Dr Kees Polderman
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The typical anatomical apex, i present, is oten inerior to the shadow o the diaphragm. Three main sorts o cardiovascular shadows happen, depending totally on physique sort or habitus. Because breast most cancers cells have an unusual anity or iodide, they become recognizable. It is very useul or examining the viscera and lymph nodes o the mediastinum and roots o the lungs, by means o both planar and reconstructed. The arch o the aorta (20) is obliquely positioned (more sagittal than transverse), with the ascending end anteriorly within the midline, and the descending end posteriorly and to the let o the vertebral bodies (17). The pulmonary trunk (27) orms the stem o an inverted Y, with the arms ormed by the best (28) and let (29) pulmonary arteries. The proper pulmonary artery (28) passes beneath the arch o the aorta [between ascending (24) and descending (25) aortae]. A scan on the level o the utmost diameter o the guts demonstrates all our chambers (32�35) and the diagonal slant o the interventricular septum (between 33 and 35)-see inset. Reconstructed rom information generated and accumulated by spiral magnetic resonance imaging. The remainder o the constructions within the superior mediastinum pass via the superior thoracic aperture to the foundation o the neck or pass between the neck and abdomen. Within the superior mediastinum, structures happen in systemic layers, proceeding rom anterior to posterior: (1) lymphoid system (thymus), (2) blood vascular system (veins frst, then arteries), (3) respiratory system (trachea), (4) alimentary system (esophagus), and (5) lymph vascular system. The sample o the branches o the arch o the aorta is atypical in approximately 35% o people. Contents embrace the esophagus and esophageal nerve plexus, thoracic aorta, thoracic duct and lymphatic trunks, posterior mediastinal lymph nodes, and azygos and hemi-azygos veins. The azygos/hemi-azygos venous system constitutes the venous counterpart to the thoracic aorta and its posterior mediastinal branches. The thoracic portion o the sympathetic trunks and thoracic splanchnic nerves may or is in all probability not thought-about elements o the posterior mediastinum. Anterior mediastinum: the smallest subdivision o the mediastinum, between sternum and transversus thoracis muscles, signifcant primarily as a surgical plane, incorporates primarily unfastened connective tissue and, in inants and kids, the inerior lengthen o the thymus. Surace anatomy o thoracic viscera: the heart and great vessels are in the central thorax, surrounded laterally and posteriorly by the lungs, and are overlapped anteriorly by the lines o pleural reection and anterior borders o the lungs, sternum, and the central part o the thoracic cage. The position o the mediastinal viscera is decided by position relative to gravity, part o respiration, and the build and physical situation o the person. The transverse thoracic plane intersects the sternal angle and demarcates the good vessels superiorly rom the pericardium/ heart. The xiphisternal junction offers a sign o the central tendon o the diaphragm. It is a fexible, dynamic container, housing most o the organs o the alimentary system and part o the urogenital system. Containment o the abdominal organs and their contents is offered by musculo-aponeurotic walls anterolaterally, the diaphragm superiorly, and the muscular tissues o the pelvis ineriorly. Interposed between the more rigid thorax and pelvis, this association permits the stomach to enclose and shield its contents while providing the fexibility required by respiration, posture, and locomotion. Through voluntary or refexive contraction, its muscular roo, anterolateral partitions, and foor can elevate inner (intraabdominal) strain to assist expulsion o air rom the thoracic cavity (lungs and bronchi) or o fuid. The anterolateral stomach wall and a quantity of other organs lying in opposition to the posterior wall are lined on their inside elements with a serous membrane or peritoneum (serosa) that refects (turns sharply and continues) onto the abdominal viscera (L. Thus, a bursal sac or lined potential house (peritoneal cavity) is ormed between the walls and the viscera that usually incorporates solely sufficient extracellular (parietal) fuid to lubricate the membrane overlaying most o the suraces o the buildings orming or occupying the stomach cavity. Visceral motion related to digestion happens reely, and the double-layered refections o peritoneum passing between the walls and the viscera provide passage or the blood vessels, lymphatics, and nerves. Variable quantities o at may occur between the partitions and viscera and the peritoneum lining them. The belly cavity orms the superior and major part o the abdominopelvic cavity. The aircraft o the pelvic inlet (superior pelvic aperture) arbitrarily, but not physically, separates the stomach and the pelvic cavities. Consequently, the more superiorly placed belly organs (spleen, liver, part o the kidneys, and stomach) are protected by the thoracic cage. The larger pelvis (expanded half o the pelvis superior to the pelvic inlet) helps and partly protects the lower stomach viscera (part o the ileum, cecum, appendix, and sigmoid colon). The body has been sectioned in the median plane to present the belly and pelvic cavities as subdivisions o the continuous abdominopelvic cavity. Nine regions o the belly cavity are used to describe the location o belly organs, pains, or pathologies (Table 5. The regions are delineated by our planes: two sagittal (vertical) and two transverse (horizontal) planes. The transpyloric airplane, extrapolated halfway between the superior borders o the manubrium o the sternum and the pubic symphysis (typically the L1 vertebral level), commonly transects the pylorus (the distal, extra tubular half o the stomach) when the affected person is recumbent (supine or prone). The boundary between the anterior and lateral walls is indenite; thereore, the term anterolateral stomach wall is oten used. Some buildings, similar to muscles and cutaneous nerves, are in each the anterior and lateral walls. The anterolateral belly wall is bounded superiorly by the cartilages o the 7th�10th ribs and the xiphoid process o the sternum and ineriorly by the inguinal ligament and the superior margins o the anterolateral features o the pelvic girdle (iliac crests, pubic crests, and pubic symphysis). The anterolateral belly wall consists o pores and skin and subcutaneous tissue (supercial ascia) composed mainly o at, muscle tissue and their aponeuroses and deep ascia, extraperitoneal at, and parietal peritoneum. The skin attaches loosely to the subcutaneous tissue, except on the umbilicus, where it adheres rmly. Most o the anterolateral wall includes three musculotendinous layers; the ber bundles o every layer run in dierent directions. This threeply construction is much like that o the intercostal spaces in the thorax. The belly wall Linea Vertical anterior abdominal muscle tissue alba Flat anterolateral stomach muscles Anterior Fascia o Anterolateral Abdominal Wall the subcutaneous tissue over most o the wall includes a variable quantity o at. Males are particularly susceptible to subcutaneous accumulation o at in the decrease anterior stomach wall. In morbid obesity, the at is many inches thick, oten orming a number of sagging olds (L. Superior to the umbilicus, the subcutaneous tissue is according to that ound in most areas. Inerior to the umbilicus, the deepest part o the subcutaneous tissue is reinorced by many elastic and collagen bers, so it has two layers: the superfcial atty layer (Camper ascia) and the deep membranous layer (Scarpa ascia) o subcutaneous tissue. The membranous layer continues ineriorly into the perineal area because the membranous layer o subcutaneous tissue o the perineum (supercial perineal or Colles ascia), but not into the thighs. The investing ascias here are extremely skinny, being represented principally by the epimysium (outer brous connective tissue layer surrounding all muscles-see Chapter 1, Overview and Basic Concepts) supercial to or between muscular tissues.
Lymph rom the parasternal nodes enters the bronchomediastinal lymphatic trunks, which additionally drain lymph rom the thoracic viscera. The termination o the lymphatic trunks varies; historically, these trunks are described as merging with each other and with the jugular lymphatic trunk, draining the head and neck to orm a brief right lymphatic duct on the best facet or coming into the termination on the thoracic duct on the let facet. However, in many (perhaps most) cases, the trunks open independently into the junction o the inner jugular and subclavian veins, the best or let venous angles, that orm the proper and let brachiocephalic veins. Posterior intercostal arteries, branches o the thoracic aorta within the 2nd, 3rd, and 4th intercostal areas. The lymphatic drainage o the breast is important as a outcome of o its function within the metastasis o most cancers cells. Lymph passes rom the nipple, areola, and lobules o the mammary glands to the subareolar lymphatic plexus. Lymph drainage rom this plexus is as ollows: Most lymph (>75%), especially rom the lateral breast quadrants, drains to the axillary lymph nodes, initially to the anterior or pectoral nodes or essentially the most part. However, some lymph could drain directly to other axillary nodes or even to interpectoral, deltopectoral, supraclavicular, or the nerves o the breast derive rom anterior and lateral cutaneous branches o the 4th�6th intercostal nerves. The branches o the intercostal nerves pass through the pectoral ascia covering the pectoralis main to attain overlying subcutaneous tissue and skin o the breast. The branches o the intercostal nerves convey sensory bers rom the pores and skin o the breast and sympathetic bers to the blood vessels within the breasts and easy muscle in the overlying pores and skin and nipple. Surace Anatomy o Thoracic Wall the clavicles (collar bones) lie subcutaneously, orming bony ridges at the junction o the thorax and neck. They could be palpated easily all through their length, particularly where their medial ends articulate with the manubrium o the sternum. The clavicles demarcate the superior division between zones o lymphatic drainage: above the clavicles, lymph fows ultimately to inerior jugular lymph nodes; beneath them, parietal lymph (that rom the physique wall and upper limbs) fows to the axillary lymph nodes. Lateral mammary branches Lateral mammary branches of lateral cutaneous branches of posterior intercostal arteries (A) Arteries of mammary gland Anterior view Internal jugular v. The mammary gland is equipped rom its medial aspect primarily by perorating branches o the inner thoracic artery and by several branches o the axillary artery (principally the lateral thoracic artery) superiorly and laterally. Venous drainage is to the axillary vein (mainly) and the internal thoracic veins [a. The sternum (breast bone) lies subcutaneously within the anterior median line and is palpable throughout its size. Between the prominences o the medial ends o the clavicles on the sternoclavicular joints, the jugular notch in the manubrium could be palpated between the distinguished medial ends o the clavicles. The notch lies on the degree o the inerior border o the body o T2 vertebra and the house between the first and 2nd thoracic spinous processes. The manubrium, approximately four cm long, lies on the stage o the our bodies o T3 and T4 vertebrae. The sternal angle is palpable and oten seen in younger people as a outcome of o the slight movement that happens at the manubriosternal joint throughout orced respiration. Most lymph, especially that rom the superior lateral quadrant and heart o the breast, drains to the axillary lymph nodes, which, in turn, are drained by the subclavian lymphatic trunk. The body o the sternum, approximately 10 cm lengthy, lies anterior to the best border o the guts and vertebrae T5�T9. The intermammary clet (midline melancholy or cleavage between the mature emale breasts) overlies the sternal body. The xiphisternal joint is palpable and is oten seen as a ridge, at the degree o the inerior border o T9 vertebra. The costal margins, ormed by the joined costal cartilages o the 7th�10th ribs, are easily palpable as a outcome of they extend inerolaterally rom the xiphisternal joint. The ribs and intercostal areas present a basis or locating or describing the place o buildings or websites o trauma or pathology on or deep to the thoracic wall. To rely the ribs and intercostal spaces anteriorly, slide the ngers (digits) laterally rom the sternal angle onto the 2nd costal cartilage and start counting the ribs and areas by transferring the ngers rom right here. The 1st intercostal space is that superior to the 2nd costal cartilage-that is, intercostal areas are numbered based on the rib orming their superior boundary. Spinous strategy of C7 Scapular strains Posterior median line (C) Posterior another is used to find the following space. I the ngers are eliminated rom the thoracic wall while counting spaces, the nger could simply be returned to the identical house, mistaking it or the one below. While the ribs and/or intercostal spaces provide the "latitude" or navigation and localization on the thoracic wall, several imaginary strains acilitate anatomical and clinical descriptions by offering "longitude. Additional traces (not illustrated) are extrapolated along the borders o palpable bony ormations, such as the parasternal and paravertebral traces (G. Breasts are the most prominent surace eatures o the anterior thoracic wall, particularly in ladies. In reasonably athletic individuals, the contour o the pectoralis main muscle tissue is obvious, separated in the midline by the intermammary clet overlying the sternum, with the lateral border orming the anterior axillary old. Inerolaterally, nger-like slips, or digitations o the serratus anterior, have a serrated (sawtooth) appearance as they attach to the ribs and interdigitate with the external oblique. The inerior ribs and costal margins are oten apparent, particularly when the stomach muscles are contracted. Their fattened superior suraces show no sharp demarcation rom the anterior surace o the thoracic wall, but laterally and ineriorly, their borders are nicely dened. The areola usually darkens throughout being pregnant and retains the darkened pigmentation thereater. The areola is generally dotted with the papular (small elevated) openings o the areolar glands (sebaceous glands within the skin o the areola). On event, one or both nipples are inverted (retracted); this minor congenital anomaly may make breasteeding dicult. Colostrum, a creamy white to yellowish premilk fuid, could secrete rom the nipples over the last trimester o being pregnant and during preliminary episodes o nursing. The breasts in aged ladies are usually small as a outcome of o the decrease in at and the atrophy o glandular tissue. Carcinoma o the Breast Understanding the lymphatic drainage o the breasts is o practical importance in predicting the metastases (dispersal) o most cancers cells rom a carcinoma o the breast (breast cancer). Carcinomas o the breast are malignant tumors, usually adenocarcinomas (glandular cancer) arising rom the epithelial cells o the lactierous ducts within the mammary gland lobules. Metastatic cancer cells that enter a lymphatic vessel normally pass through two or three teams o lymph nodes. Intererence with dermal lymphatics by cancer may cause lymphedema (edema, Breast Quadrants For the anatomical location and description o tumors and cysts, the surace o the breast is split into our quadrants. Larger dimples (ngertip size or bigger) end result rom cancerous invasion o the glandular tissue and brosis (brous degeneration), which causes shortening or places traction on the suspensory ligaments. Subareolar breast most cancers could cause retraction o the nipple by an identical mechanism involving the lactierous ducts.
The ureters move obliquely through the muscular wall o the urinary bladder in an ineromedial direction, getting into the outer surace o the bladder approximately 5 cm aside, however their inner openings into the lumen o the empty bladder are separated by solely hal that distance. This oblique passage by way of the bladder wall orms a one-way "fap valve," the interior strain o the lling bladder causing the intramural passage to collapse. In addition, contractions o the bladder musculature act as a sphincter stopping the refux o urine into the ureters when the bladder contracts, growing inside stress throughout micturition. Urine passes down the ureters by means o peristaltic contractions, a ew drops being transported at intervals o 12�20 seconds. In males, the only structure that passes between the ureter and the peritoneum is the ductus deerens. The ureter lies posterolateral to the ductus deerens and enters the posterosuperior angle o the bladder, just superior to the seminal gland. It then passes close to the lateral half o the ornix o the vagina and enters the posterosuperior angle o the bladder. The arterial provide to the pelvic components o the ureters is variable, with ureteric branches extending rom the widespread iliac, internal iliac, and ovarian arteries. The ureteric branches anastomose alongside the size o the ureter orming a steady blood supply, although not necessarily eective collateral pathways. The most fixed arteries supplying the terminal elements o the ureter in emales are branches o the uterine arteries. The blood supply o the ureters is a matter o great concern to surgeons operating in the region (see the Clinical Box "Iatrogenic Compromise o Ureteric Blood Supply"). The venous drainage rom the pelvic parts o the ureters generally parallels the arterial provide, draining to veins with corresponding names. The nerves to the ureters derive rom adjoining autonomic plexuses (renal, aortic, superior, and inerior hypogastric;. Aerent (pain) bers rom the ureters ollow sympathetic bers in a retrograde direction to reach the spinal ganglia and spinal cord segments o T10�L2 or L3. Branches supplying the stomach hal o the ureter method medially, while these supplying the pelvic hal approach laterally. I essential, traction o the ureters is applied gently and solely towards the blood supply to avoid disruption o the small branches. Nerve fbers rom the renal, aortic, and superior and inerior hypogastric plexuses extend to the ureter, carrying visceral aerent and sympathetic fbers to the T10�L2(3) spinal sensory ganglia and twine segments. Parasympathetic fbers, rom the S2�S4 spinal wire segments, are distributed to the pelvic part o the ureter. The bladder is a temporary reservoir or urine and varies in size, shape, position, and relationships according to its content material and the state o neighboring viscera. When empty, the grownup urinary bladder is situated in the lesser pelvis, lying partially superior to and partially posterior to the pubic bones. It is separated rom these bones by the potential retropubic space (o Retzius) and lies mostly inerior to the peritoneum, resting on the pubic bones and pubic symphysis anteriorly and the prostate (males) or anterior wall o the vagina (emales) posteriorly. The bladder is comparatively ree within the extraperitoneal subcutaneous atty tissue, besides or its neck, which is held rmly by the lateral ligaments o bladder and the tendinous arch o the pelvic ascia-especially its anterior part, the puboprostatic ligament in males and the pubovesical ligament in emales (see also. In emales, for the reason that posterior side o the bladder rests instantly upon the anterior wall o the vagina, the lateral attachment o the vagina to the tendinous arch o the pelvic ascia, the paracolpium, is an oblique however necessary actor in supporting the urinary bladder. In inants and young children, the urinary bladder is nearly totally within the abdomen even when empty. An empty bladder in adults lies almost entirely in the lesser pelvis, its superior surace level with the superior margin o the pubic symphysis. As the bladder lls, it enters the greater pelvis as it ascends within the extraperitoneal atty tissue o the anterior stomach wall. Compare its relation to the anterior abdominal wall, pubic symphysis, and degree o the supravesical ossa to that o the nondistended (empty) bladder partly B. In this emale pelvis, the uterus was sectioned in its personal median aircraft and is depicted as though it coincided with the median aircraft o the physique, which is seldom the case. With the bladder empty, the normal disposition o the uterus proven here-bent on itsel (anteexed) at the junction o the physique and cervix o the uterus and tipped anteriorly (anteverted)-causes its weight to be borne primarily by the bladder. Adult bladder and prostate demonstrating their pelvic location (inset) and the suraces o the bladder. Coronal section o urinary bladder and prostate within the aircraft o the prostatic urethra. The apex o the bladder factors toward the superior edge o the pubic symphysis when the bladder is empty. The undus o the bladder is opposite the apex, ormed by the somewhat convex posterior wall. The body o the bladder is the main portion o the bladder between the apex and the undus. On each side, the pubic bones and ascia overlaying the levator ani and superior obturator internus muscle lie in contact with the inerolateral suraces o the bladder. Consequently, in males, the undus is separated rom the rectum centrally by only the ascial rectovesical septum and laterally by the seminal glands and ampullae o the ductus deerentes. In emales, the undus is instantly related to the superior anterior wall o the vagina. Toward the neck o the male bladder, the muscle bers orm the involuntary inside urethral sphincter. This sphincter contracts throughout ejaculation to forestall retrograde ejaculation (ejaculatory refux) o semen into the bladder. In males, the muscle bers in the neck o the bladder are continuous with the bromuscular tissue o the prostate, whereas in emales, these bers are steady with muscle bers in the wall o the urethra. The ureteric orifces and the interior urethral orice are at the angles o the trigone o the bladder. The ureteric orices are encircled by loops o detrusor musculature that tighten when the bladder contracts to help in preventing refux o urine into the ureter. It is often more distinguished in older men owing to enlargement o the posterior lobe o the prostate. The major arteries supplying the bladder are branches o the internal iliac arteries (see Table 6. In emales, the vaginal arteries replace the inerior vesical arteries and ship small branches to postero-inerior elements o the bladder. The obturator and inerior gluteal arteries also supply small branches to the bladder. It additionally receives blood rom the deep dorsal vein o the penis, which drains into the prostatic venous plexus. It primarily drains through the inerior vesical veins into the internal iliac veins; however, it might drain via the sacral veins into the inner vertebral venous plexuses. In emales, the vesical venous plexus envelops the pelvic half o the urethra and the neck o the bladder, receives blood rom the dorsal vein o the clitoris, and communicates with the vaginal or uterovaginal venous plexus. Sympathetic ibers are conveyed rom inerior thoracic and higher lumbar spinal cord ranges to the vesical (pelvic) plexuses primarily by way of the hypogastric plexuses and nerves, whereas parasympathetic ibers rom sacral spinal twine ranges are conveyed by the pelvic splanchnic nerves and the inerior hypogastric plexus. Presynaptic sympathetic fbers rom the T11�L2 or L3 spinal twine ranges concerned in innervation o the bladder, prostate, and proximal urethra move by way of lumbar splanchnic nerves to the aortic/hypogastric system o plexuses, synapsing within the plexuses en route to the pelvic viscera.
When the child has been rewarmed to a rectal temperature of 35�C, weaning bypass is discontinued. It is usually not necessary to monitor central venous pressure with a right atrial catheter and no pacing wires are placed. Creation of a Pleuro-Pericardial Window In order to reduce the danger of late pericardial tamponade a pleuro-pericardial window ought to be created. The rightsided pleura is opened and the pericardium is opened posteriorly to within approximately 1 cm of the phrenic nerve. Incision Closure Although a heavy absorbable suture, such as polydioxanone, can be utilized for sternal closure, the large knots which result can be palpable for many weeks and even months and can be bothersome to parents and children. We therefore use light gauge stainless-steel wire to approximate the decrease end of the sternum. The remainder of the closure is routine with steady Vicryl to the presternal fascia and linea alba with continuous Vicryl to the subcutaneous fats and subcuticular Vicryl completing wound closure. It is essential that a light-weight gauge Vicryl be employed to decrease the risk of a response to the suture materials. The whole thoracic cavity is retracted cephalad improving exposure for aortic cannulation specifically. Care should be taken to avoid suctioning within the left atrium which ought to stay nearly full all through the process. The left atrium should stay full of blood at all times and no air ought to be introduced. The echocardiographer should have made a notice in their report regarding the usual connection of a superior and inferior proper pulmonary vein entering the left atrium. This could be confirmed by external and not inside statement at the time of surgery. The suture line should proceed from inferior to superior in order that if a tiny quantity of air has been introduced into the left atrium it ought to spill out into the best atrium as closure is accomplished. As an extra precaution, the cardioplegia needle should now be eliminated and the left ventricle gently massaged from apex towards base. However, the lower finish of the pores and skin incision could be restricted under these circumstances. Dissection of the superior vena cava before bypass facilitates recognition of the pulmonary veins as distinct from the azygous vein by the color of the blood within the veins. Dissection of the superior vena cava must be undertaken with nice care to avoid disturbing the proper phrenic nerve. If a Warden procedure is to be performed, then a proper angle thin-walled plastic venous cannula must be placed within the left innominate vein. The cannula should have a sufficiently small tip that blood can move around the cannula from the contralateral inner jugular vein as is finished for venous cannulation for the bidirectional Glenn shunt. A regular straight cannula may be inserted through the best atrial free wall into the inferior vena cava. Cardiopulmonary Bypass and Cardioplegia Mildly hypothermic bypass with cooling to 30�32�C is generally acceptable. A normal oblique incision in the right atrium is made with careful preservation of coronary arteries passing across the atrial free wall and with care taken to not divide the crista terminalis. A retractor is placed within the internal orifice of the superior vena cava with gentle retraction to avoid harm to the sinus node. Care ought to be taken to keep away from pursestringing the caval orifice or the orifice of the right higher lobe pulmonary vein. Relatively broad bites should be taken on the patch with much closer bites being taken on the affected person. Usually the coronary sinus ostium is closed with a patch of autologous pericardium. Coronary sinus effluent will drain via the unroofed section of coronary sinus into the left atrium, however this results in an acceptable small right to left shunt. If there have been a coronary sinus septal defect, then consideration would want to be given to closing the actual coronary sinus septal defect itself rather than the ostium of the coronary sinus which is the more usual surgical approach for dealing with a coronary sinus septal defect. The left atrial end is oversewn and the cephalad end is anastomosed to the tip of the right atrial appendage. It is mostly useful to apply deep hypothermic circulatory arrest for placement of an autologous pericardial baffle which redirects the anomalous venous return. When deep hypothermia has been achieved, the aortic cross-clamp has been utilized and cardioplegia infused then circulatory arrest is begun. An autologous pericardial patch is sutured across the inside orifice of the Scimitar vein with care taken to avoid pursestringing the orifice. Under these circumstances, the vein can be divided and reimplanted instantly into the left atrium. It may be present in affiliation with numerous different anomalies or often be isolated. Surgical administration is indicated if the left to proper shunt is calculated to be greater than 1. It could additionally be essential to undertake catheterization to quantitate the diploma of shunting. The ascending vertical vein is divided just below its junction with the left innominate vein. It is partially filleted open and is anastomosed to the base of the left atrial appendage which is opened longitudinally. Alternative strategies could additionally be utilized for different types of partial anomalous pulmonary venous connection. Scimitar Syndrome the arterial blood provide to the best lung must be fastidiously defined preoperatively. Pursestringing may end up in subsequent problems with growth related narrowing of the pulmonary venous pathway. However, there was a comparatively excessive incidence of postoperative pericardial effusions and postpericardiotomy syndrome. A complete potential evaluation of each intraoperative course and postoperative course was undertaken. Postoperative comparisons included pain scores at 6, 12, and 24 hours, frequency of emesis, analgesic requirements, respiratory rate and fuel change, and size of intensive care unit and whole hospital stay. No important variations have been recognized between the mini- and full sternotomy approaches. Only improved cosmesis was recognized as an advantage for the mini-sternotomy strategy. The authors additionally concluded that the mini-sternotomy approach leads to a cosmetically superior end result for the affected person with out compromising safety. The function of thoracoscopic and robotic surgical strategies proceed to be explored, significantly in Asia where the excessive cost of system closure has slowed the introduction of this method. Innovative image-guided methods that employ new fixation methods for patch closure have been described. The mean age of the patients at the time of surgical procedure was 20 years reflecting the fact that many of those patients had been postpubertal. The downside of predicting the submammary fold in prepubertal sufferers is a crucial one.
With the heart now decompressed an aortotomy is made transversely and is prolonged towards the noncoronary sinus of Valsalva. The the rest of the first dose of cardioplegia is infused selectively into both coronary ostia. A variety of valvuloplasty methods can be found and have been described by us6 and others. The diameter of the central opening of the valve in addition to the placement and mobility of the commissures and raphes is famous. Primary Repair Excess fibrous tissue, which tends to construct up around raphes (rudimentary fused commissures), is aggressively eliminated (so-called "shaving"), giving the cusp more mobility. Fused commissures with adequate suspension to the aortic wall are opened with a scalpel. Simple tears involving in any other case competent cusps are repaired primarily, often with a 5/0 Prolene working suture. Prolapsed however in any other case competent and pliable cusps are shortened by resuspension of the cusps to the commissures with pledget-supported sutures. In circumstances of central cusp incompetence with dilation of the sinuses of Valsalva, a sinus of Valsalva discount plasty is performed to scale back commissural splaying. This is finished by resecting a wedge of noncoronary sinus, followed by primary closure of the aortotomy. Treated Autologous Pericardial Patch Repair Perforated cusps are repaired with a pericardial patch sutured into the Valve Repair and Replacement 399 perforation. Deficient cusps, normally ensuing from a longstanding balloon-induced tear with retraction of the free cusp edge. The patch is deliberately tailor-made so that it overlaps the opposite free cusp edge by a quantity of millimeters. The free edge of the patch must be barely longer and redundant so that the majority patches are further anchored to at least one commissure (usually anteriorly), thereby resuspending the leaflet. If the native cusp is very stiff or calcified, the cusp is partially or utterly resected and reconstructed with a pericardial patch. Generally, nevertheless, as a lot as attainable of the native valve is left intact as a result of massive patches in young youngsters have a risk of accelerated calcification. If the two cusps are poor at a commissure, two pericardial patches are used to increase the deficient cusps and reconstruct the commissure. Usually the 2 patches shall be sutured together and are supported at a higher stage than the original commissure. Aortic Valve-Sparing Procedures Associated with Aortic Rroot Replacement Both David from Toronto, Canada and Cameron from Johns Hopkins have described a number of techniques that allow the regurgitant aortic valve to be preserved when an aneurysmal aortic root. Valve competence is regained by reducing the sinotubular diameter and by applicable resuspension of the commissures inside the overlying tube graft. There are many variations of this operation, most of which now involve reimplantation of the coronary arteries. Results of Surgery Bacha6,24 reported the results of 81 sufferers younger than 19 years with average or severe aortic regurgitation who underwent surgical aortic valvuloplasty in Boston between 1989 and 2005. Aortic regurgitation was congenital in 20 circumstances, after treatment of aortic stenosis in 30, from other accidents to the aortic valve in 12, and from different causes in 19. Ten of 18 sufferers with average or extreme aortic stenosis before repair had a lower to delicate, whereas two had development from delicate to average. Estimated freedoms from aortic valve substitute had been seventy two � 6% at 5 years and 54 � 9% at 7. The authors concluded that surgical aortic valvuloplasty is a legitimate option with good intermediate results for children and adolescents with aortic regurgitation from quite lots of causes, significantly for sufferers with lower than reasonable aortic stenosis. An internal suture line (not shown) attaches the remnants of the sinuses to the internal surface of the graft. Thirty sufferers (97%) underwent valve-preserving procedures using a Valsalva graft. Surgical aortic valvuloplasty in kids and adolescents with aortic regurgitation: acute and intermediate effects on aortic valve function and left ventricular dimensions. Anatomy Structural problems of the mitral valve inflicting stenosis can occur at the level of the papillary muscles, at the stage of the chords, on account of leaflet abnormalities including commissural fusion or in the instant supravalvar region. A supravalvar mitral net is a fibrous ring mendacity on the atrial floor of the mitral leaflets which often restricts leaflet movement and should in itself be obstructive. Congenitally stenotic mitral valves usually display elements of obstruction at multiple stage. The so-called "mitral arcade" has fused commissures, thickened and immobile leaflets, and shortened and thickened chords. It is exceedingly rare that the patient with congenital Parachute mitral valve with thickened chordae Ao Single papillary m. Diagnostic Studies the plain chest X-ray demonstrates pulmonary congestion and enlargement of the pulmonary arteries. The echo should define structural abnormalities of the mitral valve on the leaflet, subvalvar, and supravalvar levels. Measurement of the diameter in two planes is essential as is calculation of the mitral valve area. A Doppler gradient ought to be estimated: a imply gradient of less than four or 5 mm could be considered to end result from delicate stenosis, 6�12 mm is more doubtless to be reasonable stenosis; whereas higher than thirteen mm is severe. Severe stenosis is nearly always associated with systemic pressure in the proper coronary heart. Three-dimensional echocardiography could additionally be helpful in planning surgical repair and in assessing the outcomes of surgical procedure. Medical and Interventional Therapy Mild and average mitral stenosis can be managed with the same old pharmacologic methods for treating congestive coronary heart failure. The mitral valve may be structurally quite regular and but functionally stenotic due to underdevelopment. In reality, a hypoplastic mitral valve is seen way more generally than isolated structural mitral stenosis because that is normally the situation in hypoplastic left heart syndrome. Pathophysiology and Clinical Features the pathophysiology of mitral stenosis is covered intimately in textbooks of acquired heart disease. In the neonate with very severe stenosis it may not be potential for the left coronary heart to help the systemic circulation alone and the child shall be prostaglandin dependent. The latter entity nonetheless is more likely to end in essential signs later in the first year of life. The signs of mitral stenosis in the toddler embody all the standard options of congestive heart failure, significantly failure to thrive. Although the balloon may have the ability to reduce the diploma of stenosis, nearly certainly this might be on the price of necessary regurgitation. A controlled diploma of regurgitation may be useful in encouraging progress of the hypoplastic annulus but our sense has been that this is rather more tough to achieve with the stenotic mitral valve in distinction to the stenotic aortic valve. Survival free from failure of biventricular restore or mitral valve reintervention was 55% at 1 12 months. The likelihood of reaching a profitable surgical valvotomy is small and may be pretty precisely predicted by the structural look of the valve by echocardiography.
Anastomoses happen the nerve provide to the rectum is rom the sympathetic and parasympathetic systems. The sympathetic provide is rom the lumbar spinal cord, conveyed through lumbar splanchnic nerves and the hypogastric/pelvic plexuses and thru the peri-arterial plexus o the inerior mesenteric and superior rectal arteries. The parasympathetic supply is rom the S2�S4 spinal cord degree, passing through the pelvic splanchnic nerves and the let and proper inerior hypogastric plexuses to the rectal (pelvic) plexus. The lumbar and pelvic splanchnic nerves and hypogastric plexuses have been retracted laterally or readability. Identication o the ureters throughout their ull course via the pelvis is a vital safety measure. The denuded ureteral phase becomes gangrenous and leaks or ruptures 7�10 days ater surgical procedure. It is useul to realize that though the blood provide to the abdominal section o the ureter approaches rom a medial path, that o the pelvic section approaches rom a lateral path. Although passage o small calculi (stones) normally causes little or no ache, larger ones produce extreme pain. Stones that descend the size o the ureter trigger pain described as migrating "rom loin to groin" (rom the lateral stomach to inguinal regions). The ache brought on by a calculus is a colicky (severe) ache, which results rom hyperperistalsis in the ureter, superior to the level o the obstruction. The obstruction could happen anywhere along the ureter, however it occurs most oten on the three websites the place the ureters are usually comparatively constricted. The presence o calculi can oten be conrmed by an abdominal radiograph, an intravenous urogram. Lithotripsy uses shock waves to break up a stone into small ragments which would possibly be handed in the urine. This image on the L1 vertebral degree demonstrates an enlarged right kidney with a dilated intrarenal amassing system (blue arrow). In the lesser pelvis, a calcifc density seems on the ureterovesical junction (red arrow) with dilation o the ureter. Cystocele, Urethrocele, and Urinary Incontinence Damage to the pelvic foor during childbirth. When intra-abdominal pressure will increase (as when stress-free the pelvic foor and "bearing down" to compress the bladder throughout urination), the base o the bladder and higher urethra is pushed against the anterior wall o the vagina, which lacking help will in turn bulge into the vaginal lumen and should protrude through the vaginal orice into the vestibule-cystocele (herniation o the urinary bladder). Urethral catheter course, or angle o the urethra (urethrocele), diminishing the similar old passive compression o the urethra that helps to keep urinary continence during temporary increases in intra-abdominal strain at times exterior o urination. Nonsurgical treatments include pelvic foor muscle workouts, pessaries (devices placed in the vagina to present help and resistance), and pharmacotherapy. Surgical treatment involves retethering o the vagina, and/or the position o support on to the urethra. Posterior rupture o the bladder normally leads to passage o urine extraperitoneally into the perineum. Using a high-requency electrical present, the tumor is eliminated in small ragments, which are washed rom the bladder with water. Suprapubic Cystotomy Although the superior surace o the empty bladder lies at the level o the superior margin o the pubic symphysis, because the bladder lls, it extends superiorly above the symphysis into the free areolar tissue between the parietal peritoneum and anterior belly wall. Consequently, the distended bladder may be punctured (suprapubic cystotomy) or approached surgically superior to the pubic symphysis or the introduction o indwelling catheters or instruments without traversing the peritoneum and getting into the peritoneal cavity. Urinary calculi, oreign bodies, and small tumors can also be removed rom the bladder by way of a suprapubic extraperitoneal incision. Light wire Urinary bladder Tube for fluid Prostate Rupture o Bladder Because o the superior place o the distended bladder, it might be ruptured by injuries to the inerior part o the anterior stomach wall or by ractures o the pelvis. The rupture may outcome within the escape o urine extraperitoneally or intraperitoneally. It can be easily dilated with out harm; consequently, the passage o catheters or cystoscopes is simpler in emales than in males. Inections o the urethra, and especially o the bladder, are extra widespread in girls as a result of the emale urethra is brief, extra distensible, and is open to the exterior through the vestibule o the vagina. Rectal Examination Many buildings related to the antero-inerior part o the rectum may be palpated by way of its walls. Enlarged inner iliac lymph nodes, pathological thickening o the ureters, swellings in the ischio-anal ossae [e. Tenderness o an infamed appendix can also be detected rectally i it descends into the lesser pelvis (pararectal ossa). The inside facet o the rectum could be examined with a proctoscope, and biopsies o lesions may be taken via this instrument. The operator must also know that the transverse rectal olds, which give useul landmarks or the procedure, could briefly impede passage o these devices. The ureters descend subperitoneally into the pelvis, passing inerior to the ductus deerens o males or the uterine artery o emales, the latter relationship being o particular surgical importance. The ureters penetrate the bladder wall obliquely rom its postero-inerior angle, creating a one-way valve. The pelvic portion o each ureter is served by the inerior vesical (male) or vaginal (emale) artery and the vesical venous plexus and internal iliac veins. Calculi, more doubtless to turn out to be entrapped the place the ureter crosses the pelvic brim or enters the bladder, produce severe groin ache. Urinary bladder: the superior and inerior portions o the urinary bladder are fairly distinct anatomically and unctionally. The body o the bladder is highly distensible, embedded in free extraperitoneal at, and covered on its superior side with peritoneum, all o which allow growth with flling. In distinction, the relatively indistensible neck o the bladder is anchored in place by pelvic ligaments and the oor o the bladder overlying it (which consists of the trigone o the bladder) and remains comparatively unchanged with flling. The neck and adjacent inerior physique are served by inerior vesical arteries and the vesical venous plexus. Sympathetic fbers rom inerior thoracic and superior lumbar spinal cord segments keep the tonus o the bladder neck and, in males throughout ejaculation, stimulate contraction o the internal urethral sphincter to stop reux o semen. Parasympathetic fbers conveyed by pelvic splanchnic nerves rom the S2�S4 spinal cord segments inhibit the neck musculature and stimulate increased tonus o the detrusor muscle o the bladder partitions or urination. Visceral aerent fbers conducting ache sensation rom the roo o the bladder (superior to the pelvic pain line) ollow the sympathetic fbers retrogradely to spinal sensory ganglia. Urethra: the male urethra consists o our components, two o which are the intramural and prostatic components. The intramural part varies in size and caliber, depending on whether the bladder is flling or emptying. The prostatic urethra is distinguished each by its surroundings and the constructions that open into it. It is surrounded by the prostate, the muscular anterior "lobe" that includes the trough-like superior extension o the external urethral sphincter anteriorly, and by the glandular lobes posteriorly. The prostatic ducts open into prostatic sinuses on both sides o the urethral crest.
Indications for Surgery the indications for mitral valve repair for mitral regurgitation ought to be fairly a bit much less stringent than these applied for mitral stenosis. On the other hand, if surgery is delayed there will be secondary modifications of the valve which is in a position to improve the issue of repair and reduce the likelihood that repair shall be profitable. It should be highly unlikely that valve replacement is required at a first attempt to improve a regurgitant mitral valve surgically. Cardiopulmonary bypass is managed with bicaval cannulation, delicate or reasonable hypothermia, and cardioplegic arrest. Real-time three-dimensional echocardiography is a helpful complement to normal twodimensional echocardiography. Frothing will definitely occur if the cardioplegia is injected as a jet from a distance through the valve. Usually the predominant jet will be via the cleft although there may also be central regurgitation. The relative positions of the valve leaflets must be very rigorously noted, significantly on the level of the cleft. The cleft should be very accurately approximated which may be achieved by very cautious statement of how the refined irregularities of the cleft margins match collectively. Minor variations within the leaflet tissue can function landmarks to guide subsequent suturing of the cleft. Cleft Closure In the reoperative setting the cleft margins are often thickened and rolled and will hold sutures well. A steady method is probably probably the most safe technique utilizing working 6/0 or 5/0 Prolene. However, it may be more difficult to very accurately align the cleft margins as desired if a continuous suture is used. It could also be preferable to use interrupted sutures which can be strengthened with fine pericardial pledgets if the valve leaflet tissue is fragile. Annuloplasty for Central Regurgitation If regurgitation by way of the center of the valve is noted after closure of the cleft it goes to be essential to carry out an annuloplasty. Therefore, commissuroplasty sutures are positioned at one or both commissures as initially described by Reed. On event a 3rd annuloplasty suture have to be placed instantly posteriorly to tighten the annulus additional. It is important to keep in thoughts that the circumflex coronary artery lies near the annulus posteriorly and laterally. Chordal Shortening, Chordal Transfer the various techniques popularized by Carpentier for rheumatic mitral valve illness and degenerative valve disease are not often used for children with congenitally irregular valves. However, the pediatric surgeon should definitely be acquainted with these techniques which are broadly utilized by adult cardiac surgeons for restore of mitral valves with degenerative disease. It must be potential to essentially get rid of any regurgitant jet with the low strain testing that can be carried out in this way. The contraction of the annulus that happens with ventricular systole should additional tighten the valve and compensate for the upper stress will probably be uncovered to when the center is ejecting. Mitral Valve Replacement for Regurgitation the approach for mitral valve substitute for regurgitation is similar as for stenosis. The necessary distinction is that the annulus could be very likely to be a generous dimension in order that supraannular positioning is unlikely to be essential. There were two hospital deaths and two late deaths in sufferers who underwent mitral valve repair. Three of those 4 patients underwent mitral valve alternative because of residual mitral incompetence. There have been no hospital deaths in the sufferers who underwent mitral valve substitute although there were two late deaths. Six sufferers had a total of 10 episodes of prosthetic valve thrombosis though in all instances thrombolytic remedy with urokinase was successful. Actuarial survival and freedom from cardiac events at 10 years after operation had been 87% and 73% in kids who underwent mitral valve repair and 90% and 67% for those who underwent replacement. The explanation for regurgitation was chordal anomalies in 69% of sufferers, annular dilation in 16%, and platelet anomalies in 14%. Of these sufferers, 88% had commissural plication annuloplasty, 11 had modified Devega procedures, 5 had cleft closure and three had plication of the anterior leaflet. The only communication between the atrialized ventricle and the infundibulum is thru the anteroseptal commissure of the tricuspid valve. It is essential to distinguish structural pulmonary atresia from useful atresia by which the pulmonary valve fails to open due to high pulmonary artery strain from a patent ductus. A Wolff�Parkinson�White type of accessory pathway, with associated pre-excitation, is current in roughly 10% of patients. Associated noncardiac anomalies embrace low-set ears, micrognathia, cleft lip and palate, absent left kidney, megacolon, undescended testes, and bilateral inguinal hernias. Fetal echocardiography has revealed that this anomaly carries an especially excessive fee of demise in utero. All systemic venous return should move from right to left, across the atrial septum and through the foramen ovale. Metabolic acidosis ought to be treated with bicarbonate infusion, and inotropic support should be given. Medical management of the older youngster or grownup with a gentle diploma of cyanosis should be geared toward symptomatic reduction solely. It is feasible, that as with other types of valve repair, success is extra doubtless with earlier surgery earlier than secondary pathologic adjustments including annular enlargement have progressed. There are few helpful reviews to information the choice concerning the necessity for and timing of surgical procedure within the infant and neonate although Knott-Craig and colleagues have begun to develop a useful management algorithm. However, the severely cyanotic child who can be stabilized with this management has the potential for bettering over days and weeks as pulmonary resistance falls. Management options for the neonate with structural pulmonary atresia are mentioned beneath under Technical Considerations. When associated anomalies had been present, solely 15% of infants survived to 2 years of age. Nevertheless, normally, sufferers who survive past early childhood can anticipate comparatively few limitations. If the neonate has an adequate cardiac output however is set by echocardiography to have structural pulmonary atresia, surgical procedure will certainly be wanted. Starnes originally described this process for neonates with functional somewhat than structural pulmonary atresia. The procedure entails pericardial patch closure of the tricuspid valve, putting the coronary sinus on the ventricular aspect of the patch. All infants had been asymptomatic on the time of follow-up, with development on the fiftieth percentile for height and the 20th percentile for weight. Two kids underwent profitable Fontan procedures approximately 2 years after their preliminary palliative process, while one youngster had a Glenn shunt positioned. Danielson and colleagues have had considerable experience with an identical approach to tricuspid valve reconstruction. In addition, accessory conduction pathways, inflicting ventricular pre-excitation, are mapped and divided.
Postnatally, the patent parts o the umbilical arteries run antero-ineriorly between the urinary bladder and the lateral wall o the pelvis. It runs anteroineriorly on the obturator ascia on the lateral wall o the pelvis and passes between the obturator nerve and vein. Within the pelvis, the obturator artery gives o muscular branches, a nutrient artery to the ilium, and a pubic branch. Anterior divisions o the internal iliac arteries normally provide most o the blood to pelvic constructions. In a typical variation (20%), an aberrant or accessory obturator artery arises rom the inerior epigastric artery and descends into the pelvis along the standard route o the pubic branch. The extrapelvic distribution o the obturator artery is described with the decrease limb (Chapter 7). In emales, it could occur-with practically equal requency-as a separate department o the inner iliac artery or as a department o the uterine artery. The uterine artery is an additional department o the inner iliac artery in emales, usually arising individually and immediately rom the internal iliac artery. It descends on the lateral wall o the pelvis, anterior to the interior iliac artery, and passes medially to attain the junction o the uterus and vagina, where the cervix (neck) o the uterus protrudes into the superior vagina. The relationship o ureter to artery is oten remembered by the phrase "water (urine) passes underneath the bridge (uterine artery). On reaching the side o the cervix, the uterine artery divides into a smaller descending vaginal department, which provides the cervix and vagina, and a larger ascending branch, which runs along the lateral margin o the uterus, supplying it. The ascending branch biurcates into ovarian and tubal branches, which proceed to provide the medial ends o the ovary and uterine tube and anastomose with the ovarian and tubal branches o the ovarian artery. The origin o the arteries rom the anterior division o the interior iliac artery and distribution to the uterus and vagina are shown. The anastomoses between the ovarian and tubal branches o the ovarian and uterine arteries and between the vaginal branch o the uterine artery and the vaginal artery provide potential pathways o collateral circulation. These communications happen, and the ascending department courses, between the layers o the broad ligament. The vaginal artery supplies quite a few branches to the anterior and posterior suraces o the vagina. The center rectal artery might arise independently rom the interior iliac artery, or it may come up in common with the inerior vesical artery or the inner pudendal artery. The inside pudendal artery, larger in males than in emales, passes inerolaterally, anterior to the piriormis muscle and sacral plexus. It leaves the pelvis between the piriormis and coccygeus muscle tissue by passing via the inerior part o the larger sciatic oramen. The internal pudendal artery then passes across the posterior facet o the ischial spine or the sacrospinous ligament and enters the ischio-anal ossa through the lesser sciatic oramen. The inside pudendal artery, together with the inner pudendal veins and branches o the pudendal nerve, passes through the pudendal canal in the lateral wall o the ischioanal ossa. As it exits the canal, medial to the ischial tuberosity, the interior pudendal artery divides into its terminal branches, the perineal artery and dorsal arteries o the penis or clitoris. The inerior gluteal artery is the bigger terminal branch o the anterior division o the interior iliac artery. It passes posteriorly between the sacral nerves (usually S2 and S3) and leaves the pelvis via the inerior part o the larger sciatic oramen, inerior to the piriormis muscle. It provides the muscles and pores and skin o the buttocks and the posterior surace o the thigh. When the inner iliac artery divides into anterior and posterior divisions, the posterior division typically gives rise to the ollowing three parietal arteries. Within the ossa, the artery divides into an iliac department, which provides the iliacus muscle and ilium, and a lumbar branch, which supplies the psoas major and quadratus lumborum muscle tissue. Lateral sacral arteries: Superior and inerior lateral sacral arteries could arise as independent branches or via a typical trunk. The lateral sacral arteries move medially and descend anterior to the sacral anterior rami, giving o spinal branches, which move by way of the anterior sacral oramina and provide the spinal meninges enclosing the roots o the sacral nerves. Some branches o these arteries move rom the sacral canal by way of the posterior sacral oramina and supply the erector spinae muscular tissues o the back and the skin overlying the sacrum. Superior gluteal artery: the biggest branch o the posterior division, the superior gluteal artery provides the gluteal muscles in the buttocks. As it passes ineriorly, the ovarian artery adheres to the parietal peritoneum and runs anterior to the ureter on the posterior abdominal wall, often giving branches to it. As the ovarian artery enters the lesser pelvis, it crosses the origin o the external iliac vessels. This vessel descends in or near the midline anterior to the bodies o the last one or two lumbar vertebrae and the sacrum and coccyx. During pelvic laparoscopic procedures, it offers a useul indication o the midline on the posterior wall o the pelvis. Beore the median sacral artery enters the lesser pelvis, it sometimes provides rise to a pair o L5 arteries. As it descends over the sacrum, the median sacral artery gives o small parietal (lateral sacral) branches that anastomose with the lateral sacral arteries. It also gives rise to small visceral branches to the posterior part o the rectum, which anastomose with the superior and center rectal arteries. The median sacral artery represents the caudal finish o the embryonic dorsal aorta, which gotten smaller because the tail-like caudal eminence o the embryo disappeared. They anastomose with the inner vertebral venous plexus (Chapter 2), providing an alternate collateral pathway to attain either the inerior or superior vena cava. It may present a pathway or metastasis o prostatic or ovarian cancer cells to vertebral or cranial websites. Lymph Nodes o Pelvis the lymph nodes receiving lymph drainage rom pelvic organs are variable in quantity, dimension, and location. They receive lymph mainly rom the inguinal lymph nodes; nonetheless, they receive lymph rom pelvic viscera, especially the superior parts o the center to anterior pelvic organs. Internal iliac lymph nodes: clustered across the anterior and posterior divisions o the internal iliac artery and the origins o the gluteal arteries. They receive drainage rom the inerior pelvic viscera, deep perineum, and gluteal region and drain into the common iliac nodes. Sacral lymph nodes: lie within the concavity o the sacrum, adjoining to the median sacral vessels. They obtain lymph rom postero-inerior pelvic viscera and drain either to inside or common iliac nodes. These nodes start a typical route or drainage rom the pelvis that passes next to the lumbar (caval/aortic) nodes. Inconstant direct drainage to the widespread iliac nodes happens rom some pelvic organs. Both primary and minor teams o pelvic nodes are extremely interconnected, so that many nodes may be removed with out disturbing drainage. While the lymphatic drainage tends to parallel the venous drainage (except or that to the exterior iliac nodes, the superior rectal artery is the direct continuation o the inerior mesenteric artery. It crosses the let common iliac vessels and descends in the sigmoid mesocolon to the lesser pelvis.
References
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