Lymph drainage from the breast. Topography of the breast. Pathways of lymphatic drainage from the mammary gland in normal conditions and with metastasis. Lymphatic drainage from the organs of the chest cavity Lymphatic drainage from the heart

Lymph outflow pathways from the breast

Biology and genetics

They fall into the following The lymph nodes. Fickle 15 interthoracic lymph nodes nodi lymphtici interpectorlis located between the pectoralis major and minor muscles. The efferent vessels from them are sent to the preaortic nodes but can flow directly into the thoracic duct and the left jugular trunk. Part of the afferent lymphatic vessels bypasses the lymph nodes and directly flows into the efferent vessels or subclavian jugular and bronchomediastinal trunks, which leads to distant metastasis of tumor cells from ...

Lymph outflow pathways from the breast

The afferent vessels originate from the lymphatic networks of the lobules and skin, and they pass along with the intrarammar veins and their branches. A three-dimensional capillary network is formed around the milk lobules, and a one-dimensional planar network is formed in the skin of the gland, especially well expressed in the peripapillary field. The afferent lymphatic vessels diverge from the inside of the gland in radial directions in accordance with the topography of the lobes, forming many anastomoses, including between the right and left glands.

They flow into the following lymph nodes.

1. Axillary - 12-45 - ( nodi lymphatici axillares ) into the medial, lower, central, apical groups located between the medial wall of the cavity and the axillary artery and vein. Most afferent vessels join the medial group.
2. Nonpermanent 1-5 interthoracic lymph nodes ( nodi lymphatici interpectoralis ) located between the pectoralis major and minor muscles.
3. Peri-sternal or retrosternal - 2-20 on each side - ( nodi lymphatici para-, seu retrosternales ), located behind the sternum along the internal thoracic vein. They are considered the most dangerous during metastasis, since the right and left have connections between themselves and receive lymph not only from the mammary gland and chest wall, but also from the pleura, pericardium, liver, lower epigastric and upper diaphragmatic nodes. The efferent vessels from them are sent to the preaortic nodes, but can flow directly into the thoracic duct and the left jugular trunk.
4. Anterior mediastinal - 12-37 - ( nodi lymphatici mediastinales anteriores ), localized in the upper part of the anterior mediastinum on the superior vena cava (precaval), on the aortic arch and its arteries (preaortocarotid) and along the left brachiocephalic vein (horizontal chain).

Deep cervical (internal jugular, 32-83 - nodi lymphatici cervicales profundi ), which are located in several packages - the lateral group lying along the edge of the trapezius muscle; supraclavicular group, located above the clavicle and parallel to it.

The efferent lymphatic vessels - axillary and deep cervical vessels are involved in the formation of paired subclavian and jugular trunks, which in turn flow into the thoracic and right lymphatic ducts or into the jugular venous angle and its forming veins - the brachiocephalic, subclavian and internal jugular. Part of the afferent lymphatic vessels bypasses the lymph nodes and directly flows into the efferent vessels or subclavian, jugular and bronchomediastinal trunks, which leads to distant metastasis of tumor cells from the mammary gland into internal organs chest cavity and neck.

The outflow of lymph from the mammary gland is considered by quadrants. Why are 4 quadrants distinguished by drawing two mutually perpendicular lines on the gland at the level of the nipple and the areola. From the upper lateral quadrant, lymph flows through the afferent vessels to the axillary nodes - medial, lower and apical, from the lower lateral quadrant - to the peristernal, medial and lower axillary nodes. From the superior medial quadrant, the afferent vessels go to the parasternal, anterior mediastinal, and axillary nodes; from the inferior medial quadrant, to the parasternal and axillary nodes.

Personal antitumor prophylaxis requires frequent examination and palpation of the gland and lymph nodes associated with it (at least once a week). Any kind of compaction in the gland, discharge from it, soreness, an increase in the size of part of the gland or lymph nodes related to it will require urgent consultation specialist oncologist.

Lymphatic bed of the lungs and lymph nodes of the chest cavity.

Skeletotopia: between the III and VI ribs from above and below and between the parasternal and anterior axillary lines from the sides.

Structure. Consists of 15–20 lobules, surrounded and separated by processes of the superficial fascia. The lobules of the gland are arranged radially around the nipple. Each lobule has its own excretory, or milky, duct with a diameter of 2-3 mm. The lactiferous ducts converge radially to the nipple and expand in an ampulla-like manner at its base, forming the lactiferous sinuses, which outwardly narrow again and open at the apex of the nipple with pinholes. The number of holes on the nipple is usually less than the number of lactiferous ducts, since some of them at the base of the nipple are interconnected.

Blood supply: branches of the internal thoracic, lateral thoracic, intercostal arteries. The deep veins accompany the arteries of the same name, the superficial ones form a subcutaneous network, some branches of which flow into the axillary vein.

Innervation: lateral branches of the intercostal nerves, branches of the cervical and brachial plexuses.

Lymph drainage. lymphatic system female mammary gland and the location of regional lymph nodes are of great practical interest due to the frequent damage to the organ by a malignant process.

The main way of outflow of lymph is to the axillary lymph nodes in three directions:

1. through the anterior thoracic lymph nodes (Zorgius and Bartels) along the outer edge of the pectoralis major muscle at the level of the second or third rib;

2. intrapectorally - through Rotter's nodes between the pectoralis major and minor muscles;

3. transpectorally - by lymphatic vessels, penetrating the thickness of the large and small pectoral muscles; nodes are located between their fibers.

Additional ways of outflow of lymph:

1. from the medial section - to the lymph nodes in the course of the internal thoracic artery and anterior mediastinum;

2. from the upper section - to the subclavian and supraclavicular nodes;

From the lower section - to the nodes abdominal cavity.

mastitis

Classification of purulent mastitis:

1. superficial (premammary) mastitis, located in the peripapillary zone or above the stroma of the gland directly under the skin;

2. intramammary mastitis, located in the lobules of the gland itself;

3. retromammary mastitis, located under the deep sheet of the capsule of the mammary gland to the own fascia of the breast. Incisions for superficial mastitis are carried out paraoreolyarno or in the radial direction, without affecting the halo, dissecting the skin and subcutaneous tissue.

Incisions for intramammary mastitis are made at the site of greatest softening in the radial direction, 6-7 cm long, without affecting the halo.

Stages:

1. skin incision, subcutaneous tissue, gland tissue;

2. opening of the abscess;

3. destruction of partitions with neighboring abscesses until a single cavity is formed in a blunt way;

4. removal of necrotic tissues;

5. thorough washing of the abscess cavity with an antiseptic solution;

6. drainage (rubber strips are usually used).

To open a retromammary abscess, an incision is made along the lower transitional fold of the mammary gland. The skin and tissue are dissected in layers, the mammary gland is lifted and the pectoralis major muscle is peeled off from the fascia, and the abscess is opened. The abscess cavity is drained.

45. Three-stage cone-circular amputation of the thigh in the middle third. Analysis of the topography of neurovascular formations in the femoral stump.

Amputation of a limb is the removal of its peripheral part along the length of the bone. Removal of the peripheral part of the limb at the level of the joint space is called exarticulation. These are two types of limb truncation. They belong to crippling, disabling operations, so the question of their implementation is always decided by a group of doctors - a council.

Three-stage - at the first moment, the skin, subcutaneous tissue and own fascia are cut. At the second moment, superficial muscles are cut along the edge of the contracted skin. At the third moment, deep muscles are cut along the edge of the contracted superficial muscles. The bone is cut along the edge of the contracted deep muscles. This operation was developed by N. I. Pirogov during amputation of the thigh.

Circular (circular) amputation is characterized by the fact that the incision line of soft tissues is perpendicular to the axis of the limb.

Types of circular amputations depending on the method of dissection of soft tissues:

Amputation stages

general principle amputations and exarculations is that all of them, without exception, are carried out in three stages:

Stage I - dissection of soft tissues

Stage II - processing of the periosteum and sawing of the bone

Stage III - stump toilet

Three-stage amputation

It is usually carried out on the hip or shoulder, i.e. where there is one bone. With this method, the amputation knife cuts soft tissues in three steps, all three at different levels. The first step is to dissect the skin, subcutaneous tissue, superficial and own fascia.

In the second step, the superficial muscles are dissected along the level of the contracted skin. In the third step, the deep muscles are dissected along the edge of the skin pulled in the proximal direction.

Three-stage amputation

otherwise called cone-circular, since soft tissues are dissected in a circular manner. As a result of the fact that they were dissected at different levels, the stump looks like a retracted cone, the top of which is located on the sawdust of the bone.

The advantage of a three-stage or cone-circular amputation is technically easy to perform.

The disadvantages of cone-circular amputation is that they are not very economical. Flap amputations allow the use of tissue more advantageously and well prosthetics. But patchwork amputations, in turn, are more technically difficult to perform.

Another disadvantage of circular amputations is that after them extensive central scars are formed, covering the entire diameter of the stump, and they are located on the supporting surface of the stump, therefore they are not prosthetized.

Skeletotopia: between the III and VI ribs from above and below and between the parasternal and anterior axillary lines from the sides.

Structure. Consists of 15–20 lobules, surrounded and separated by processes of the superficial fascia. The lobules of the gland are arranged radially around the nipple. Each lobule has its own excretory, or milky, duct with a diameter of 2-3 mm. The lactiferous ducts converge radially to the nipple and expand in an ampulla-like manner at its base, forming the lactiferous sinuses, which outwardly narrow again and open at the apex of the nipple with pinholes. The number of holes on the nipple is usually less than the number of lactiferous ducts, since some of them at the base of the nipple are interconnected.

The gland is located between the sheets of the superficial fascia, which form its capsule, and is surrounded by fatty tissue on all sides (with the exception of the nipple and areola).

Between the fascial capsule of the gland and the own fascia of the breast are retromammary fiber and loose connective tissue, as a result of which the gland is easily displaced in relation to the chest wall. A synovial bursa sometimes forms under the mammary gland.

Numerous spurs extend from the fascial capsule of the mammary gland into its thickness, which surround individual lobules, are located along the course of the lactiferous ducts, delimiting the fiber in which the blood or macular vessels and nerves pass. The presence of connective tissue spurs contributes to the formation and delimitation of streaks during purulent-inflammatory processes in the gland, which should be taken into account when making incisions for the outflow of pus.

Blood supply: branches of the internal thoracic, lateral thoracic, intercostal arteries. The deep veins accompany the arteries of the same name, the superficial ones form a subcutaneous network, some branches of which flow into the axillary vein.

Innervation: lateral branches of the intercostal nerves, branches of the cervical and brachial plexuses.

Lymph drainage. The lymphatic system of the female mammary gland and the location of regional lymph nodes are of great practical interest due to the frequent damage to the organ by a malignant process.

The lymphatic vessels of the parenchyma of the gland are larger, they form plexuses in the intralobular and paraglandular tissue, and in the gland itself and along the ducts and blood vessels There are networks of lymphatic capillaries. The efferent lymphatic vessels pass in the direction from the areolar circle to the deep areolar plexus, anastomosing with the superficial cutaneous lymphatic vessels (this explains the early infiltration of the skin vessels during metastasis malignant tumors- "skin track" of metastases).

From the plexuses, larger efferent lymphatic vessels are formed, which run along the outer edge and anterior surface of the fascial sheath of the pectoralis major muscle or intrafascially. They are connected by numerous anastomoses with the lymphatic vessels of the skin and subcutaneous tissue of the abdominal wall, opposite the mammary gland, with the vessels of the intercostal spaces.

The main way of outflow of lymph from the mammary gland is the axillary path - towards a large group of axillary lymph nodes (about 4/b of lymph drains in this direction).

The axillary group consists of 20-40 lymph nodes, which can be divided into 5 groups according to topographic and anatomical features (see "Axillary region"). There is no strict sequence of flow into the nodes of the efferent lymphatic vessels: they can end in the nodes located on the 2nd-3rd tooth of the superior serratus muscle (Zorgius nodes), but they can also pass to the nodes of other groups. In the event of a violation of the outflow along the main axillary path (which can occur as a result of blockade of the lymphatic vessels by multiple metastases), a roundabout lymphatic circulation occurs, in which the outflow of lymph increases along additional paths:

subclavian - in the subclavian nodes,

transpectorally - through the pectoralis major muscle and

interpectorally - to the vessels enveloping the edge of the pectoralis major muscle, into the intermuscular and subclavian nodes,

parasternally - to the lymph nodes along the internal thoracic arteries and veins through the intercostal space (usually the second - third), to the supraclavicular and cervical and similar lymph nodes opposite side; through anastomoses with the lymphatic vessels of the epigastric region - into the lymphatic network of the preperitoneal tissue with subsequent connections with the vessels of other areas.

The main way of outflow of lymph is to the axillary lymph nodes in three directions:

1. through the anterior thoracic lymph nodes (Zorgius and Bartels) along the outer edge of the pectoralis major muscle at the level of the second or third rib;

2. intrapectorally - through Rotter's nodes between the pectoralis major and minor muscles;

3. transpectorally - along the lymphatic vessels penetrating the thickness of the large and small pectoral muscles; nodes are located between their fibers.

Additional ways of outflow of lymph:

1. from the medial section - to the lymph nodes in the course of the internal thoracic artery and anterior mediastinum;

2. from the upper section - to the subclavian and supraclavicular nodes;

3. from the lower section - to the nodes of the abdominal cavity.

The lymphatic system of the mammary gland is represented by a network of lymphatic vessels located in three floors (Fig. 9-23).

Most superficially under the base of the piles
foot nipple is located mammary lim
phatic plexus (plexus lymphaticus
subpapillars). Superficial lymph drainage from
mammary gland is carried out intradermally
but it goes in the opposite direction.

Deeper within the areola
lies superficial pericircular
plexus (plexus areolaris superficialis).

Even deeper is the deep circumcircle

plexus (plexus areolaris profundus). Groups of lymph nodes

Axillary lymph nodes (nodi
lymphatic! axillares) - lim main group
phatic nodes that receive lymph from
mammary gland. Some of them lie on top
nostno, subfascially. Axillary lim
phatic nodes are subdivided into five
groups: lateral (external), middle
(central), posterior (subscapular),
medial (thoracic, paramammary) and
apical (apical).

» Lateral (external) axillary nodes (nodi lymphatic! axillares laterales) located on the lateral wall of the axillary cavity near the coracobrachialis muscle outward from the neurovascular bundle. Mostly they take lymph from the free upper limb.

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* Middle (central) axillary nodes (nodi fymphatiti axillares centrales) are located along the axillary vein, mainly along its anterior and medial surface. Lymph flows to these nodes from the outer quadrants of the mammary gland, the anterior and lateral sections of the chest wall and the upper section of the anterior abdominal wall. * Posterior (subscapular) axillary nodes (nodi lymphatic! axillares posterior subscapulares) located along the subscapular artery. They receive lymph from the back chest, subscapular region, and sometimes from the mammary gland.

* Medial (thoracic, paramammary) axillary lymph nodes \nodi lymphatici axillares mediates (pectorales, paramammarii)], localized along the outer edge of the pectoralis major muscle along the lateral thoracic vessels,

are the nodes of the first stage for the outer quadrants of the breast. The lymph node located on the third tooth of the dentate muscle is the lymph node of the first stage (lymph node Zorgius). Lymph node located on the fourth tooth - lymph node Bartels, * Apical (apical) axillary lymph nodes }