 In this video, the female pelvic lymphatics will be demonstrated. Throughout this video, cranial word is to the left. To enter the peritoneal cavity, we will open the anterior abdominal wall and peritoneum. The connective tissue sheet behind the ascending colon and transverse colon was stripped, and then the colon was reflected to the left. The connective tissue behind the duodenum was cleared away. The right kidney, surrounded by the renal fascia, comes into view. Hidden within the renal fascia is the ureter and the ovarian vessels. Tracing along the ureter, we find that the renal fascia is divided into the ovarian vessel sheath and the fascia which surrounds the ureter. Outside these fasciae lies the umbilical vesicle fascia. Reflecting the external iliac artery and obturator nerve to the left, we see the iliac fascia covering the iliosoas muscle. In the right pelvic half showing the iliac vessels, note that the obturator nerve runs within the inter-iliac angle. Before reaching the aortic bifurcation, some lymphatics ascend along the internal iliac artery, but most lymphatics cross this artery to reach the inter-iliac angle. Viewing the pelvis from lateral, after removal of the hip bone, we see the external iliac artery and the obturator nerve. Here we see the inter-iliac nodes. Lymphatics from the lower part of the pelvic organs converge along the obturator nerve and reach the inter-iliac nodes. Returning the external iliac artery to the original position, we see the obturator nerve, artery, and vein. We can see the inter-iliac angle and the large nodes situated between the external and internal iliac arteries. These nodes receive lymphatics from the lower extremity along the external iliac artery and also the lymphatics from the pelvic and internal organs. Thus, these nodes are very significant. You can see that small lymph vessels enter these nodes after crossing over the medial umbilical ligament. Lateral to the round ligament is the medial umbilical ligament. This ligament was the umbilical artery in the fetus, which, after birth, became obliterated. The proximal portion became the superior vesicle artery. Reflecting this medial ligament, we can find the superior vesicle artery. In addition to this artery, many arteries for the internal organs originate from the internal iliac artery. Now we can easily trace the above-mentioned small lymphatics originating from the pelvic internal organs. The medial umbilical ligament is cut to view these lymphatics. The superior vesicle artery is cut as well in order to trace the lymphatics along these arteries. These lymphatics travel along the superior vesicle artery to the internal iliac artery. Also of importance is the uterine artery, which originates from the internal iliac artery and crosses over the ureter to reach the uterus. By cutting the uterine artery, we can closely trace the lymphatics which run along the artery. Shifting the ureter medially, we trace a lymph vessel from it, which runs transversally across the common iliac artery and reaches the large node in front of the inferior vena cava. Again moving distally, the aforementioned lymphatics along the uterine arteries are seen. These lymphatics are cut to view the autonomic nerves. Looking now at the left key pelvic structures from the right, we can see the large external iliac nodes, as well as the inter-iliac nodes. This is the medial umbilical ligament and the superior vesicle artery. We will cut this artery to view the uterine artery. Tracing the uterine artery, which supplies the cervix of the uterus and vagina, we note that it crosses over the ureter. Looking closely, we see numerous lymphatics which run along the uterine artery. These lymphatics drain into the external iliac nodes. In front of the uterine artery, we see numerous lymphatics from the uterus and bladder, which drain into the inter-iliac nodes. From these nodes, lymph vessels ascend along the anterior surface of the common iliac artery. Note that a few lymph vessels ascend along the medial side of the common iliac artery. Here, as the ovarian artery and ureter cover the pelvic cavity, we will cut some vessels. First, we cut the left ovarian artery and the left ureter. Also in the right side, the ovarian vessels and ureter are cut. Next, we cut the sigmoid arteries and also the superior rectal artery. The rectum is shifted frontward. Between the rectum and the sacrum, a distinct membrane is seen. It contains both hypogastric nerves, so it may be provisionally called the hypogastric nerve fascia. The few connections between this fascia and the rectum are cut. Looking now at the left side, we pull the rectum to the right. To view the lymphatics, we cut the uterine artery and also the uterine vein. Lymphatics along the uterine artery drain into the external iliac nodes. Interestingly, these lymphatics run outside the hypogastric nerve fascia, so it contains the pelvic plexus. We can carefully separate this fascia from the lymphatic vessels. Now we will cut and remove the inferior vesicle vein and also the inferior vesicle artery. The accompanying lymphatics are also cut, as well as those along the uterine artery. Lateral to the pelvic organs lies an important autonomic nerve plexus called the pelvic or inferior hypogastric plexus. The sympathetic component is from the lumbar sympathetic trunk. The parasympathetic component is from S2 to S4 pelvic splenchnic nerves. Now we will look closely at the superior hypogastric plexus. By shifting the inferior mesentery artery, we see that only a few nerves descend from the abdominal aortic plexus to continue to the superior hypogastric plexus. The primary contribution to the formation of the superior hypogastric plexus is from the right and left lumbar splenchnic nerves. From this plexus tracing downward, we note that it bifurcates into the right and left hypogastric nerves. These two hypogastric nerves are connected by the above mentioned hypogastric nerve fascia. Tracing the right hypogastric nerve distally, we note that it reaches the rich pelvic plexus lateral to the rectum. Now we will trace the parasympathetic components forming this plexus. Parasympathetic branches from S2 and S3 first join to form a loop. Later, behind S3, the branch from S4 also contributes to form the parasympathetic pelvic splenchnic nerves. These pelvic splenchnic nerves join the sympathetic hypogastric nerve to form the pelvic plexus. From this pelvic plexus, numerous branches are distributed to the pelvic organs, originating from the same S2 to S4 levels as the pelvic splenchnic nerves are the levator aninerve and the pudendal nerve. The composition of the pelvic plexus has been shown. In Part 2, we will trace the iliac lymphatics to the paraeortic lymphatics and reach the thoraxic duct. The paraeortic lymph nodes are divided into several chains according to the relationship to the aorta and inferior vena cava. At the level of the left renal vein, these lymphatics converge to form the thoraxic duct behind the aorta. To facilitate dissection of the lymphatics, we will cut the superior hypogastric plexus. At the level of the aortic bifurcation, the superior hypogastric plexus is formed. It then divides into the right and left hypogastric nerves. A thin membrane connects the rectum and sacrum. This rectal sacrophagia may serve as an important pathway. Now, on the left side, we will remove the iliac vessels to examine the lymphatic connections surrounding these vessels. We will dissect the external iliac chain from in front of and behind the external iliac artery. Now we will dissect the internal iliac artery and the external iliac vein and continue to examine the inter-iliac angle. Now we will look at the lymphatics behind the iliac arteries. After removal of the iliac artery, we note lymphatic connections between the lateral and medial chains. Tracing the medial chain, we find it reaches the subaortic nodes. Joining this medial chain are lymphatics from the genital urinary organs and also from the rectum. After piercing the hypogastric nerve fascia, lymphatics from the rectum converge via the sacral nodes and then reach the subaortic nodes. Now, on the right side, we will examine the lymphatic connections. Medial and lateral to the iliac vessels, rich lymphatic chains are observed. After removal of the right iliac vessels, we note the rich connections behind the vessels. Held by the forceps is the right common iliac vein. Now we will trace this vein cranial word. This vein is joined by the left common iliac vein to form the inferior vena cava. The left common iliac vein is cut. In front of the lower most part of the inferior vena cava lies a large flat node which is connected to the right lateral iliac chain. With this node shifted, the IVC is cut. To further examine the connection between the iliac lymphatics and the para aortic lymphatics, the lower most part of the abdominal aorta is cut. With the inferior vena cava, we will trace the right iliac lymphatics toward the aorta. Also on the left side, we trace the iliac lymphatics. Now we can see the arrangement of the lymphatics and in particular the subaortic nodes at the level of the aortic bifurcation. From the subaortic nodes, three longitudinal lymphatic chains ascend, the interaortic cable chain, the lateral aortic chain and the lateral cable chain. There is a transverse connection between the lateral cable and lateral aortic chains. A right lumbar splenchnic nerve penetrates the lower most pre-cable node. Now tracing from the lower end of IVC to the level of the left renal vein, we can see the lymph nodes on the posterior surface of the pancreas head. Lymphatics from these retro pancreatical duodenal nodes of Ruri air drain into the interaortic cable nodes just below and above the renal vein. In order to see the lymphatic connections behind the inferior vena cava, we remove it. Now you can see rich lymphatics as well as the retro cable nodes. Moving now to the aorta, you see the pre-aortic nodes. The aforementioned interaortic cable nodes are more clearly seen also. We have to cut the origin of a lumbar artery. After carefully separating the lymphatics the aorta is cut at the level of the renal arteries. You can see numerous rich lymphatic connections and the retro aortic nodes. To obtain pure lymphatic networks, we will trace and remove interfering lumbar splenchnic nerves. Tracing the right lumbar splenchnic nerve, a thin branch from the superior mesentery plexus is found to join this nerve. This is then cut. The right lumbar splenchnic nerve is traced to the lumbar sympathetic trunk. This nerve is cut at the origin and then pulled out of the lymph node group. Also in the left side, similar nerves are removed. Now we will trace the iliac lymphatics to the para aortic lymphatics and then to the thoracic duct. You can see the close relation of the obturator nerve and the right iliac lymphatics. The right and left iliac lymphatics unite just before the aortic bifurcation. The right and left iliac lymphatics are stripped from the pelvic wall. The para aortic lymphatics are removed from the vertebral column. The iliac and para aortic lymphatics have been completely removed on block, maintaining the topographical organization. Tracing the para aortic lymphatics further, we find that in this specimen there are two thoracic ducts. Now we will look at the distribution of the pelvic plexus to the uterus and bladder. The peritoneum covers the uterus seen in the middle and the bladder on the right. In the gap between the rectum and uterus we find the recto uterine pouch. Now we will look at the structural relationships after median sectioning the viscera. First we will examine the right half. Here is the bottom of the peritoneal cavity. The loose connective tissue between the peritoneum and the anterior wall of the rectum is cleared away. In the gap between the uterus and peritoneum the forceps is inserted but it is more difficult to separate. There is a septal structure between the rectum and vagina called the rectovaginal septum also known as the known Villiers fascia. By pushing the forceps through this septum and returning the right half of the viscera back to the original position we can see that the pelvic plexus is situated just lateral to this rectovaginal septum. With the pelvic organs reflected laterally we will look at the distributing branches of the pelvic plexus and particularly those reaching the uterine cervix and bladder neck. After organ reflection and viewed from inside we note that the uterine and vesicle branches are intermingled and relatively inseparable. Looking now at the left half first from the inside and then with the uterus pulled to the right we open the gap between the uterus and the bladder. Now we will see the branches distributed to the uterus and bladder neck. Although these branches are intermingled we can separate those to the bladder from those to the uterus. The female pelvic lymphatics with special reference to the autonomic nerves have been demonstrated.