The thoracic lymphatic duct drains. Topography of the thoracic lymphatic duct. Indications and technique of HLP catheterization. Possible complications. Abdominal thoracic duct

The right lymphatic duct, ductus lymphaticus dexter, has a length of no more than 10-12 mm and is formed from the confluence of three trunks: truncus jugularis dexter, which receives lymph from the right region of the head and neck, truncus subclavius dexter, which carries lymph from the right upper limb, and truncus bronchomediastinalis dexter , which collects lymph from the walls and organs of the right half of the chest and the lower lobe of the left lung. The right lymphatic duct drains into the right subclavian vein. Quite often it is absent, in which case the three trunks listed above independently flow into the subclavian vein

4. Spinal cord: external structure, topography The spinal cord, medulla spinalis (Fig. 878, 879), has a relatively simple structural principle and a pronounced segmental organization compared to the brain. It provides connections between the brain and the periphery and carries out segmental reflex activity.

The spinal cord lies in the spinal canal from the upper edge of the 1st cervical vertebra to the 1st or upper edge of the 2nd lumbar vertebra, repeating to a certain extent the direction of curvature of the corresponding parts of the spinal column. In a fetus of 3 months, it ends at the level of the V lumbar vertebra, in a newborn - at the level of the III lumbar vertebra.

The spinal cord without a sharp border passes into the medulla oblongata at the exit of the first cervical spinal nerve. Skeletotopically, this border runs at the level between the lower edge of the foramen magnum and the upper edge of the 1st cervical vertebra. Below, the spinal cord passes into the cerebral cone, conus medullaris, continuing into the terminal thread (spinal), filum terminate (spinate), which has a diameter of up to 1 mm and is a reduced part of the lower spinal cord. The terminal thread, with the exception of its upper sections, where there are elements of the nervous tissue, is a connective tissue formation. Together with the hard shell of the spinal cord, it penetrates the sacral canal and attaches at its end. That part of the terminal thread, which is located in the cavity of the dura mater and is not fused with it, is called the internal terminal thread, filum terminate internum; the rest of it, fused with the dura mater, is the outer terminal thread (hard shell), filum terminale externum (durale). The terminal thread is accompanied by the anterior spinal arteries and veins, as well as one or two roots of the coccygeal nerves.

The spinal cord does not occupy the entire cavity of the spinal canal: between the walls of the canal and the brain there remains a space filled with adipose tissue, blood vessels, meninges and cerebrospinal fluid.

The length of the spinal cord in an adult ranges from 40 to 45 cm, the width is from 1.0 to 1.5 cm, and the average weight is 35 g.

There are four surfaces of the spinal cord: a somewhat flattened anterior, slightly convex posterior, and two lateral, almost rounded, passing into the anterior and posterior.

The spinal cord does not have the same diameter throughout. Its thickness increases slightly from bottom to top. The largest size in diameter is noted in two spindle-shaped thickenings: in the upper section - this is the cervical thickening, intumescentia cervicalis, corresponding to the exit of the spinal nerves going to the upper limbs, and in the lower section - this is the lumbosacral thickening, intumescentia lumbosacralis - the place where the nerves exit to lower limbs. In the region of the cervical thickening, the transverse size of the spinal cord reaches 1.3-1.5 cm, in the middle of the thoracic part - 1 cm, in the region of the lumbosacral thickening - 1.2 cm; the anteroposterior size in the area of thickening reaches 0.9 cm, in the thoracic part - 0.8 cm.

The cervical thickening begins at the level of the III-IV cervical vertebra, reaches the II thoracic, reaching the greatest width at the level of the V-VI cervical vertebra (at the height of the fifth sixth cervical spinal nerve). The lumbosacral thickening extends from the level of the IX-X thoracic vertebra to the 1st lumbar, its greatest width corresponds to the level of the XII thoracic vertebra (at the height of the third lumbar spinal nerve).

The shape of the transverse sections of the spinal cord at different levels is different: in the upper part the section has the shape of an oval, in the middle part it is rounded, and in the lower part it approaches a square.

On the anterior surface of the spinal cord, along its entire length, there is a deep anterior median fissure, fissura mediana ventralis (anterior) (Fig. 880-882, see Fig. 878), into which the fold of the pia mater protrudes - the intermediate cervical septum, septum cervicale intermedium. This gap is less deep at the upper and lower ends of the spinal cord and is most pronounced in its middle sections.

On the posterior surface of the brain there is a very narrow posterior median sulcus, sulcus medianus dorsalis, into which a plate of glial tissue penetrates - the posterior median septum, septum medianum dorsale. The fissure and groove divide the spinal cord into two halves - right and left. Both halves are connected by a narrow bridge of brain tissue, in the middle of which is the central canal, canalis centralis, of the spinal cord.

On the lateral surface of each half of the spinal cord are two shallow grooves. The anterolateral groove, sulcus ventrolateralis, is located outward from the anterior median fissure, more distant from it in the upper and middle parts of the spinal cord than in its lower part. The posterolateral sulcus, sulcus dorsolateralis, lies outward from the posterior median sulcus. Both sulci run along almost the entire length of the spinal cord.

In the cervical and partly in the upper thoracic regions, between the posterior median and posterolateral grooves, there is an unsharply pronounced posterior intermediate groove, sulcus intermedius dorsalis (see Fig. 881).

In the fetus and newborn, a rather deep anterior intermediate sulcus is sometimes found, which, following the anterior surface of the upper sections of the cervical spinal cord, is located between the anterior median fissure and the anterolateral sulcus.

Anterior radicular filaments, fila radicularia, which are processes of motor cells, emerge from or near the anterolateral sulcus. The anterior root filaments form the anterior root (motor), radix ventralis (motoria). The anterior roots contain centrifugal (efferent) fibers that conduct motor and autonomic impulses to the periphery of the body: to striated and smooth muscles, glands, etc.

The posterolateral groove includes the posterior radicular filaments, consisting of processes of cells that lie in the spinal ganglion. The posterior radicular threads form the posterior root (sensitive), radix dorsalis. The posterior roots contain afferent (centripetal) nerve fibers that conduct sensory impulses from the periphery, that is, from all tissues and organs of the body, to the central nervous system.

The spinal node (sensitive), ganglion spinale (see Fig. 879, 880), is a spindle-shaped thickening located on the back root. It is a cluster of mostly pseudo-unipolar nerve cells. The process of each such cell is divided in a T-shape into two processes: a long peripheral one is sent to the periphery as part of the spinal nerve, n. spinalis, and ends in a sensitive nerve ending; a short central one follows as part of the posterior root to the spinal cord (see Fig. 947). All spinal nodes, with the exception of the node of the coccygeal root, are tightly surrounded by the dura mater; the nodes of the cervical, thoracic and lumbar regions lie in the intervertebral foramina, the nodes of the sacral region lie inside the sacral canal.

Ascending pathways of the spinal cord and brain; right hemisphere (semi-schematically).

The direction of the roots is not the same: in the cervical region they depart almost horizontally, in the thoracic region they go obliquely downward, in the lumbosacral region they follow straight down (see Fig. 879).

The anterior and posterior roots of the same level and one side immediately outward from the spinal node are connected, forming the spinal nerve, n. spinalis, which is thus mixed. Each pair of spinal nerves (right and left) corresponds to a specific area - a segment - of the spinal cord.

Therefore, there are as many segments in the spinal cord as there are pairs of spinal nerves.

The spinal cord is divided into five parts: the cervical part, pars cervicalis, the thoracic part, pars thoracica, the lumbar part, pars lumbalis, the sacral part, pars sacralis, and the coccygeal part, pars coccygea (see Fig. 879). Each of these parts includes a certain number of segments of the spinal cord, segmenta medullae spinalis, i.e. sections of the spinal cord that give rise to one pair of spinal nerves (right and left).

The cervical part of the spinal cord consists of eight cervical segments, segmenta medullae spinalis cervicalia, the thoracic part - 12 thoracic segments, segmenta medullae spinalis thoracicae, the lumbar part - five lumbar segments, segmenta medullae spinalis lumbalia, the sacral part - five sacral segments, segmenta medullae spinalis sacralia, and, finally, the coccygeal part is made up of one to three coccygeal segments, segmenta medullae spinalis coccygea. There are 31 segments in total.

external base of the skull

The occipital bone, the posterior surfaces of the pyramids, and the temporal bones take part in the formation of the posterior cranial fossa.

Between the back of the Turkish saddle and the large occipital foramen there is a slope.

The internal auditory (right and left) opening opens into the posterior cranial fossa, from which the vestibulocochlear nerve (VIII pair) emerges, and the facial nerve (VII pair) exits from the canal of the facial nerve. The tongue-pharyngeal (IX pair), vagus (X pair) and accessory (XI pair) nerves exit through the jugular foramen of the base of the skull. The nerve of the same name passes through the canal of the hypoglossal nerve - the XII pair. From the cranial cavity, in addition to the nerves, the internal jugular vein exits through the jugular foramen, passing into the sigmoid sinus. The formed foramen magnum connects the cavity of the posterior cranial fossa with the spinal canal, at the level of which the medulla oblongata passes into the spinal cord.

The outer base of the skull (basis cranii extema) in its anterior section is closed by the facial bones (the bone palate is distinguished in it, bounded in front by the alveolar process of the upper jaw and teeth), and the posterior section is formed by the outer surfaces of the sphenoid, occipital and temporal bones

In this area there are a large number of holes through which the vessels and nerves pass, providing blood supply to the brain. The central part of the outer base of the skull is occupied by a large occipital foramen, on the sides of which the occipital condyles are located. The latter are connected to the first vertebra of the cervical spine. The exit from the nasal cavity is represented by paired openings (choanas), passing into the nasal cavity. In addition, on the outer surface of the base of the skull are the pterygoid processes of the sphenoid bone, the external opening of the carotid canal, the styloid process, the stylomastoid foramen, the mastoid process, the musculo-tubal canal, the jugular foramen and other formations.

In the skeleton of the facial skull, the central place is occupied by the nasal cavity, eye sockets, oral cavity, infratemporal and pterygo-palatine fossae

2.hard and soft palate

The oral cavity itself is bounded from above by the hard palate and part of the soft palate, from below - by the tongue together with the muscles that form the bottom of the oral cavity, in front and from the sides - by the dentition and gums. Behind, the boundary of the cavity is the soft palate with a tongue that separates the mouth from the pharynx. In newborns, the oral cavity is short and low due to the absence of teeth. As the dentition develops, it gradually acquires a definitive volume. In people in adulthood, the shape of the oral cavity has individual characteristics. In short-headed ones, it is wider and higher than in long-headed ones.

Depending on the shape of the hard palate, the height of the alveolar processes, the vault (dome) formed by the upper wall of the oral cavity can be of different heights. In people with a narrow and high face (dolichocephalic type), the arch of the palate is usually high, in people with a wide and low face of the brachycephalic type) the arch of the palate is flattened. It has been noticed that people with a singing voice have a higher vault of the sky. With an increased volume of the oral cavity, one of the resonator cavities is the physical basis for the development of vocal data.

The soft palate hangs freely, fixed at the top along the bony elements of the hard palate. With calm breathing, it separates the oral cavity from the pharynx. At the moment of swallowing food, the soft palate is set horizontally, separating the oropharynx from the nasopharynx, i.e., isolating the food tract from the respiratory tract. The same happens during the implementation of vomiting movements. The mobility of the soft palate is provided by its muscles, which are able to strain it, raise and lower it. The action of this muscle is carried out automatically.

The bottom of the oral cavity, or its lower base, consists of soft tissues, the support of which is mainly the maxillohyoid and chin muscles.

The functions of the mouth are regulated by a complex nervous apparatus in which nerve fibers take part: motor secretory, sensory and gustatory.

The oral cavity performs a variety of physiological functions: here the food is subjected to mechanical grinding, here it begins to undergo chemical processing (exposure to saliva). With the help of ptyalin contained in saliva, the saccharification of starchy substances begins. The soaking and coating with saliva makes hard food easy to swallow; without saliva, swallowing would not be possible. The work of the salivary glands is closely related to stimuli in the external environment, and is an innate unconditioned reflex. In addition to this unconditioned reflex, salivation can also be a conditioned reflex, i.e., saliva can be released with an irritant coming from the eye - light, ear - acoustic, skin - tactile.

Excitation of the nervous apparatus of the salivary glands, i.e. increased salivation, can occur when certain chemicals enter the oral cavity (for example, pilocarpine), with various inflammatory processes in the oral cavity (for example, with stomatitis), with damage to other organs (for example, stomach, intestines), with trigeminal neuralgia. Inhibition of the nervous apparatus of the salivary glands, i.e., a decrease in salivation, occurs under the influence of certain chemicals (atropine) and under the influence of reflex moments (fear, excitement).

The oral cavity is a checkpoint where food substances are tested using the sense of taste and smell. In the numerous taste buds of the tongue, fibers of the taste nerve terminate. With indigestion, the patient feels a bad taste in the mouth, the tongue is covered with plaque - it becomes coated. According to Pavlov, this is a self-healing reflex on the part of the body; a reflex occurs in the intestine, which is transmitted through the trophic nerves to the tongue, causing a loss of taste, i.e., abstinence from food, thereby ensuring rest for the digestive canal.

The first act of swallowing takes place in the oral cavity. When sucking, the soft palate descends and closes the oral cavity from behind, in front the oral cavity is closed by the action of m. orbicularis oris, which lengthens the baby's lips like a trunk around the nipple or horn. With cleft lip intact m. orbicularis oris is disturbed, and the act of sucking is difficult.

The sucking act can continue indefinitely, since with the lowered palatine curtain, nasal breathing occurs normally.

During the act of swallowing, the root of the tongue descends, the soft palate rises to a horizontal position, separating the nasopharyngeal cavity from the oral cavity. The tongue pushes food into the formed funnel. At the same time, the glottis closes, food comes into contact with the walls of the pharynx, exciting the contraction of the pharyngeal muscles and constrictors, which push the bolus of food further into the esophagus.

The oral cavity is involved in speech: speech is impossible without the participation of the tongue. During phonation, the soft palate rises and falls to regulate the nasal resonator. This explains the complications during sucking, swallowing and phonation, which entail fissured defects of the palate, paralysis of the palatine curtain, etc.

The oral cavity is also used for breathing.

In the oral cavity there is always a large number of microorganisms and their associations. These various microbes, mixing with saliva and food debris, cause a number of chemical processes in the mouth, the deposition of calculus on the teeth, in the glands, etc. Hence the need for oral hygiene becomes clear.

3) Superior vena cava and brachiocephalic veins

The brachiocephalic and superior vena cava are located in the tissue of the anterior mediastinum directly behind the thymus gland, and the superior vena cava, in addition, lies behind the anterior-medial section of the right mediatinal pleura, and below - inside the pericardial cavity. The right and left brachiocephalic veins arise from the confluence of the respective subclavian and internal jugular veins behind the sternoclavicular joints.

V. brachiocephalica dextra is located behind the right half of the sternum handle from the right sternoclavicular joint to the attachment of the cartilage of the 1st rib to the sternum, where the right and left brachiocephalic veins, having merged with each other, form the superior vena cava. To the anterior outer-lower part of the right brachiocephalic vein, especially if it is long, and the mediastinal pleura adjoins its lateral surface. The right phrenic nerve runs between the pleura and vein. Behind and medial to the right brachiocephalic vein lies the brachiocephalic trunk, behind the right vagus nerve.

V. brachiocephalica sinistra is located transversely or obliquely behind the handle of the sternum, projecting from the left sternoclavicular joint to the junction of the cartilage of the right I rib with the sternum or at any point below, to the level of attachment of the upper edge of the second costal cartilage to the sternum. The thymus gland is adjacent to the vein in front, the aortic arch, the brachiocephalic trunk and the left common carotid artery are adjacent to the vein, and the perinarard is below. V. intercostalis superior sinistra flows into the left brachiocephalic vein or into the left venous angle, which goes forward from the posterior mediastinum, located between the aortic arch and the left mediastinal pleura. This vein serves as a guide for ligation of the ductus arteriosus, which is located below the vein.

V. cava superior goes from top to bottom, lies behind the right edge of the sternum in the area between the cartilages of the 1st and 3rd ribs and enters the pericardial cavity at the level of the second intercostal space. Here, a large v usually flows into it from behind. Azygos

The upper part of the superior vena cava is located in the tissue of the anterior mediastinum to the right of the ascending aorta and to the left of the right mediastinal pleura. Between the vein and the pleura, the right phrenic nerve is directed downward, accompanied by a. and v. pericardiacophrenicae. The lower part of the vein is located in the pericardial cavity and lies anterior to the root of the right lung and to the right of the aorta. Lymphatic vessels and anterior mediastinal lymph nodes adjoin the extrapericardial part of the superior vena cava, as well as both brachiocephalic veins. Outside the pericardial cavity, from the mouth of the superior vena cava to the right pulmonary artery, there is a sail-shaped ligament, which circularly covers the right pulmonary artery with two leaves and firmly connects the artery with the vein. The veins of the mediastinum and neck (vv. mediastinales, thymicae, pericardiacae, bronchiales, tracheales, thoracicae internae, vertebrales and branches of the plexus thyreoi-deus impar) flow into the right and left brachiocephalic veins, as well as into the superior vena cava.

4. Hypoglossal nerve, its nucleus

The hypoglossal nerve is motor (Fig. 9.10). Its nucleus is located in the medulla oblongata, while the upper part of the nucleus is located under the bottom of the rhomboid fossa, and the lower one descends along the central canal to the level of the beginning of the pyramidal tract decussation. The nucleus of the XII cranial nerve consists of large multipolar cells and a large number of fibers located between them, by which it is divided into 3 more or less separate cell groups. The axons of the cells of the nucleus of the XII cranial nerve gather into bundles that penetrate the medulla oblongata and emerge from its anterior lateral groove between the inferior olive and the pyramid. Subsequently, they leave the cranial cavity through a special hole in the bone - the hypoglossal nerve canal (canalis nervi hypoglossi), located above the lateral edge of the foramen magnum, forming a single trunk.

Coming out of the cranial cavity, the XII cranial nerve passes between the jugular vein and the internal carotid artery, forms a hyoid arch, or loop (ansa cervicalis), passing here in close proximity to the branches of the spinal nerves coming from the three upper cervical segments of the spinal cord and innervating the muscles, attached to the hyoid bone. In the future, the hypoglossal nerve turns forward and is divided into lingual branches (rr. linguales), which innervate the muscles of the tongue: hyoid-lingual (t. hypoglossus), syllable (t. styloglossus) and chin-lingual (t. genioglossus) y and also longitudinal and transverse muscles of the tongue (t. longitudinalis and t. transversus linguae).

When the XII nerve is damaged, peripheral paralysis or paresis of the half of the tongue of the same name occurs (Fig. 9.11), while the tongue in the oral cavity shifts to the healthy side, and when protruding from the mouth it deviates towards the pathological process (the tongue "points to the focus"). This happens due to the fact that the t. genioglossus of the healthy side pushes the homolateral half of the tongue forward, while its paralyzed half lags behind and the tongue turns in its direction. The muscles of the paralyzed side of the tongue atrophy over time, become thinner, while the relief of the tongue on the side of the lesion changes - it becomes folded, "geographical".

1. Muscles of the forearm

back group

Surface layer

The long radial extensor of the wrist (m. extensor carpi radialis longus) (Fig. 116, 118) flexes the forearm at the elbow joint, extends the hand and takes part in its abduction. The muscle has a fusiform shape and is distinguished by a narrow tendon, significantly exceeding the length of the abdomen. The upper part of the muscle is covered by the brachioradialis muscle. The point of its beginning is located on the lateral epicondyle of the humerus and the lateral intermuscular septum of the shoulder fascia, and the place of attachment is on the dorsum of the base of the second metacarpal bone.

The short radial extensor of the wrist (m. extensor carpi radialis brevis) unbends the hand, slightly retracting it. This muscle is slightly covered by the long radial extensor of the wrist, starts from the lateral epicondyle of the humerus and the fascia of the forearm, and is attached to the dorsal surface of the base of the III metacarpal bone.

1 - biceps muscle of the shoulder;

2 - shoulder muscle;

4 - aponeurosis of the biceps muscle of the shoulder;

5 - round pronator;

6 - brachioradialis muscle;

7 - radial flexor of the hand;

9 - long palmar muscle;

10 - superficial finger flexor;

11 - long flexor of the thumb;

12 - short palmar muscle;

13 - palmar aponeurosis

Muscles of the forearm (front view):

1 - shoulder muscle;

2 - supinator;

3 - tendon of the biceps muscle of the shoulder;

4 - long radial extensor of the wrist;

5 - deep finger flexor;

6 - brachioradialis muscle;

7 - long flexor of the thumb;

8 - round pronator;

10 - square pronator;

11 - muscle that opposes the thumb of the hand;

12 - muscle leading the little finger;

13 - short flexor of the thumb;

14 - tendons of the deep flexor of the fingers;

15 - tendon of the long flexor of the thumb;

16 - tendons of the superficial flexor of the fingers

Muscles of the forearm (front view):

1 - round pronator;

2 - tendon of the biceps muscle of the shoulder;

3 - supinator;

4 - interosseous membrane;

5 - square pronator

Muscles of the forearm (back view):

1 - brachioradialis muscle;

2 - triceps muscle of the shoulder;

3 - long radial extensor of the wrist;

6 - extensor of the fingers;

8 - extensor of the little finger;

9 - a long muscle that removes the thumb of the hand;

10 - short extensor of the thumb;

11 - extensor retinaculum;

12 - long extensor of the thumb;

13 - extensor tendons of the fingers

Muscles of the forearm (back view):

1 - arch support;

2 - deep finger flexor;

3 - a long muscle that abducts the thumb of the hand;

4 - long extensor of the thumb;

5 - short extensor of the thumb;

6 - extensor of the index finger;

7 - extensor retinaculum;

8 - extensor tendons of the fingers

The extensor digitorum (m. extensor digitorum) unbends the fingers and takes part in the extension of the hand. The abdomen of the muscle has a fusiform shape, the direction of the bundles is characterized by a two-pinnate shape.

Its point of origin is located on the lateral epicondyle of the humerus and the fascia of the forearm. In the middle of its length, the abdomen passes into four tendons, which on the back of the hand pass into tendon extensions, and those with their middle part are attached to the base of the middle phalanges, and with their lateral parts to the base of the distal phalanges of the II–V fingers.

The extensor of the little finger (m. extensor digiti minimi) (Fig. 118) unbends the little finger. A small fusiform muscle that originates on the lateral epicondyle of the humerus and inserts at the base of the distal phalanx of the fifth finger (little finger).

The ulnar extensor of the wrist (m. extensor capiti ulnaris) (Fig. 118) unbends the hand and abducts it to the ulnar side. The muscle has a long fusiform abdomen, begins on the lateral epicondyle of the humerus and fascia of the forearm, and is attached to the base of the dorsal surface of the fifth metacarpal bone.

deep layer

the upinator (m. supinator) (Fig. 116, 117, 119) rotates the forearm outwards (supinates) and takes part in the extension of the arm in the elbow joint. The muscle has the shape of a thin rhomboid plate. Its point of origin is on the crest of the supinator of the ulna, the lateral epicondyle of the humerus and the capsule of the elbow joint. The place of attachment of the arch support is located on the lateral, anterior and posterior sides of the upper third of the radius.

The long muscle that abducts the thumb of the hand (m. abductor pollicis longus) (Fig. 118, 119) abducts the thumb and takes part in the abduction of the brush. The muscle is partially covered by the extensor of the fingers and the short radial extensor of the wrist, has a flat bipennate abdomen, turning into a thin long tendon. It originates on the posterior surface of the ulna and radius and inserts at the base of the first metacarpal.

Short extensor thumb brush (m. extensor pollicis brevis) (Fig. 118, 119) abducts the thumb and unbends its proximal phalanx. The point of origin of this muscle is located on the posterior surface of the neck of the radius and the interosseous membrane, the attachment point is on the basis of the proximal phalanx of the thumb and the capsule of the first metacarpophalangeal joint.

The long extensor of the thumb (m. extensor pollicis longus) (Fig. 118, 119) unbends the thumb, partly retracting it. The muscle has a spindle-shaped abdomen and a long tendon. The starting point is located on the posterior surface of the body of the ulna and the interosseous membrane, the attachment point is at the base of the distal phalanx of the thumb.

The extensor of the index finger (m. extensor indicis) (Fig. 119) unbends the index finger. This muscle is sometimes absent. It is covered by the extensor of the fingers, has a narrow, long, spindle-shaped abdomen.

It starts on the posterior surface of the body of the ulna and the interosseous membrane, and is attached to the dorsum of the middle and distal phalanges of the index finger.

2.Male and female urethra

The male urethra, urethra masculina, has an average length of up to 20-23 cm, is divided into three parts: prostatic, pars prostatica, membranous, pars membranacea, and spongy, pars spongiosa.

It starts from the bladder with the internal opening of the urethra, ostium urethrae internum, and extends to the external opening of the urethra, ostium urethrae externum. located at the top of the glans penis. The part of the urethra from the internal opening to the seminal hillock, colliculus seminalis, is called the posterior urethra, the distal part is the anterior urethra. The urethra along its course forms an S-shaped bend: the first, prostatic, part, going from top to bottom, forms a convex posterior arc with the membranous and the beginning of the spongy part, enveloping the pubic symphysis from below, the subpubic curvature; the initial part of the spongy part of the urethra, passing through the section of the penis fixed by the ligaments, forms with its hanging part the second knee, the bulge directed anteriorly, the prepubic curvature. The division of the urethra into these three parts is determined by the characteristics of the formations that surround it. The prostatic part, pars prostatica, penetrates the prostate gland from above, from behind down and forward. It has a length of 3–4 cm and begins in a narrow part from the internal opening of the urethra (the first bottleneck of the canal). In the middle of its length, an expansion of the urethra (the first expansion) is formed. On the back wall of the mucous membrane, starting from the uvula of the bladder, uvula vesicae urinariae, which is a longitudinal roller on the surface of the triangle of the bladder, there is a median fold - the crest of the urethra, crista urethralis. In the middle of its length, the crest passes into a longitudinally located seed mound, colliculus seminalis: distally, this fold reaches the membranous part. At the top of the seed mound there is a longitudinally located pocket - the prostate uterus, utriculus prostaticus.

On each side of the crest of the urethra are the mouths of the ejaculatory ducts. On both sides of the seminal hillock, between it and the wall of the urethra, the mucous membrane of the urethra forms folds; in the groove limited by them, which is called the prostatic sinus, sinus prostaticus, the mouths of the prostatic ducts, ductuli prostatici, open; part of the grooves sometimes opens on the seed mound itself.

The membranous part, pars membranacea, is the shortest part of the urethra, has a length of 1.5–2 cm. It is tightly fixed in the urogenital diaphragm through which it passes. The proximal section of this part of the canal is the narrowest throughout the entire canal (the second bottleneck); the distal section, passing into the spongy part, becomes wider. The internal opening of the urethra and the proximal part of the prostate part of it are covered by a smooth muscle internal sphincter of the urethra, the fibers of which are a continuation of the muscles of the bladder triangle and are woven into the muscular substance of the prostate gland. The membranous part of the canal and the distal part of the prostate cover the striated muscle fibers of the sphincter of the urethra, m. sphincter urethrae. These fibers are part of the deep transverse muscle of the perineum, due to which the membranous part is fixed at the exit from the pelvis and its mobility is very small; this is further enhanced by the fact that part of the muscle fibers of the urogenital diaphragm passes to the prostatic part and to the spongy and, thus, the membranous part becomes even less mobile.

The spongy part, pars spongiosa, is the longest part of the urethra, has a length of 17–20 cm. It begins with its widest section (second extension), embedded in the bulb of the penis, bulbous fossa, and, as indicated, reaches at the top of the head spongy body of the external opening of the urethra, representing the third bottleneck of the canal. The orifices of the bulbourethral glands open into the posterior (lower) wall of the bulbous part. Proximal to the external opening of the urethra is located in the sagittal direction of the extension - the scaphoid fossa of the urethra. fossa navicularis urethrae, which is the third extension along the canal. The mucous membrane of the upper wall here forms a flap of the navicular fossa, valvula fossae navicularis, transversely located on the upper wall of the fossa, thereby separating the pocket open anteriorly. On the upper wall of the spongy part, transverse folds lie in two rows, limiting the small (0.5 mm), anteriorly open lacunae of the urethra, lacunae urethrales, into which the tubular alveolar glands of the urethra, glandulae urethrales, open.

Throughout the urethra there are longitudinal folds that cause its extensibility. The lumen of the urethra at the level of the prostatic and membranous parts appears to be lunate, convex upward, which depends on the ridge and the seminal hillock; throughout the spongy part, in its proximal part, the lumen has the form of a vertical slit, in the distal part - a transverse slit, and in the region of the head - an S-shaped slit.

The lining of the urethra is made up of elastic fibers. A pronounced muscle layer is present only in the prostate and membranous parts; in the spongy part, the mucous membrane is directly fused with spongy tissue, and its smooth muscle fibers belong to the latter. The mucous membrane of the urethra in the prostate has a transitional epithelium, in the membranous - multi-row prismatic, at the beginning of the spongy - single-layer prismatic, and the rest of the length - multi-row prismatic. Innervation: plexus hypogastricus, lumbosacralis. Blood supply: aa.. pudendae interna et extema.

The female urethra, urethra feminina, starts from the bladder with an internal opening, ostium urethrae internum, and is a tube 3–3.5 cm long, slightly curved posteriorly with a bulge and enveloping the lower edge of the pubic symphysis from below and behind. Outside the period of passage of urine through the canal, its anterior and posterior walls are adjacent to one another, but the walls of the canal are characterized by significant extensibility and its lumen can be stretched up to 7–8 mm. The back wall of the canal is closely connected with the anterior wall of the vagina. When exiting the pelvis, the canal pierces the diaphragma urogenitale (see the muscles of the perineum) with its fascia and surrounded by arbitrary muscle fibers of the sphincter, i.e. sphincter urethrae. The external opening of the canal, ostium urethrae externum, opens on the eve of the vagina in front of and above the opening of the vagina and is a bottleneck of the canal. The wall of the female urethra consists of membranes: muscular, submucosal and mucous membranes. In the loose tela submucosa, penetrating also into the tunica muscularis, there is a choroid plexus, which gives the tissue a cavernous appearance on the cut. The mucous membrane, tunica mucosa, lies in longitudinal folds. Numerous mucous glands, glandulae urethrales, open into the canal, especially in the lower parts.

The female urethra receives arteries from a. vesicalis inferior and a. pudenda interna. The veins flow through the venous plexus, plexus venosus vesicalis, into v. iliaca interna. Lymphatic vessels from the upper sections of the canal are sent to nodi lymphatici iliaci, from the lower - to nodi lymphatici inguinales.

Innervation from plexus hypogastrics inferior, nn. splanchnici

The thoracic duct is formed in the retroperitoneal space at the level of the second lumbar vertebra as a result of the fusion of the right and left lumbar lymphatic trunks. Together with the aorta, it passes through the hiatus aorticus diaphragmatis into the chest cavity, where it is located in the posterior mediastinum and then flows into the left venous angle in the neck region - the confluence of v. jugularis interna sinistra u v. subclavia sinistra (Fig. 12). In some cases, it flows into the internal jugular, subclavian, or brachiocephalic vein. Sometimes the root of the thoracic duct can also be the intestinal lymphatic trunk.

The ductus thoracicus is a slightly tortuous, thin-walled muscular-endothelial tube with multiple valves. The thoracic duct is divided into non-permanent retroperitoneal and permanent thoracic and cervical sections. It has valves: one above the diaphragm, one - two - at the level of the aortic arch and one - two - in the cervical region, as well as at the mouth of the duct. The valves prevent back flow of lymph and blood from the veins into the thoracic duct. It has a length of 30 - 35 cm and a diameter in the chest cavity of 2 - 4 mm, at the mouth - 7 mm. The diameter of the thoracic duct varies throughout. The widest is the initial part - the lacteal cistern (cisterna chyli), the diameter of which is 5 - 6 mm. In some cases, it is missing. In adults, cisterna chyli occurs in 3/4 of cases, in children - less often. The milky cistern (cistern of milky juice) can be cone-shaped, spindle-shaped, elongated, bead-shaped or ampoule-shaped (Fig. 13). The lower the thoracic duct begins, the better it is expressed. The lactiferous cistern is more common, better expressed, and located lower in brachymorphs than in dolichomorphs. It serves as a kind of intermediate station, where the lymph accumulates to a certain volume, and then passes into the evacuation section of the duct and into the main vein. Another expansion of the thoracic duct in the form of a vesicle or ampulla is observed in front of its mouth. This makes it easier to find the cervical thoracic duct during surgery on it. The narrowest part of the thoracic duct is at the level of IV-VI thoracic vertebrae.

Throughout the thoracic lymphatic duct, splitting of the "islands" type can occur. The terminal section of the thoracic duct can also split (Fig. 14), then it flows into the venous angle with several branches.

Small intercostal lymphatic vessels and a large broncho-mediastinal trunk flow into the thoracic duct within the chest cavity, draining lymph from organs located in the left half of the chest (left lung, left half of the heart, esophagus, respiratory throat) and from the thyroid gland. Collateral vessels passing through the diaphragm on both sides, carrying lymph from the latero-aortic nodes, constantly flow into the thoracic ductus thoracicus. The presence of additional transdiaphragmatic roots of the thoracic duct, collateral lymphatic pathways connecting the initial and final segments of the thoracic duct with the right and left lymphatic ducts, creates the possibility of a rapid change in the direction of the lymph flow in individual parts of the lymphatic system of the chest cavity and neck in the conditions of vital activity of organs. The existence of collaterals at the thoracic duct allows its ligation.

In the chest cavity, in addition to the thoracic duct, in 37% of cases there is a ductus hemithoracicus, starting from the left upper latero-aortic or celiac lymph nodes. The semithoracic duct enters the chest cavity through the aortic orifice or through a gap in the left crus of the diaphragm. Then it goes up along the left posterior edge of the arota and at one level or another (but not higher than the third thoracic vertebra) turns to the right and flows into the thoracic duct. Complete duplication of the thoracic duct to the venous angle is rare.

In the cervical region of the ore duct, at the place where it flows into the left venous angle, the left supraclavicular, jugular trunks and the left internal trunk of the mammary gland join.

The retroperitoneal thoracic duct (cistern lactae) is located in the abdominal cavity to the right of the aorta between it and the medial part of the right crus of the diaphragm. Behind, it comes into contact with the intraperitoneal fascia, the right hypochondrium and the first lumbar artery. In front of the retroperitoneal section of the thoracic duct, there is tissue with lymph nodes located in it.

The thoracic ductus thoracicus is localized in the posterior mediastinum, in the tissue on the anterior surface of the spine between the descending aorta and the azygous vein. To the level of V - IV of the thoracic vertebrae, it rises to the right of the midline or along it. Then the thoracic duct passes through the midline, goes to the left, up and laterally to the left venous angle. Behind the thoracic duct are the right intercostal arteries, the orifices of the semi-unpaired and accessory semi-unpaired veins, as well as their anastomoses with the unpaired vein. Anterior to it are the esophagus and the right vagus nerve. In 67% of cases, the thoracic duct is covered in front by the pleura of the posterior wall of the mediastinal pocket, which is formed as a result of the transition of the right costal pleura to the mediastinal one. Such a close proximity of the thoracic duct and the right mediastinal pleura determines the possibility of a right-sided chylothorax when they are injured. To the right and left of the thoracic duct (usually to the left) lie the paravertebral lymph nodes (from 1 to 11), which are connected to the duct by short lymphatic vessels.

Above the aortic arch and up to the level of the seventh cervical vertebra, the thoracic duct is located on the vertebral bodies. Here, in 47% of cases, it lies behind the esophagus, in 36% - along its left edge, and in 16% - outward from it. When the thoracic duct is located along the left edge of the esophagus or outward from it, the ductus thoracicus wraps forward, forming an arc, bends around the left dome of the pleura, passes between the left common carotid and subclavian arteries and then flows into the left venous angle. The position of the arch of the thoracic duct corresponds to the Waldeyer's triangle of the vertebral artery. In this triangle, the thoracic duct is located outward and posterior to the left common carotid artery, vagus nerve and internal jugular vein, anterior and medial to the vertebral artery and vein, stellate sympathetic ganglion, medial to the phrenic nerve. Often the thoracic duct crosses a large lymph node here - the lowest of the chain of deep cervical nodes located along the internal jugular vein. The short efferent vessels of this node flow into the arch of the thoracic duct, which explains the frequency of damage to it during the operation to remove deep cervical lymph nodes. The arch of the thoracic duct can be high (steeply curved) or low (oblique). In 82% of cases, the arch of the cervical thoracic duct does not rise above the upper edge of the VII cervical vertebra and does not fall below its lower edge. A high position of the thoracic duct is more common in people with a dolichomorphic physique, a low position in people with a brachymorphic physique. Sometimes the thoracic duct flows into the left subclavian, vertebral, innominate and external jugular veins. Cases of location of duotus thoracicus on the neck on the right are described.

There are many lymph nodes along the thoracic duct. At present, using the antegrade method of introducing contrast into the lymphatic vessels of the lower extremities, it has been established that the movement of lymph in the thoracic duct is carried out by rhythmic contractions and relaxation of its segments every 10-15 seconds. It turned out that the peristaltic movements of the duct, which have a wave-like character, force the lymph to move continuously towards the brachiocephalic vein. The movement of the contrast agent through the thoracic duct and its release into the vein does not depend on either heart contractions or the respiratory cycle. This indicates a special regulation of the thoracic duct.

The blood supply of the thoracic lymphatic duct is carried out through adjacent arteries. The retroperitoneal thoracic duct receives arterial blood through the branches of the diaphragmatic and two upper lumbar arteries. The thoracic ductus thoracicus is supplied by branches of the posterior intercostal, vertebral, bronchial and mediastinal arteries. The cervical thoracic duct is supplied with blood by branches of the esophageal arteries, as well as branches of the vertebral artery, the left thyroid-cervical trunk, and directly the left subclavian artery.

The veins draining blood from the thoracic duct in the neck join the left subclavian and internal jugular veins and into the left venous angle. In the region of the posterior mediastinum, they flow into the unpaired, accessory semi-unpaired and left upper intercostal veins, as well as into anastomoses between the unpaired and semi-unpaired veins. Veins from the retroperitoneal thoracic duct drain into the ascending lumbar veins.

The innervation of the retroperitoneal thoracic duct involves the branches of the left celiac nerve and the XI branch of the left thoracic sympathetic node, the thoracic region - the branches of the thoracic aortic and esophageal plexus, the cervical region - the branches of the left stellate node and the sympathetic trunk.

The thoracic duct is the main lymphatic trunk of the body. It serves as a collector into which lymph flows from the entire left half of the body, the right lower limb, the right halves of the pelvis and abdomen, and the right back of the chest. Up to 90% of the lymph produced in the organs is transported through the thoracic lymphatic duct. From the thoracic duct, lymph is sent to the bloodstream. Normal lymph flow is from 1 to 2 ml / min with a duct diameter of 1 - 4 mm. The pressure at the end of the duct ranges from 6 to 15 mm of water. Art. The diameter of the lymphatic duct, the magnitude of the pressure, the speed of the lymph flow in pathological conditions change significantly.

Every day, from the thoracic duct, such a number of T- and B-lymphocytes enters the blood, which is 5-20 times higher than their total number in the blood. Ductus thoracicus takes part in the recycling of lymphocytes. Most of them (90-95%) are small lymphocytes, the smaller part is large cells that do not recirculate and can be precursors of plasma cells. The main part of recirculating cells is T-lymphocytes, B-lymphocytes account for 17%. Lymphocytes from the blood enter the tissues and then return again to the peripheral lymph, which is saturated with lymphocytes after it has passed through the lymph nodes.

The obtained data on the function of the thoracic duct and the role of lymphatic circulation in maintaining the constancy of the internal environment of the body in the last 10 years have been used in clinical surgery (external drainage of the thoracic duct, creation of a lympho-venous anastomosis, lymphosorption, catheterization) for diagnostic and therapeutic purposes in tumors, leukemia and other diseases accompanied by severe intoxication (acute pancreatitis, obstructive jaundice, peritonitis, acute poisoning, hepatitis, septicopyemia, uremia, liver cirrhosis, portal hypertension), as well as increased lymph formation and limited lymph drainage.

Rice . 1. Lymph node (blood vessels and nerves are not shown.) 1 - trabeculae; 2 - efferent lymphatic vessels; 3 - knot gate; 4 - anastomosis between the afferent and efferent vessels; 5 - medulla; 6 - bringing lymphatic vessels; 7 - node capsule; 8 - reticulum; 9 - cortex; 10 - marginal sinus

Rice. 2. The structure of the lymph node (according to Krelling and Grau)

Blood vessels are shown only in the left half: arteries are black, veins are light.

The arrows indicate the direction of lymph flow:

1 - brain cord; 2 - capsule; 3 - trabeculae, 4 - marginal sinus;

I, II-lymphatic follicles in the cortex.

Rice. 3 . Vascularization of the follicle of the lymph node (according to A. Polikar) 1 - capsule; 2 - cortical zone; 3 - light center;

4 - arteriole, forming a capillary network in the light center;

5 - venous vessels.

Rice. four . Options for the penetration of nerves into the lymph nodes (according to X. Ya. Mahanik)

a - according to the first; b - according to the second; in - on the third; g - according to the fourth option; A - artery; N - nerve; L - lymph node.

Fig.5 . Diagram of the relationship between the circulatory and lymphatic systems and lymphatic tissue (according to V. A. Florensov)

1 - blood; 2 - peripheral lymph; 3 - central lymph; 4 - lymph node tissue; 5 - lymphatic tissue not associated with the lymphatic channel.

I - into the connective tissue and the transition to the lymphatic channel;

II - through the mucous membrane into the intestinal lumen (elimination);

III - in the bone marrow.

Rice. 6. The primary reaction of the lymph node during stimulation of delayed-type hypersensitivity, in the production of antibodies and a mixed response (according to R. V. Petrov and Yu. M. Zaretskaya)

1 - medulla; 2 - germinal center; 3 - plasma cells; 4 - paracortical region (immunoblasts up to the 5th day, small lymphocytes after the 5th day); 5 - medulla, compressed as a result of an increase in paracortical areas; 6 - paracortical area (2 - 4th day - immunoblasts, after the 5th day - small lymphocytes).

Rice. 7. The mucous membrane of the ileum

I - solitary lymphatic follicles; 2 - Peyer's patches; 3 - plicae circulares; 4 - mesentery.

Rice. 8. Topographic anatomy of the palatine tonsils

1 - back wall of the pharynx; 2 - tongue; 3 - palatine tonsil; 4-soft palate; 5 - posterior palatine arch; 6 - anterior palatine arch.

Rice. 9. The structure of the palatine tonsil

1 - crypt; 2 - follicles; 3 - connective tissue capsule

Rice. 10. Arterial blood supply of the palatine tonsils

1 - common carotid artery;

2 - internal carotid artery; 3 - external carotid artery; 4 - superior thyroid artery; 5 - lingual artery; 6 - facial artery;

7 - ascending palatine artery; 8 - palatine tonsil;

9 - ascending pharyngeal artery; 10 - descending palatine artery;

11 - internal maxillary artery.

Rice. 11. Sources of innervation of the palatine and lingual tonsils

1 - sympathetic nerve; 2 - vagus nerve; 3 - pharyngeal nerve plexus; 4 - glossopharyngeal nerve; 5 - palatine tonsil; 6 - lingual tonsil.

Rice. 12. Topographic anatomy of the cervical part of the thoracic duct (the internal jugular vein is laid aside, the thoracic duct is hooked)

1 - thoracic duct; 2 - left internal jugular vein; 3 - aorta; 5 - thoracic duct; 6 - superior vena cava.

Rice. 13. Options for the beginning of the thoracic duct

a - a simple fusion of the lumbar trunks; b - double cistern of lumbar trunks; c - spindle-shaped cistern of the duct; g - cone-shaped duct cistern; e - an elongated jelly-shaped cistern of the duct; e - ampulloidal cistern of the duct.

Rice. 14. Types of structure of the terminal part of the thoracic duct

I - tree-like: a - two mouths; b - three mouths; c - four mouths;

II - deltoid: a - two mouths; b - three mouths; c - four mouths;

III - multi-highway: a - bi-highway; b - tri-main;

1 - internal jugular vein; 2 - subclavian vein, 3 - left brachiocephalic vein; 4 - thoracic duct.

thoracic duct, ductus thoracicus , collects lymph from both lower extremities, organs and walls of the pelvic and abdominal cavities, the left lung, the left half of the heart, the walls of the left half of the chest, from the left upper limb and the left half of the neck and head.

The thoracic duct is formed in the abdominal cavity at the level of the II lumbar vertebra from the confluence of three lymphatic vessels: the left lumbar trunk and the right lumbar trunk, truncus lumbalis sinister et truncus lumbalis dexter, and intestinal trunk, truncus intestinalis.

The left and right lumbar trunks collect lymph from the lower extremities, the walls and organs of the pelvic cavity, the abdominal wall, the organs of the retroperitoneal space, the lumbar and sacral sections of the spinal column and the membranes of the spinal cord.

The intestinal trunk collects lymph from the digestive organs of the abdominal cavity.

Both lumbar trunk and intestinal trunk, when connected, sometimes form an enlarged section of the thoracic duct - thoracic duct cisterna, cisterna chyli. Often it may be absent, and then these three trunks flow directly into the thoracic duct. The level of education, the shape and size of the cistern of the thoracic duct, as well as the shape of the connection of these three ducts are individually variable.

The thoracic duct cistern is located on the anterior surface of the vertebral bodies from II lumbar to XI thoracic, between the crura of the diaphragm. The lower part of the cistern lies behind the aorta, the upper one along its right edge. It gradually narrows upward and continues directly into the thoracic duct. The latter, together with the aorta, passes through the aortic opening of the diaphragm into the chest cavity.

In the chest cavity, the thoracic duct is located in the posterior mediastinum along the right edge of the aorta, between it and v. azygos, on the anterior surface of the vertebral bodies. Here the thoracic duct crosses the anterior surface of the right intercostal arteries, being covered in front by the parietal pleura.

Then the thoracic duct turns forward, goes around the left dome of the pleura, passes between the left common carotid artery and the left subclavian artery and flows into the left venous angle - the confluence v. jugularis and v. subclavia sinistra.

In the chest cavity ductus thoracicus accepts small intercostal lymphatic vessels, as well as a large left bronchomediastinal trunk, truncus bronchomediastinalis sinister, from the organs located in the left half of the chest: the left lung, the left half of the heart, the esophagus and trachea - and from the thyroid gland.

At the confluence of the left venous angle, the ductus thoracicus takes into its composition two more large lymphatic vessels:

1) left subclavian trunk, truncus subclavius sinister collecting lymph from the left upper limb;

2) left jugular trunk, truncus jugularis sinister,- from the left side of the head and neck.

The length of the thoracic duct is 35-45 cm. The diameter of its lumen is not the same everywhere: in addition to the initial expansion - the cistern, it has a slightly smaller expansion in the terminal section, near the confluence with the venous angle.

The latter are located throughout the thoracic duct. Especially a lot of valves in its upper section. The valves are located at the confluence of the duct into the left venous angle and prevent the reverse flow of lymph and the ingress of blood from the veins into the thoracic duct.

The formation of the thoracic duct occurs in the abdominal cavity, in the retroperitoneal tissue at the level of the 12th thoracic and 2nd lumbar vertebrae during the connection of the right and left lumbar lymphatic trunks. The formation of these trunks occurs as a result of the fusion of the efferent lymphatic vessels of the right and left lymph nodes of the lower back. From 1 to 3 efferent lymphatic vessels belonging to the mesenteric lymph nodes, called intestinal trunks, flow into the initial part of the thoracic lymphatic duct. This is observed in 25% of cases. The lymphatic efferent vessels of the intercostal, prevertebral, and visceral lymph nodes drain into the thoracic duct. Its length is from 30 to 40 cm. The initial part of the thoracic duct is its abdominal part. In 75% of cases, it has an ampoule-shaped, cone-shaped or spindle-shaped extension. In other cases, this beginning is a reticular plexus, which is formed by the efferent lymphatic vessels of the mesenteric, lumbar and celiac lymph nodes. This extension is called a cistern. Usually the walls of this tank are fused with the right leg of the diaphragm. During breathing, the diaphragm compresses the thoracic duct, promoting the flow of lymph. The thoracic lymphatic duct from the abdominal cavity enters the chest cavity through the aortic opening and enters the posterior mediastinum. There it is located on the anterior surface of the spinal column, between the unpaired vein and the thoracic aorta, behind the esophagus. The thoracic part of the thoracic duct is the longest. It originates at the aortic opening of the diaphragm and goes to the upper aperture of the chest, passing into the cervical duct. In the region of the 6th and 7th thoracic vertebrae, the thoracic duct deviates to the left, and exits from under the left edge of the esophagus at the level of the 2nd and 3rd thoracic vertebrae, rising up behind the left subclavian and left common carotid arteries and the vagus nerve. In the superior mediastinum, the thoracic duct runs between the left mediastinal pleura, esophagus, and spinal column. The cervical part of the thoracic lymphatic duct has a bend, forming an arc at the level of 5-7 cervical vertebrae, which goes around the dome of the pleura from above and slightly behind, and then opening with the mouth into the left venous angle or into the final section of the veins that form it. In half of the cases, the thoracic lymphatic duct expands before flowing into a vein, in some cases it bifurcates or has 3-4 stems that flow into the venous angle or into the terminal sections of the veins that form it. The ingress of blood from the vein into the duct is prevented by a paired valve located at the mouth of the thoracic lymphatic duct. Also, along the entire length of the thoracic duct, there are from 7 to 9 valves that prevent the reverse movement of lymph. The walls of the thoracic duct have a muscular outer shell, the muscles of which contribute to the movement of lymph to the mouth of the duct.

The right lymphatic duct is a vessel, 10 to 12 mm long. The broncho-mediastinal trunk, jugular trunk and subclavian trunk flow into it. It has an average of 2-3 sometimes more trunks, flowing into the angle formed by the right subclavian vein and the right internal jugular vein. In rare cases, the right lymphatic duct has one mouth.

23 lymph. Follicles of the alimentary canal.

24 Scapular region.

The boundaries of the region correspond to the blade. Scapular_region: borders correspond to the projection of the scapula. Superficial muscles - trapezius muscle,. latissimus dorsi. Deep muscles - supraspinatus muscle. infraspinatus muscle, .small round muscle,. teres major muscle..

Layered topography: 1. skin.2. subcutaneous adipose tissue.3. superficial fascia.4. own fascia.5. trapezius muscle.6. latissimus dorsi.8. supraspinous fascia.9. infraspinatus fascia.10. supraspinatus muscle.11. infraspinatus muscle.12.teres minor muscle.13.subscapularis muscle.

The scapular anastomotic arterial circle is formed by the suprascapular artery. circumflex scapular artery. deep branch

The blood supply to the formations of the region is carried out by the suprascapular and subscapular arteries, the transverse artery of the neck. The main nerves of the region are nn.suprascapularis et subscapularis.last.

Intercostal spaces.

Topography of intercostal spaces:

In the intervals between the ribs are the external and internal intercostal muscles, mm. intercostales externi et interni, fiber and neurovascular bundles. The external intercostal muscles run from the lower edge of the ribs obliquely from top to bottom and anteriorly to the upper edge of the underlying rib. At the level of the costal cartilages, the external intercostal muscles are absent and replaced by the external intercostal membrane, membrana intercostalis externa, which preserves the direction of the connective tissue bundles corresponding to the course of the muscles. Deeper are the internal intercostal muscles, the bundles of which run in the opposite direction: from bottom to top and back. Behind the costal angles, the internal intercostal muscles are no longer there, they have been replaced by the swampy bundles of the internal intercostal membrane, membrana intercostalis interna. The space between adjacent ribs, bounded from the outside and from the inside by the corresponding intercostal muscles, is called the intercostal space, spatium intercostale. It contains intercostal vessels and a nerve: a vein, below it - an artery, and even lower - a nerve (VAN). The intercostal bundle in the area between the paravertebral and middle axillary lines lies in the groove, sulcus costalis, of the lower edge of the overlying rib. The posterior intercostal arteries depart from the aorta, and the anterior ones from the internal thoracic artery. From the side of the chest cavity to the angle of the rib, they are not covered with muscles and are separated from the parietal pleura by bundles of the internal intercostal membrane and a thin sheet of intrathoracic fascia and subpleural tissue. This explains the possibility of involvement of the intercostal nerves in the inflammatory process in diseases of the pleura. The lower 6 intercostal nerves innervate the anterolateral abdominal wall. The next layer of the chest wall is the intrathoracic fascia, fascia endothoracica, which lines the intercostal muscles, ribs and costal cartilages, the sternum, and the anterior surface of the thoracic vertebrae and diaphragm from the inside. The fascia over each of these formations has the corresponding name: fascia costalis, fascia diaphragmatica, etc. In front, in close connection with the intrathoracic fascia, there is a. thoracica interna.

Breast.

The mammary gland is located on the anterior chest wall between the edge of the sternum and the anterior axillary line at the level of the III-VI (VII) ribs. The mammary gland is a complex alveolar-tubular gland and consists of 15-20 lobules with excretory milk ducts 2-3 mm in diameter. They converge radially towards the nipple, at the base of which they expand in an ampulla-like manner, forming the lactiferous sinuses. In the region of the nipple, the lactiferous ducts narrow again and, connecting in 2-3, open at the top of the nipple with 8-15 pinholes. The gland is located between the sheets of the superficial fascia, which form its capsule, and is surrounded on all sides (with the exception of the nipple and areola) by fatty tissue. Between the fascial capsule of the gland and the own fascia of the breast there are retromammary fiber and loose connective tissue, as a result of which the gland is easily displaced in relation to the chest wall. 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. The blood supply to the mammary gland is carried out by branches of the internal thoracic artery, the lateral artery of the chest, and the intercostal arteries. The veins accompany the arteries of the same name.

The lymphatic vessels of the mammary gland are well developed and can be divided into two groups: the lymphatic vessels of the skin of the mammary gland and the lymphatic vessels of the parenchyma of the gland. The capillary lymphatic network, located directly in the skin and premammary tissue, is better developed in the region of the outer quadrants of the gland, forming a superficial areolar plexus of lymphatic vessels in the region of the areola.

27. Inferior vena cava.- a large vein that opens into the right atrium and collects venous blood from the lower body. It is formed by the confluence of the right and left common iliac veins. It is located first in the retroperitoneal space, then passes through the diaphragm and enters the middle mediastinum. On the way to the heart, it receives blood from many veins. It is the largest vein in the body. The splanchnic tributaries of the IVC include: Renal veins. Gonadal veins (testicular and ovarian). hepatic veins. Adrenal veins. Parietal tributaries of the IVC are: Phrenic veins. Lumbar veins. Superior and inferior gluteal veins. Lateral sacral veins. Iliac-lumbar vein.

28. Chest area . Borders: Upper - along the jugular notch, along the upper edge of the clavicles, clavicular-acromial joints and along conditional lines drawn from this joint to the spinous process of the VII cervical vertebra. Lower - from the base of the xiphoid process, along the edges of the costal arches to X ribs, from where along conditional lines through the free ends of the XI and XII ribs to the spinous process of the XII thoracic vertebra. The chest area is separated from the upper limbs on the left and right by a line running in front along the deltoid-pectoral groove, and behind - along the medial edge of the deltoid muscle. The skin on the anterior surface is thinner than in the back, contains sebaceous and sweat glands, is easily mobile, with the exception of the sternum and posterior median region. Subcutaneous fat is more developed in women, contains a dense venous network, numerous arteries that are branches of the internal thoracic, lateral thoracic and posterior intercostal arteries, superficial nerves originating from the intercostal and supraclavicular nerves of the cervical plexus. Superficial fascia in women forms a capsule of the mammary gland. Mammary gland. Own fascia (thoracic fascia) consists of two sheets - superficial and deep (clavicular-thoracic fascia), forming fascial cases for the pectoralis major and minor muscles, and on the back wall - for the lower part of the trapezius muscle and the latissimus dorsi back muscles. In the region of the sternum, the fascia passes into the anterior aponeurotic plate, which is fused with the periosteum (there is no muscle layer in this area). Pectoralis major muscle. Superficial subpectoral cellular space. The pectoralis minor muscle. Deep subpectoral cellular space - subpectoral phlegmons can develop in these spaces. The intercostal space is a complex of formations (muscles, vessels, nerves) located between two adjacent ribs. perform the intercostal space from the tubercles of the ribs to the outer ends of the costal cartilages. In the region of the costal cartilages, the muscles are replaced by fibrous fibers of the external intercostal membrane. The fibers of the external intercostal muscles run from top to bottom and from back to front. Deeper than the outer are the internal intercostal muscles, the direction of the fibers of which is opposite to the course of the external intercostal muscles, that is, from bottom to top and from back to front. The internal intercostal muscles occupy the intercostal spaces from the corners of the ribs to the sternum. From the corners of the ribs to the spinal column, they are replaced by a thin internal intercostal membrane. The space between the external and internal intercostal muscles is made with a thin layer of loose fiber, in which the intercostal vessels and nerves pass. The intercostal arteries can be divided into anterior and posterior. The anterior arteries are branches of the internal thoracic artery. The posterior intercostal arteries, except for the two upper ones, which depart from the costal-cervical trunk of the subclavian artery, start from the thoracic aorta. The intercostal vein is located above, and the intercostal nerve is located below the artery. From the corners of the ribs to the midaxillary line, the vessels of the intercostal space are hidden behind the lower edge of the rib, and the nerve runs along this edge. Anterior to the midaxillary line, the intercostal neurovascular bundle emerges from under the lower edge of the rib. Guided by the structure of the intercostal space, it is more expedient to carry out chest punctures in the VII-VIII intercostal space between the scapular and middle axillary lines along the upper edge of the underlying rib.

29 . COLON (colon) ascending colon - (colon ascendens) TOPOGRAPHY Holotopy: right lateral region of the abdomen and right hypochondrium. Skeletotopia: right transverse processes of the lumbar vertebrae, XII rib. Syntopy: iliac, square, lumbar muscle, right lobe of the liver, transverse muscle of the abdomen, right kidney, large intestine. BLOOD SUPPLY Due to the arteries of the colon, coming from the superior and inferior mesenteric arteries (aa. mesenterica sup. et inf.): a) iliac-colon artery (a. ileocolica); b) right colic artery (a. colica dext.); c) middle colic artery (a. colica media) from the superior mesenteric; d) left colic artery (a. colica sin.) and e) sigmoid arteries (aa. sigmoideae) from the inferior mesenteric artery. VENOUS OUTFLOW Through the superior and inferior mesenteric veins (vv. mesentericae sup. et inf.) into the portal vein (v. portae). LYMPH OUTFLOW From the right half to the superior mesenteric lymph nodes (n.l. mesenterici sup.), the left to the inferior mesenteric (n.l. mesenterici inf.). INNERVATION To the left flexure of the colon from the superior mesenteric plexus (pl. mesentericus sup.), formed by branches of the celiac plexus (pl. coeliacus) and large splanchnic nerves (nn. splanchnici majores). Below the left bend - from the lower mesenteric plexus (pl. mesentericus inf.), Formed by branches of the abdominal aortic plexus (pl. aorticus abdominalis).

common carotid artery

Common carotid artery (Latin arteria carotis communis) - a paired artery, originates in the chest cavity, right from the brachiocephalic trunk (Latin truncus brachiocephalicus) and left - from the aortic arch (Latin arcus aortae), so the left common carotid artery is several centimeters longer than the right. It supplies the brain, the organ of vision and most of the head.

The common carotid artery rises almost vertically and exits through the apertura thoracis superior to the neck. Here it is located on the anterior surface of the transverse processes of the cervical vertebrae and the muscles covering them, on the side of the trachea and esophagus, behind the sternocleidomastoid muscle and the pretracheal plate of the fascia of the neck with the scapular-hyoid muscle embedded in it, (Latin musculus omohyoideus). Outside the common carotid artery is the internal jugular vein (lat. vena jugularis interna), and behind in the groove between them is the vagus nerve (lat. nervus vagus). The common carotid artery does not give branches along its course and at the level of the upper edge of the thyroid cartilage is divided into: the external carotid artery (Latin arteria carotis externa) and the internal carotid artery (Latin arteria carotis interna). At the place of division there is an expanded part of the common carotid artery - carotid sinus (lat. sinus caroticus), which is adjacent to a small nodule - sleepy glomus (lat. glomus caroticum). Normal blood flow for the brain is 55 ml / 100 g of tissue, and oxygen demand is 3.7 ml / min / 100 d. This volume of blood supply is provided by normal arteries with normal intima and undisturbed vascular lumen. Possible, due to various reasons (atherosclerosis, nonspecific aorto-arteritis, fibromuscular dysplasia, collagenosis, tuberculosis, syphilis, etc.), narrowing of the lumen of the carotid arteries leads to a decrease in the blood supply to the brain, disruption of metabolic processes in it and its ischemia. In more than 90% of cases, the culprit for the development of this pathology is atherosclerosis - a chronic vascular disease with the formation of foci of lipid (cholesterol) plaques in their walls, followed by their sclerosis and calcium deposition, leading to deformation and narrowing of the lumen of the vessels up to their complete occlusion. Unstable atherosclerotic plaques tend to ulcerate and collapse over time, which leads to arterial thrombosis, thromboembolism of its branches, or embolism by their atheromatous masses.

thoracic duct, ductus thoracicus (fig., see fig.), collects lymph from both lower extremities, organs and walls of the pelvic and abdominal cavities, left lung, left half of the heart, walls of the left half of the chest, from the left upper limb and left half of the neck and head.

The thoracic duct is formed in the abdominal cavity at the level of the II lumbar vertebra from the fusion of three lymphatic vessels: left lumbar trunk and right lumbar trunk, truncus lumbalis sinister et truncus lumbalis dexter, and intestinal trunk, truncus intestinalis.

Both lumbar trunk and the intestinal trunk, when connected, sometimes form an enlarged section of the thoracic duct - thoracic duct cisterna, cisterna chyli. Often it may be absent, and then these three trunks flow directly into the thoracic duct. The level of education, the shape and size of the cistern of the thoracic duct, as well as the shape of the connection of these three ducts are individually variable.

Heading upward, the thoracic duct deviates to the left, goes behind the esophagus and at the level of the III thoracic vertebra is to the left of it and thus follows to the level of the VII cervical vertebra. Then the thoracic duct turns forward, goes around the left dome of the pleura, passes between the left common carotid artery and the left subclavian artery and flows into the left venous angle - the confluence v. jugularis and v. subclavia sinistra.

In the chest cavity at the level of the VII-VIII vertebra, the thoracic duct can split into two or more trunks, which then reconnect. The terminal section can also split if the thoracic duct flows into the venous angle with several branches. In the chest cavity, the ductus thoracicus accepts small intercostal lymphatic vessels, as well as a large left bronchomediastinal trunk, truncus bronchomediastinalis sinister, from the organs located in the left half of the chest: the left lung, the left half of the heart, the esophagus and trachea - and from the thyroid gland.

At the confluence of the left venous angle, the ductus thoracicus takes into its composition two more large lymphatic vessels: 1) left subclavian trunk, truncus subclavius sinister collecting lymph from the left upper limb; 2) left jugular trunk, truncus jugularis sinister, - from the left half of the head and neck.

The length of the thoracic duct is 35-45 cm. The diameter of its lumen is not the same everywhere: in addition to the initial expansion - the cisterna, it has a slightly smaller expansion in the terminal section, near the confluence with the venous angle.

Along the duct lies a large number of lymph nodes. The movement of lymph along the duct is carried out, on the one hand, as a result of the suction action of negative pressure in the cavity of the chest and in large venous vessels, on the other hand, due to the pressor action of the legs of the diaphragm and the presence of valves. The latter are located throughout the thoracic duct. Especially a lot of valves in its upper section. The valves are located at the confluence of the duct into the left venous angle and prevent the reverse flow of lymph and the ingress of blood from the veins into the thoracic duct.