunks, one extending to the beginning of the subclavian vein and the other to the venous angle. D. Type B-1. The duct with two trunks runs directly to the internal jugular vein. E. Type B-2. The duct separates into three trunks after running below the left brachiocephalic vein; one trunk runs to the internal jugular vein, and the others (two branches) to the subclavian vein. F. Type C-1. One trunk is inserted into the external jugular vein and the other into the subclavian vein. G. Type C-2. One trunk is inserted into the external jugular vein and the other into the internal jugular vein. H. Type D. There are four trunks and they are inserted into the beginning of the internal and external jugular veins, and into the subclavian vein. ejv, external jugular vein; ijv, internal jugular vein; lbv, left brachiocephalic vein; sv, subclavian vein. (From Shimada K, Sato I. Morphological and histological analysis of the thoracic duct at the jugulo-subclavian junction in Japanese cadavers. Clin Anat 1997;10:163-172; used with permission.)

Kinnaert15 dissected 49 cadavers and collected 480 additional cases. He reported the termination of the thoracic duct as follows:


No evidence of left thoracic duct 0-4.5%

Multiple terminal openings:

In others’ cases 10-40%

In his cases 21%


Termination into the internal jugular vein 36%

Termination into the subclavian vein 17%

Termination into the junction of internal jugular and subclavian veins 34%

Shimada and Sato16 found that only 38% of Japanese had thoracic ducts that terminate in the jugulosubclavian angle. In comparison, previous studies by Kihara and Adachi17 found this occurrence in 78.2% of Japanese and in 33% of European subjects. Shimada and Sato noted the following sites and frequencies of termination of the trunk of the thoracic duct (Fig. 29-6), each major type also possessing subtypes not discussed here:


Venous angle 38%

Internal jugular vein 27%

External jugular vein 28%

Other, complex configurations 7%

Shimada and Sato16 noted that while the multiple complex configuration occurred only 7% of the time, this termination was highly correlated with an increased risk of metastasis in cervical or mediastinal lymph node dissections. Also, there was a high risk of injury to the terminations of the duct during radical neck dissection.

In Clinical Anatomy and Pathology of the Thoracic Duct: An Investigation of 122 Cases,18 Jacobsson presented a very useful summary of the thoracic duct which we reprint here with gratitude.

An anatomical study was made of the thoracic duct in 100 autopsy cases. A thoracic duct was found in every case and always started below the diaphragm, passed the posterior mediastinum in the thorax and discharged into the confluence of the veins in the left of the neck. In 4% of the cases a branch left the thoracic part of the thoracic duct at the aortic arch and emptied into the veins in the right side of the neck.

The beginning of the thoracic duct conformed to one of four types, depending on how the lumbar and intestinal trunks combined into the abdominal part. In 20% the thoracic duct arose from the confluence of the lumbar and intestinal trunks and in 55% it was formed after the intestinal trunk, branched or un-branched, had joined either the thoracic duct or one or both lumbar trunks. In 24% the thoracic duct ascended from a plexus formed by the lumbar and intestinal trunks. In 1% the thoracic duct had a plexiform structure throughout its course.

A cisterna chyli was found in 52% of the cases, with a roughly uniform distribution by sex. Its diameter averaged 6.7 mm but varied between 4 and 14 mm. In the thoracic part, insulae and plexus formations of the thoracic duct were found in 32%. The cervical part of the thoracic duct corresponded to one of 9 types, A, B and C having a single trunk with one (36%), two (13%) and three (3%) openings respectively into the venous system, D, E and F one or several insulae and one (18%), two (3%) and three (1%) openings respectively into the venous system, and G, H and I one or several plexuses and one (14%), two (9%) and three (3%) openings respectively, into the venous system on the left side of the neck. A total of 139 openings into the left veins in the neck were found in the l00 specimens of the thoracic duct. The most common site was the left subclavian vein (64), followed by the left venous angle (51), the left internal jugular vein (22) and the left external jugular vein (2).

Small lymph vessels emptied into the thoracic duct along its entire length and close connections were found with lymph nodes. Left jugular and subclavian trunks were often detected in the cervical part, emptying into the thoracic duct or independently into the cervical veins.

The thoracic duct was found to be irregular and its diameter was not constant, usually being greatest in the cervical part (excluding the cisterna chyli) and smallest in the lower thoracic part. Measurements at five levels gave the following average cross-sectional areas: (1) 14.7 sq. mm one centimeter from the opening into the venous system, (2) 11.5 sq. mm one-third of the way from the termination to the aortic arch, (3) 6.4 sq. mm at the aortic arch, (4) 4.5 sq. mm midway between the aortic arch and the diaphragm, and (5) 7.0 sq. mm one centimeter below the diaphragm. The largest and smallest external diameters measured in the cervical part were 8 mm and 1.5 mm.

Constrictions were observed along the thoracic duct, usually corresponding to the location of bi-cuspid valves in the vessel. The valves became more numerous as one approached the opening into the venous system, averaging 4.6 below the diaphragm, 5.9 between the diaphragm and the aortic arch, and 11.1 between the aortic arch and the termination of the thoracic duct. A terminal valve at the opening into the left cervical veins was found in 82 instances, no valve at all in the vicinity of this junction in 2 instances and a valve 1-6 mm from the opening in 55 instances.

Right Lymphatic Duct

The right lymphatic duct “typically” begins with the union of three lymphatic trunks: right jugular, right subclavian, and right bronchomediastinal (Figs. 29-7 and 29-8).

Fig. 29-7.

Variations of the lymphatic junctions at the right venous angle. A. Entry of the tributaries into the right lymphatic duct. B. Partial entry into the right lymphatic duct. C. Separate entry of the tributaries near the right venous angle. (From Heberer G, van Dongen RJAM (eds). Vascular Surgery. Berlin, Heidelberg: Springer-Verlag, 1989; used with permission.)

Fig. 29-8.

Variations in the terminal lymph trunks of the right side. a = jugular trunk; b = subclavian trunk; c = bronchomediastinal trunk; d = right lymphatic duct; e = lymph node of parasternal chain; f = lymph node of deep cervical chain. (Modified from Williams PL (ed). Gray’s Anatomy (38th ed). After Poirier & Charpy. New York: Churchill Livingstone, 1995; used with permission.)

The right bronchomediastinal trunk is regarded as the vestigial portion of the terminal (cranial) segment of the embryologic right thoracic duct. It receives lymphatic drainage from the right lung, lower left lung, right diaphragm, most of the drainage from the heart, and some drainage from the right lobe of the liver.

The right lymphatic duct is approximately 2 cm long. It is very closely related to the anterior scalene muscle. In the majority of cases, the right lymphatic duct empties into the junction of the right subclavian and right internal jugular veins. However, as demonstrated in Figures 29-7 and 29-8, its termination also has numerous variations.

Histology and Physiology

Lymph capillaries are very thin. They unite to form lymphatic vessels. Lymph capillaries are lined by endothelium and are slightly larger than blood capillaries. They are unique, however, in that they lack a continuous basal lamina and are permeable only in one direction. The edges of adjacent endothelial cells overlap significantly, providing an intercellular cleft with one or two tiny points of closer apposition and adherence.

Extracellular bundles of filaments extend outward from the endothelium between collagen bundles of the surrounding connective tissues. These bundles are believed to play a role in keeping the lumen of the vessel open. Furthermore, it is presumed that as interstitial fluid increases around the lymphatic capillary, the “anchoring” filaments open the clefts, allowing the inward flow of intercellular fluid and even large molecules. As a result, relatively large products of metabolism can enter the lymph vessel, thereafter being pushed by the contraction of surrounding muscles and interstitial pressures.

The pathway of lymph starts in interstitial tissue spaces where lymph accumulates, perhaps secondary to the slight predominance of capillary filtration and reabsorption. Lymph passes from lymph capillaries to lymphatic vessels by propulsion and contraction. The lymphatic vessels carry the fluid to the lymph nodes by way of the nodal sinuses. Efferent vessels carry the lymph to the next node in the chain, and eventually the fluid flows to lymph trunks. The trunks pass the lymph into the thoracic and right lymphatic duct, where it reaches the venous circulation.

If some lymph vessels are damaged or blocked, new vessels form readily. The system drains broadly into the venous system. It is well understood that the thoracic duct and the right lymphatic duct open into their respective brachiocephalic veins, but those who have studied these vessels report openings of lymph vessels into the inferior vena cava, renal, suprarenal, azygos, and iliac veins.

Lymph capillaries and lymphatic vessels have one-way valves which open upon contraction of the vascular wall. These valves permit the passage and circulation of lymph fluid (3 to 5 liters daily) into larger vessels and, ultimately, to the thoracic ducts. The valves are bicuspid and prevent backflow.

Lymphatic vessels always follow minute arteries and veins. They resemble veins in structure but have thinner walls, more valves, and contain lymph nodes at various intervals along their length.

The exact number of lymph nodes in the body is not known and estimates vary greatly. According to Gray’s Anatomy,7 a normal young adult body contains some 400-450 lymph nodes, distributed approximately as follows: head and neck, 60-70; thorax, 100; abdomen and pelvis, 230; arm and thoracoabdominal wall (supraumbilical area), 30; leg and lower abdominal wall and superficial buttocks and perineum, 20. Conversely, Bailey and Love’s Short Practice of Surgery19 reported a total of 800 lymph nodes, 300 of which are located in the neck.

Lymph nodes are responsible for filtering lymph and producing antibodies by responding to antigens. Nodes vary greatly in size, ranging from 1-2 mm to 3-4 cm in diameter.20 Each node (Fig. 29-9) is covered by a capsule of dense connective tissue which sends trabecular extensions to the center of the lymph node. The nodal parenchyma is divided into two regions: cortex and medulla.

Fig. 29-9.

A semi-schematic frontal section of a lymph node. (Modified from Woodburne RT, Burkel WE. Essentials of Human Anatomy, 9th Ed. New York: Oxford University Press, 1994; with permission.)

The cortex is the outer and more densely staining part of the lymph node. The cortex contains lymph nodules or follicles (aggregations of lymphocytes) which contain lighter staining germinal centers. According to Roth and Reith,21 the germinal center is a “morphological indication of lymphatic tissue response which ultimately leads to lymphocyte, plasma cell, and antibody formation.” The germinal center may be the site of genesis of the immune system.

The innermost part of the lymph node is the medulla. The lymphoid tissue of the medulla is organized into medullary cords and medullary sinuses. The medullary cords consist of reticular fibers and cells that develop around tiny blood vessels. Accordingly, small lymphocytes, macrophages, and mature plasma cells can be found in association with medullary cords. The medullary sinuses converge in the vicinity of efferent lymphatic vessels and serve to drain the lymph node. Stellate cells found within the sinuses form a weblike series of microscopic baffles, allowing interaction with macrophages in the wall of the sinus. This interaction may create a trap for cells passing through the lumen of the sinus.

The lymphatic and blood vascular systems are fellow travelers, with multiple interactions in health and disease. There are two principal pathways by which malignant cells spread via the lymphatic system:


Permeation of minute lymphatic vessels, which ultimately leads to growth and spread to regional lymph nodes

Lymphatic metastasis by tumor cell emboli, which may bypass a lymph node or become entrapped in the lymph node

The lymph nodes may act as temporary filters, in which metastatic malignant cells are trapped, propelled into vessels, or destroyed.

It is known that lymph nodes can effectively arrest the passage of particulate matter and blood cells, and entrap and destroy bacteria. Some viruses, however, can proliferate rapidly within the lymph node and thereafter easily disseminate throughout the body. Similarly, lymph nodes may fail to entrap other kinds of cells carried in the lymph. For example, a large percentage of cancer cells may transit in lymphatic vessels without being arrested at the node.

When malignant cells are entrapped within the node they may proliferate rapidly, greatly increasing the size of the node. Non-tender, hard, compacted masses of nodes usually contain metastatic carcinoma or very aggressive intrinsic neoplasms. The particular location of the lymph gland enlargement often provides very definite clues as to the location and nature of the primary lesion.

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Interstitial fluid from the brain and spinal cord, especially the gray matter, drains through perivascular spaces and paravascular compartments of the subarachnoid space to reach the regional lymph nodes. For example, cervical lymph nodes receive interstitial fluid drainage from the brain, while lumbar lymph nodes receive interstitial fluid drainage from the spinal cord.

Lymphatic capillaries are present along the peripheral nerves. Lymphatics are scanty, but present, in the periosteum of bone and in tendons.

Many anomalies and variations occur within the origin, distribution, and termination of the thoracic duct.

When the thoracic duct itself enters the venous system on the right, there is frequently an anomalous retroesophageal right subclavian artery.

All the lymphoid tissue of the human body forms approximately 1% of the body weight (about ó the weight of the liver).

The cisterna chyli and the right lymphatic duct and thoracic duct can be ligated with impunity.

Lymphocytes and lymph always circulate within the nodal parenchyma.

On its pathway to the neck, the thoracic duct is not interrupted by lymph nodes; therefore, lymph which is already filtered by several groups of lymph nodes is drained directly into the veins.

Since the valves do not work after death, blood can regurgitate into the ducts, causing the involved segments to resemble veins.

After injury or ligation of a lymphatic vessel, the lumen of the vessel becomes solid, and later the endothelium recanalizes.

Acquired cutaneous lymphangiectasia, with areas of skin affected by obstruction and destruction of lymphatic drainage, was reported by Garcia-Doval et al.,22 who stated that this was the first case associated with altered lymph flow in cirrhosis and ascites.

We quote from Gidvani et al.,23 who stressed the need to include Castleman’s disease in the differential diagnosis of pediatric lymphoproliferative disorders:

Castleman’s disease (also known as angiofollicular lymph node hyperplasia, angiomatous lymphoid hamartoma, and giant lymph node hyperplasia) is an uncommon lymphoproliferative disorder that most frequently is seen as an asymptomatic mass in the mediastinum. Little is known about the cause of this disorder, but the bulk of the evidence points toward faulty immunoregulation, which results in the excessive proliferation of B lymphocytes and plasma cells in lymphoid organs.


Rarely, the cisterna chyli may suffer isolated injury in blunt abdominal trauma.24


In this book, surgery of the lymphatic system (lymphadenectomy) is presented in the chapters of the concerned organs.

Though it is not within the scope of this chapter to cover lymphedema, the senior author of this chapter (JES) asks the reader’s indulgence to reminisce about a well known professor, Dr. Emmanuel Kondoleon (1879-1939), with whom he studied as a second-year medical student. The senior author watched him perform the Kondoleon operation for elephantiasis on a patient’s lower extremity. From the incision to the closing, the thrill of observing “the master” remains with him today, with fond and proud memories.

Anatomic Complications

Iatrogenic injury during surgery, or penetrating injuries of the neck, thorax, and upper abdomen may injure the thoracic duct and lead to chylorrhea. The thoracic duct may be injured at its beginning, middle, or terminal portion during a number of surgical procedures, including but not limited to:


Hiatal hernia repair

Distal esophageal surgery

Surgery of aortic aneurysm

Esophageal resection

Thoracic aortic aneurysm surgery

Scalene biopsy

Left radical neck surgery

According to Woodburne and Burkel,8 injuries to the thoracic duct can produce 75-200 cc of chylous drainage per hour. This is enough fluid to soak the patient’s pillow and upper bed if it drains out, to collapse the lung (chylothorax), or to produce an enlarged abdomen (chyloperitoneum).

Chylous draining may occur during neck surgery or with penetrating injuries. It may be persistent or temporary. If the draining is persistent, ligation is essential.

Nussenbaum and colleagues25 performed a patient trial of conservative treatment of chyle fistula, including nutritional modification, pressure dressings, and closed drainage. This medical management failed in 20%. They support early operative intervention if the peak 24-hour drainage is greater than 1000 mL: “Persistent low-output drainage after 10 days is associated with a prolonged management course and treatment-related complications. Optimal treatment of these patients is unclear.”

We quote from Gregor26 on the management of chyle fistula:

Total parenteral nutrition allows for control of the fluid and protein loss while avoiding flow of chyle, and in most cases it results in resolution. In those cases that do not resolve, fibrin glue with some type of mesh and muscle flaps usually succeed in closure.

If the thoracic duct is injured within the thorax, chylothorax with secondary collapse of the left lung can result. If repeated aspiration is unsuccessful, ligation is needed not only to avoid restriction of the lung but also to avoid chylous ascites and decreased nutrition.

Thoracoscopic ligation of the thoracic duct has been used to treat chylothorax following esophagectomy.27 For the same condition, Merigliano et al.28 advocate early thoracic duct ligation, with re-operation performed immediately after diagnosis. Sakata et al.29 treated primary chylopericardium by thoracoscopic thoracic duct ligation and partial pericardiectomy.

Chylous ascites can occur secondary to injury of the cisterna chyli or the proximal subdiaphragmatic part of the thoracic duct. With chylous ascites, the abdominal cavity becomes tremendously enlarged due to accumulation of fluid. Again, ligation is necessary.

Beghetti et al.30 studied the etiology and management of pediatric chylothorax:

Prevention, early recognition, and treatment of potential complications, such as superior vena cava thrombosis or obstruction, may further improve success of conservative treatment. Congenital chylothorax seems different and may require a specific approach.

It is well known that radiation treatment, as well as some surgical procedures, produces dilatation of the lymphatic vessels, the so-called acquired lymphangiectasis. Celis et al.31 treat this complication with CO2 laser ablation with good results.


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