Plate 4

The various vascular procedures that are carried out on the major vessels in the retroperitoneal area of the abdominal cavity make familiarity with these structures essential. Likewise, surgery of the adrenal glands and the genitourinary system invariably involves one or more of the branches of the abdominal aorta and inferior vena cava.

The blood supply to the adrenals is complicated and different on the two sides. The superior arterial supply branches from the inferior phrenic artery (1) on both sides. The left adrenal receives a branch directly from the adjacent aorta. A similar branch also may pass behind the vena cava to the right side, but the more prominent arterial supply arises from the right renal artery. The major venous return (3) on the left side is directly to the left renal vein. On the right side, the venous supply may be more obscure, as the adrenal is in close proximity to the vena cava and the venous system (2) drains directly into the latter structure.

The celiac axis (A) is one of the major arterial divisions of the abdominal aorta. It divides into the left gastric, splenic, and common hepatic arteries. Immediately below this is the superior mesenteric artery (B), which provides the blood supply to that portion of the gastrointestinal tract arising from the foregut and midgut. The renal arteries arise laterally from the aorta on either side. The left renal vein crosses the aorta from the left kidney and usually demarcates the upper limits of arteriosclerotic abdominal aneurysms. The left ovarian (or spermatic) vein (13) enters the left renal vein, but this vessel on the right side (5) drains directly into the vena cava.

In removing an abdominal aortic aneurysm, it is necessary to ligate the pair of ovarian (or spermatic) arteries (4), as well as the inferior mesenteric artery (C). In addition, there are four pairs of lumbar vessels that arise from the posterior wall of the abdominal aorta (14). The middle sacral vessels will also require ligation (12). Because of the inflammatory reaction associated with the aneurysm, this portion of the aorta may be intimately attached to the adjacent vena cava.

The blood supply to the ureters is variable and difficult to identify. The arterial supply (6, 7, 8) arises from the renal vessels, directly from the aorta, and from the gonadal vessels, as well as from the hypogastric arteries (11). Although these vessels may be small and their ligation necessary, the ureters should not be denuded of their blood supply any further than is absolutely necessary.

The aorta terminates by dividing into the common iliac arteries (9), which in turn divide into the external iliac (10) and the internal iliac (hypogastric) (11) arteries. From the bifurcation of the aorta, the middle sacral vessel (12) descends along the anterior surface of the sacrum. There is a concomitant vein that usually empties into the left common iliac vein at this point (12).

The ovarian arteries (4) arise from the anterolateral wall of the aorta below the renal vessels. They descend retroperitoneally across the ureters and through the infundibulopelvic ligament to supply the ovary and salpinx (15). They terminate by anastomosing with the uterine artery (16), which descends in the broad ligament. The spermatic arteries and veins follow a retroperitoneal course before entering the inguinal canal to supply the testis in the scrotum.

The uterine vessels (16) arise from the anterior division of the internal iliac (hypogastric) arteries (11) and proceed medially to the edge of the vaginal vault opposite the cervix. At this point, the artery crosses over the ureter (“water under the bridge”) (17). The uterine vein, in most instances, does not accompany the artery at this point but passes behind the ureter. In a hysterectomy, the occluding vascular clamps must be applied close to the wall of the uterus to avoid damage to the ureter. The uterine vessels then ascend along the lateral wall of the uterus and turn laterally into the broad ligament to anastomose with the ovarian vessels.

The lymphatic networks of the abdominal viscera and retroperitoneal organs frequently end in lymph nodes found along the entire abdominal aorta and inferior vena cava. Lymph nodes about the celiac axis (A) are commonly involved with metastatic cancer arising from the stomach and the body and tail of the pancreas. The para-aortic lymph nodes, which surround the origin of the renal vessels, receive the lymphatic drainage from the adrenals and kidneys.

The lymphatic drainage of the female genital organs forms an extensive network in the pelvis with a diversity of drainage. The lymphatic vessels of the ovary drain laterally through the broad ligament and follow the course of the ovarian vessels (4, 5) to the preaortic and lateroaortic lymph nodes on the right and the precaval and laterocaval lymph nodes on the left. The fallopian tubes and the uterus have lymphatic continuity with the ovary, and communication of lymphatics from one ovary to the other has also been demonstrated.

Lymphatics of the body and fundus of the uterus may drain laterally along the ovarian vessels in the broad ligament with wide anastomoses with the lymphatics of the tube and ovary. Lateral drainage to a lesser extent follows a transverse direction and ends in the external iliac lymph nodes (18). Less frequently, tumor spread occurs by lymphatic trunks, which follow the round ligament from its insertion in the fundus of the uterus to the inguinal canal and end in the superficial inguinal lymph nodes (22).

The principal lymphatic drainage of the cervix of the uterus is the preureteral chain of lymphatics, which follow the course of the uterine artery (16) in front of the ureters and drain into the external iliac (18), the common iliac (19), and obturator lymph nodes. Lesser drainage is by way of the retroureteral lymphatics, which follow the course of the uterine vein, pass behind the ureter, and end in the internal iliac (hypogastric) lymph nodes (20). The posterior lymphatics of the cervix, less constant than the other two, follow an anteroposterior direction on each side of the rectum to end in the para-aortic lymph nodes found at the aortic bifurcation (21).

The lymphatics of the prostate and bladder, like those of the cervix, are drained particularly by nodes of the external iliac chain (18) and occasionally also by the hypogastric (20) and common iliac lymph nodes (19).