 To understand the lymphatic pathways surrounding the trachea, the relationships to some major vessels such as the arch of the aorta, brachiosophallic trunk, the brachiosophallic vein angle, and the jugulose upclavian junction should be considered. Also significant are the right and left recurrent laryngeal nerves. The ascending lymphatic pathways are roughly classified into right and left pathways, and each pathway is further divided into superficial and deep groups. Dissection of specimen 1 is demonstrated. The head is directed towards the left. The infrahioid muscles of the right neck are reflected laterally. The internal jugular and subclavian veins unite to form the venous angle. Both medial and lateral to the internal jugular vein, lymphatic chains with transverse connections are seen. The lateral chain reaches the venous angle. Between the brachiosophallic trunk and the right and left brachiosophallic veins, there is a small triangular area. You can see an ovoid lymph node in this triangle. From this node, a thick lymph vessel, which runs along the right brachiosophallic vein, is dissected. This lymph vessel reaches the venous angle. In addition, a lymph vessel from the lower margin of the thyroid gland traverses the brachiosophallic trunk and drains into this node, sometimes called the brachiosophallic angle node. Between the internal jugular vein and the common carotid artery, the vagus nerve is seen. A deep vessel from the brachiosophallic angle node runs beneath the vagus and finally reaches a deep node close to the venous angle. The brachiosophallic angle node seems to be a critical intermediary node in the right ascending pathway. From the tracheal bifurcation to the right venous angle, the right lymphatic pathways are classified into two pathways, the superficial pathway via the critical brachiosophallic angle node and the deep pathway. Here the diaphragm has been cut and the esophageal hiatus has been opened. From the lymphatics of the left pulmonary ligament, first we trace the descending lymph vessels which run via the nodes of the esophageal hiatus. These vessels then connect to the left gastric nodes close to the cardia. We are looking now at an ascending chain which runs along the left inferior pulmonary vein and reaches the tracheal bifurcation lymph nodes. These tracheal bifurcation nodes also receive lymph vessels which run along the lower margin of the left bronchus. Now, looking at the transitional area of the trachea and right bronchus, you can see a well-developed node group, the right tracheobronchial nodes. And tracing the ascending superficial pathway via the brachiosophallic angle node, we see it reaches the venous angle. Tracing the deep pathway, it traverses the subclavian artery, communicates with deep nodes, and then reaches the venous angle. From the right approach, with the lung reflected, we will look at the complex lymphatic composition within a critical triangular area between the arch of the azygous, brachiosophallic and subclavian arteries, and the posterior wall of the esophagus. Here we see the right peritracheal node group, roughly divided by the vagus nerve. The nodes anterior to it are closely related to the lung, while the posterior nodes are related to the esophagus. Numerous connections run between the two groups. These connections then finally converge at a node at the origin of the right recurrent nerve behind the subclavian artery. This node is at the highest level in the mediastinum. Looking at the relationships to the surrounding structures, we see the same node, the highest mediastinal lymph node, and trace its ascending lymph vessel. This traversing lymph vessel follows a complicated course and crosses superficial to the subclavian artery. Finally, this lymph vessel drains into the supraclavicular nodes close to the jugular subclavian venous angle. In the left side, the superficial and deep left pathways are defined according to the relation to the aortic arch and the ligamentum arteriosum. Looking at the superficial lymphatics reaching the left brachiosophallic vein and tracing downward, we see numerous lymph vessels and nodes between the aortic arch and the left pulmonary artery. These are the nodes of the ligamentum arteriosum, sometimes called the nodes of botol. Dissecting more deeply between the aortic arch and the left pulmonary artery, we can clearly see the left recurrent laryngeal nerve and the ligamentum arteriosum and the above-mentioned nodes of the ligamentum arteriosum. Medial and deep to the ligament lies a large group of nodes, the left tracheobronchial nodes. Here we see the complex lymphatic networks surrounding the trachea and compressed by the aortic arch. By reflecting the aortic arch to the left, we note lymph vessels at the level of the lower margin of the thyroid gland. These vessels drain into the venous angle. From the above-mentioned left tracheobronchial node group, two pathways ascend. We see the well-developed node chain which traverses to join the right deep pathway. Also, there is an ascending node chain which runs between the trachea and the left recurrent nerve. This is the paratracheal node chain or sometimes called the left recurrent nerve chain. Though seemingly not so developed, this paratracheal node chain is a critical pathway due to its relationship to the left recurrent nerve. Looking at the very same area from the right, by reflecting the right lung and esophagus to the front and left, we can see the posterior surface of the esophagus as well as the left recurrent laryngeal nerve and its esophageal branches. The numerous esophageal branches run transversely. Interestingly, they enter the esophageal wall in a segmental manner. From this approach, simply by shifting the left recurrent laryngeal nerve, it is possible to reach the left paratracheal node chain. Thus, this chain is virtually accessible from the right. In another specimen, we will look at a lesser-developed left paratracheal chain. The left brachiocephalic vein is cut and reflected. Tracing the node chain from the tracheobifurcation and from the left lung, we see it drains into the right tracheobronchial nodes. A thick communication from this right tracheobronchial node group ascends to directly reach the right jugulo-subclavian venous angle. To examine the left lymphatic pathways in greater detail, next we approach from the left side. From the left approach, we see the left phagus, the aortic arch, and the ligamentum arteriosum. The origin of the left recurrent laryngeal nerve is also seen. By reflecting the aortic arch, we can find a rather small left tracheobronchial node. However, there is no left paratracheal chain, as we had seen in specimen 1. The lymph vessel from this node drains directly into the upper segment of the thoraxic duct. Just below the thyroid gland, we see other paratracheal nodes, from which a few vessels drain into the terminal portion of the thoraxic duct. Shifting back to the right approach, we will view this paratracheal area. Here is the left recurrent laryngeal nerve. For orientation, we insert a black paper slip at the left tracheobronchial angle. The right lung is reflected to the left, and the esophagus is cut to better view the left paratracheal area from the right. From the above-mentioned left tracheobronchial node, we see communications with a node of the right group, rather behind the bronchi. From this node, we see the above-mentioned direct communication to the thoraxic duct. In another specimen, we will carefully trace the left lymphatic pathways. With the left brachioscephalic vein cut and reflected, we are able to note the vagus nerve and trace the left superficial lymphatic chain to find that it drains into the left jugular subclavian venous junction. Tracing downwards, we see the nodes of the ligamentum arteriosum and their superficial connection with the nodes along the left bronchus. Note the connection running between the left pulmonary artery and the arch of the aorta. By reflection of the aortic arch, we see the nodes of the ligamentum arteriosum connect to the left tracheobronchial nodes. These nodes receive lymphatics along the left bronchus. Thus, lymphatics completely encircle the left pulmonary artery. Note that between the left margin of the trachea and the left recurrent laryngeal nerve, in this specimen, there is no lymphatic chain. However, there are numerous thick connections to the right side. Note the large conglomerate group of both pre- and peritracheal nodes. Thus, all of the left lymphatics drain into the right side. From these nodes, there are two pathways reaching the right venous angle. Most lymphatics drain into this angle via the brachioscephalic angle nodes. However, we also note more deep pathways. Although the right subclavian artery has been removed, we see one pathway which runs via the node near the lower margin of the subclavian artery. Another pathway ascends to reach the node deep to this artery and close to the origin of the right recurrent laryngeal nerve. From these highest mediastinal nodes, numerous terminal lymphatics converge at the right venous angle. To observe the connection between the superficial and deep lymphatics, the ligamentum arteriosum is cut and the aortic arch is reflected. In the upper left screen, the nodes of the ligamentum arteriosum connect with the left tracheobronchial nodes. Now we will observe a well-developed paraesophageal node. Looking at the lower thoraxic portion of the esophagus from the right, we find a well-developed node attached to the anterior surface of the esophagus on the left margin. Now we will remove the connective tissue. By lifting this node, we see that the upper limb vessel connects to nodes of the tracheobifercation, while the lower limb vessel descends to reach the diaphragm. In this video, we demonstrated numerous peritracheal lymphatics and their varied pathways for surgical reference. For lung and esophageal surgery, it is critical to understand the complex relationships of the trachea and esophagus to the intricate blood vessels and autonomic nerves. Here from the left, with the common carotid artery cut and removed, we will trace various autonomic branches. We note a nerve which crosses the terminal portion of the thoraxic duct and gives off numerous branches. This cardiac nerve runs slightly medial to the common carotid artery. Numerous branches run both superficial and deep to the aortic arch to finally reach the cardiac plexus. By cutting and replacing this cardiac nerve, we are able to look more closely at the intricate relationships immediately adjacent to the terminal portion of the thoraxic duct. We see two terminal limb vessels from the left tracheobronchial node, which reach the thoraxic duct. Note also the nerve deep to the terminal portion of the thoraxic duct. Looking now at the aortic arch area, we see numerous well-developed superficial nodes. By reflecting the aortic arch, we note the left recurrent laryngeal nerve along the trachea. Here is the cardiac nerve, which we previously cut. It reaches the left pulmonary artery. Now we will shift to the right. We can see the right common carotid artery, the vegas nerve, and numerous autonomic branches which cross over the subclavian artery to send along the brachycephalic trunk. Next, we will more closely view this brachycephalic trunk area. In order to comprehend the deep nerve interconnections, we will cut the brachycephalic trunk and reveal the compressed area between the brachycephalic trunk and trachea. First, we trace the descending vegas nerve to the mediastinum. By reflecting the brachycephalic trunk, we see the origin of the right laryngeal nerve from the vegas nerve. This recurrent nerve ascends along the trachea to reach the thyroid and larynx. Also, we see a nerve descending from the sympathetic trunk. Interestingly, due to the narrow passageway compressed by the brachycephalic trunk and trachea, interconnections are developed. Note that the right recurrent nerve and vegas nerves are anastomost with sympathetic branches. Here, with the brachycephalic trunk as well as much of the right aortic arch removed, we will view the origination level of the right and left recurrent laryngeal nerves. Looking closely, we see numerous right recurrent nerve branches to the trachea. The terminal ascending branch passes between the two branches of the inferior thyroid artery. Now, we will trace the left recurrent nerve from its vagal origin between the aortic arch and left bronchus. It ascends between the aortic arch and trachea. Note the numerous branches to the trachea. This left recurrent laryngeal nerve then ascends under limb vessels and below the inferior thyroid artery. To observe the terminal branches of the recurrent nerve in the larynx, the thyroid cartilage is median sectioned and reflected. First, we locate the superior laryngeal nerve which supplies the creco-thyroid muscle. The terminal portion of the recurrent nerve enters just behind the articular surface of the creco-thyroid joint and supplies the intrinsic muscles of the larynx. The internal branch of the superior laryngeal nerve descends close to the recurrent nerve. In this specimen, however, they do not anastomose. In another specimen, we will trace the arteries to the trachea and bronchus. First, we will observe the inferior thyroid artery. Here we can see the origin of this artery from the subclavian artery. To look more deeply, we cut and remove the major vessels. We can now see the complete course of the right recurrent laryngeal nerve. This nerve originates from the vagus nerve. Near the origination, numerous branches are sent to the trachea. Note the relationship between this recurrent nerve and the inferior thyroid artery. Contrary to its name, the inferior thyroid artery does not only supply the thyroid gland. Interestingly, it also sends branches to the trachea. In this specimen, though, the tracheal distribution of this artery is minor. Tracing an internal thoraxic arterial branch which originates from the subclavian artery, we find it descends along the vagus nerve and reaches the upper border of the initial portion of the right bronchus. To view the branching of the left inferior thyroid artery, we reflect the brachycephalic vein and cut the middle thyroid vein as well as other veins. With the aortic arch reflected, the upper portion of the thoraxic duct comes into view. The thoraxic duct runs between the esophagus and the left subclavian artery to reach the left venous angle. The left inferior thyroid artery sends two branches to the trachea and esophagus. Also, we see two esophageal veins running alongside the arterial branches. From the right approach, as in typical esophageal surgery, we will observe the arterial supply. In addition to the right bronchial artery of internal thoraxic origin, here you can see the right highest intercostal artery of aortic origin. This intercostal artery sends an important bronchial artery to the right lung. It also sends several esophageal branches. Also, the lower adjacent right intercostal arteries send esophageal branches. Along an esophageal artery, a small para-esophageal lymph node is seen. Here, in examination of a right bronchial artery of aortic arch origin, we see it is intertwined amongst nodes of the tracheal bifurcation. After careful reflection of the left bronchus, we note the origin of this bronchial artery from the inner arc of the arch of the aorta. Interestingly, this right bronchial artery has a common origin with two left bronchial arteries. We can see that behind the left bronchus, there is a rich vagal network to the pulmonary plexus. Also behind this bronchus lies a complex esophageal plexus. Descending from the level of the left bronchi, we also see that the right and left vagae pass behind the bronchi and anastomals inferior to the tracheal bifurcation to form a nerve plexus. Descending further to the level above the diaphragm, we see the formation of the anterior and posterior vagae. Both are made up of left and right vagal branches. However, the left contribution is prominent in the anterior and posterior vagas. In a different specimen, we will trace a thick artery in the left pulmonary ligament. In a close-up view, we locate this thick artery amongst numerous pulmonary ligament nodes and bronchial nodes. Tracing centrally with the left lung reflected, we find that this artery originates from the lower end of the aortic arch. Note the well-developed nodes of the pulmonary ligament. Here in another specimen, we will examine the right bronchial arteries. After reflection of the aortic arch, we note that these arteries run both in front of and behind the left bronchus and reach the lower margin of the right bronchus. Tracing behind the left bronchus, we find that both arteries independently originate from the aortic arch. The upper originating artery crosses in front of the bronchus while the lower artery runs behind the bronchus. From the descending aorta, two small arteries originate. These arteries run directly to reach the left margin and the posterior surface of the esophagus. Along the lower artery, a vein from the esophagus runs and winds around the aorta to drain into the hemiozygous vein. In this video, various types of arterial and nerve distributions were shown for surgical reference.