 Here we will examine the lymphatics related to stomach cancer surgery. However, knowledge of the precise arterial arrangement is necessary first. For orientation, we locate the ciliac trunk close to the pancreas head. Note its three main branches, the sponic artery, left gastric artery, and common hepatic artery. The left gastric artery, after giving off a cardio branch, divides into anterior and posterior gastric branches, which run along the lesser curvature. Interestingly, in this specimen, the common hepatic artery divides into four branches, the left and right hepatic branches, gastroduodenal artery, and the right gastric artery. The right gastric artery anestimosis with the left gastric artery at the angular incisor. Moving to the pylorus, we find the supraduodenal arteries, which are distributed to the first superior portion of the duodenum. Back to the left and right branches of the hepatic artery, we see the right branch gives off the cystic artery, which runs over Callow's Triangle made up of the liver, the common hepatic duct, and the cystic duct. Reflecting the stomach cranially, we see the division of the gastroduodenal artery into the right gastroduodenal artery and the anterior superior pancreatical duodenal artery. Tracing the anterior superior pancreatical duodenal artery, we see it meets the anterior inferior pancreatical duodenal artery to form an arterial arcade. The inferior artery originates from the superior mesenteric artery and gives off branches to the initial portion of the duodenum. The superior mesenteric artery is surrounded by an autonomic nerve plexus. By removing these nerves, we can locate the origin of the anterior inferior pancreatical duodenal artery from the superior mesenteric artery. There is another transverse running artery which joins the anterior pancreatical duodenal arcade to form the pre-pancreatic arcade. Tracing this artery, we find it originates from SMA. Returning the gastroduodenal artery, we find it gives off the posterior superior pancreatical duodenal artery, which runs on the posterior surface of the pancreas head, close to the common bile duct. Moving toward SMA, we find it gives off the common inferior pancreatical duodenal artery, which divides into anterior and posterior branches. Here we follow the posterior branch, and note it meets the corresponding superior branch to form the posterior pancreatical duodenal arcade. Next, we will follow the splenic artery and its branches. Reflecting the stomach upwards, we see the ciliac trunk, the common hepatic artery, left gastric artery, and the splenic artery. The splenic artery and vein run together along the upper border of the pancreas. Numerous branches from the splenic artery supply the pancreas. Following the splenic artery, we see that it gives off a branch to the left side of the greater curvature. Note that its branches enter the posterior surface of the stomach rather than the greater curvature. Another artery from the splenic artery enters the posterior surface of the stomach. It is the posterior gastric artery, which is distributed near the cardia. Note along the greater curvature, the left and right gastroepiploid arteries appear to meet. Returning the stomach, we see the short gastric arteries supply the fundus. Here is another specimen with the stomach reflected upwards, with the large torturous splenic artery. And reflecting the stomach to the right, we find the left inferior phrenic artery, which passes close to the left suprarino gland and reaches the diaphragm. This artery gives off a branch, called the cardioesophageal artery, which reaches the left side of the cardia. Interestingly, this artery will be significant, we will see later, it serves as a pathway along which efferent lymphatics run from the pericardial nodes. Now we will look at the lymphatics of this region. Looking at the stomach, we see the cardia and the pylorus. The left lobe of the liver has been removed. We see the caudate lobe surrounded by arterial folds. We can insert a finger behind the caudate lobe in the upper recess of the omental bursa and grasp these arterial folds. In the left fold are the left gastric artery and vein, and in the right fold, the common hepatic artery. From the hepatic artery, the right gastric artery originates and returns to the lesser curvature in a recurrent type course. The left gastric artery divides into anterior and posterior branches. The anterior branch gives off a cardial branch and runs along the lesser curvature and communicates with the right gastric artery to form a loop along the lesser curvature. Along the lesser curvature, we see numerous lymph nodes near the left gastric artery. Also lymphatics along the hepatic branch of the vagus communicate with these left gastric nodes. Note this completely independent lymph vessel within the lesser omentum. And additionally, we see lymphatics which run along the left gastric vein. Now moving to the cardiolymphatics, the pericardial nodes communicate in three different directions. Here we see the right communication with the aforementioned left gastric nodes. Let's look at another direction of cardiac lymphatics passing through the esophageal hiatus of the diaphragm. Looking at the cardiosophageal region, we see the aforementioned pericardial nodes as well as additional nodes near the esophageal hiatus of the diaphragm. We open the hiatus and remove the fatty and connective tissues surrounding the esophagus. We can now see the lymphatics which encircle the lower end of the esophagus. This network includes the pericardial nodes of the rightward communication. We also see another direction of communication with the nodes in the right angle between the esophagus and diaphragm or the posterior diaphragmatic nodes. Now we will look at the third direction of the rightward communication. We reflect the stomach to the right and also reflect the spleen and pancreas body to reveal the splenic artery and vein and the posterior surface of the pancreas body. Note the lymphatics along the splenic artery which cross over the posterior gastric artery to reach the left ciliac nodes. Unfortunately, we did not dissect the lymphatics along the posterior gastric artery. Moving to the left inferior phrenic artery and vein, we note the cardiosophageal branch of the left inferior phrenic artery. Returning the cardioregion by pulling the stomach, again we see the left group of pericardial nodes. If we trace these lymphatics, we find they descend along the left inferior phrenic vessels. The lymphatics then converge with the left gastric lymphatics to finally reach the large left ciliac nodes behind the spenic vessels at the level of the left renal vein. Now we will look at the greater curvature where the gastroepiploid vessels form an arterial arch. Along this arch, lymphatics run. Starting from the left gastroepiploid vessels and tracing to the right, we reach the right gastroepiploid artery near the pylorus. Here we see large lymph nodes, the pyloric nodes, which lie just below the pylorus and in front of the pancreas head. Here, from a wider view, we will look at the pyloric nodes. These pyloric nodes hold a significant position. They are located just at the bifurcation of the gastrodoadenal artery where it divides into the right gastroepiploid artery and the anterior superior pancreatic odoadenal artery. These nodes receive lymphatics from not only vessels along the gastroepiploid arteries, but also from vessels on the anterior surface of the pancreas head and from vessels along the second part of the doodenum. Interestingly, from these pyloric nodes, lymph does not flow upwards to the ciliac trunk. Rather, it flows downward to the superior mesentery vessels. Next, we will look at the lymphatics along the hepatic pedicle, which contains the bile duct, portal vein, and hepatic artery. Following the lymphatics along the right gastric artery, we reach the well-developed lymphatic network on the anterior surface of the hepatic pedicle. Some of the lymph drains into nodes along the common hepatic artery. However, some lymphatics run downward and to the right to reach a node situated to the right of the common bile duct. It is the so-called epiploid foreman node. Reflecting the liver and pancreas head, we see the epiploid foreman node connect to the superior retro-pancreatic doodenal nodes of Ruvier, which are situated on the posterior surface of the lower end of the hepatic pedicle. These nodes receive numerous lymphatics, not only from the posterior surface of the hepatic pedicle, but also from the posterior surface of the pancreas head. From these Ruvier nodes, lymphatics run proximally, superficial to the nerve plexus, and reach the interaortical cable nodes just above and below the left renal vein. Note the connection between these interaortical cable nodes on the surface of the left renal vein. Here, the inferior vena cava and the left renal vein have been removed. Note how the lymphatics from SMA convert to a thick lymph vessel, which descends obliquely to the right of the aorta. These lymphatics drain into the retrocaval nodes and interaortical cable nodes. Next, we will remove part of the aorta to review the lateral aortic lymphatic chain. Lymphatics from the right side and from the left side and those along SMA converge at the cisterna caili and form the thoraxic duct. The thoraxic duct then ascends between the thoraxic aorta and the ozygous vein. The basic abdominal lymphatics have been demonstrated. Before observing the ciliac plexus, first we will examine the anterior vagus trunk, a parasympathetic component. From the hepatic artery, first the right gastric artery is given off. Then another branch is given off, though not a genuine left gastric artery. Then lower, we find the true left gastric artery directly from the ciliac trunk. The branches from the accessory left gastric artery are distributed to the cardiosophageal region. This accessory artery serves as a marker for the hepatic branch of the anterior vagus. At the hiatus of the diaphragm, we can see the anterior vagus trunk. Here with the diaphragm cut from the level of the tracheal bifurcation, you can see plexus formation of the left and right vagus nerves. Moving downwards, we note that the left vagus is the major component of the anterior vagus trunk. However, some branches from the right vagus also contribute to its formation. From the anterior vagus trunk, we now see its hepatic branch. This hepatic branch runs along the accessory left gastric artery and bifurcates into that reaching the portahepatus and that which descends along the hepatic pedicle to rejoin the hepatic plexus. In this specimen, the anterior gastric branch is not well developed. However, numerous intermediate branches run within the lesser momentum to reach the angular notch and the pyloric region. Now we will observe the posterior vagus trunk, which contributes to the formation of the ciliac plexus. The major component of the posterior vagus trunk is the right vagus. However, the left vagus also contributes to its formation. The posterior vagus trunk reaches the area of the left gastric artery. Reflecting the stomach, we see numerous branches distributed to its posterior surface. Here we note a branch which descends along the posterior gastric artery to reach the splenic artery. Tracing another branch of the posterior vagus, the ciliac branch, we see it runs behind the hepatic branches of the anterior vagus to reach the left gastric artery near the ciliac trunk. This is the parasympathetic component of the ciliac plexus. We will observe the sympathetic component of the ciliac plexus. To trace the sympathetic nerve, we reflect the right portion of the diaphragm medially and downwards. From the thoraxic sympathetic chain, a few branches originate to form the greater splenic nerve. Where this nerve pierces the diaphragm, a small ganglion is seen. Also, the lesser splenic nerve and the sympathetic trunk pierce the diaphragm. In order to observe the right ciliac ganglion, we cut the diaphragm. We see the inferior vena cava and the right adrenal gland. We now cut the right superior superrenal arteries in order to reflect the adrenal gland and view the course of the splenic nerve. Returning the gland, numerous superrenal arterial branches from the inferior phrenic artery are cut in order to view the right ciliac ganglion, which is the termination of the greater splenic nerve. The greater splenic nerve forms the lateral limb of the right ciliac ganglion. Now we will observe the medial limb of the formation of the ciliac ganglion. With the spleen reflected to the right, we will look at the left ciliac ganglion. As we saw with the right side, the greater splenic nerve contributes and also the posterior vagus reaches the ciliac trunk and finally the left ciliac ganglion. Returning to the right side, we notice that from the right ciliac ganglion, numerous branches run along the ciliac and superior mesenteric arteries and are distributed to the posterior surface of the pancreas head and bile duct. Also from this ganglion, branches are distributed to the adrenal gland and kidney. Close to these autonomic nerve plexuses, a thick limb vessel runs. Lymphatics from the above-mentioned area converge to this thick vessel and then drain into the interaortical cable lymph nodes. Here in a unique view, these structures will be dissected from behind. With the muscles removed and complete laminectomy, the spinal cord is easily viewed. By mid-sectioning the spinal column longitudinally, the vertebral bodies are viewed. The vertebral column was removed from the surrounding structures. In the upper thoraxic area, the esophagus is viewed and lower we see the aorta and the esophagus vein and also the intercostal veins which drain into the esophagus. The right intercostal arteries pass behind the esophagus vein and even lower we see the lumbar arteries. The right and left lumbar trunks unite to form the thoraxic duct. We cut the intercostal vessels to obtain a better view of the thoraxic duct. Following the natural course of the thoraxic duct, we note that it shifts from ascending directly behind the esophagus to running along its left margin. In the lumbar region, we observe the abdominal aorta as well as the right and left crura of the diaphragm which surround it. Shifting the aorta slightly, we see the upper border of the aortic hiatus. In the lumbar region, we see the left and right renal arteries and the aorta. Note there is a space between the aorta and the inferior vena cava. This space contains the interaortic ocaval lymph nodes. Left to the aorta, the lateral aortic lymph nodes are well developed in this specimen and they form a chain. These lymphatics from along the right and left sides of the aorta continue to the lumbar trunks and contribute to the formation of the thoraxic duct. Note the various lymphatics as well as the nodes into the initial portion of the thoraxic duct. At the level of the aortic hiatus, the lymphatics arrangement is very complex. The left cru of the diaphragm is reflected to review the left renal artery. Interestingly, below the left renal artery, large lateral aortic lymph nodes are seen. Also just above it, more lateral aortic nodes are located. Now, by cutting the left renal artery, more lymphatic connections are revealed. Likewise, on the right side, we cut the rather thin right renal artery, as well as the supernumerary renal artery above it and that to the adrenal gland in preparation for the removal of the aorta. Now, with the intercostal vessels removed, we will observe the terminal portion of the thoraxic duct. First, we will trace the thoraxic duct from the origin upwards. Then we reach the cervical region where the duct goes between the left subclavian and common carotid arteries. The duct is in close proximity to the vagus nerve and the left vertebral vein. It winds around the internal juggler vein to drain into the left venous angle, which is formed by the union of the internal juggler and subclavian veins. Now, at the upper thoraxic level, we longitudinally cut the thoraxic duct and open it to reveal a typical valve. Now we will remove the aorta at the level slightly below the aortic arch. We cut the aorta and then reflect it as far as the aortic hiatus of the diaphragm. From the esophageal hiatus to the aortic hiatus, we cut part of the diaphragm to observe the posterior surface of the abdominal esophagus. Now we will cut the ciliac trunk as well as the superior mesentery artery. We can shift the aorta as far as the inferior mesentery artery. Finally, we cut the aorta just above the inferior mesentery artery in order to view the intact abdominal emphatics from behind. Now we will observe ciliac plexus formation from behind. Near the ciliac trunk and just above the left renal vein, the well-developed ciliac plexus can be seen. The right ciliac anglion and right greater splanchnic nerve also reach this plexus. Here we see the posterior surface of the lower esophagus. The posterior vagus trunk bifurcates and enters the corresponding ciliac ganglia. By shifting the left renal vein slightly below the superior mesentery artery, we see pre-aortic lymph nodes. We now cut the left renal vein to the pre-aortic lymphatics. Numerous rather thick lymphatics are connected. These pre-aortic nodes serve as intermediary nodes between the lymphatics from the internal organs and the nodes along the aorta. Lymph nodes surrounding the abdominal aorta, the thoraxic duct, and the ciliac plexus were dissected from behind.