5.

ANATOMY OF THE HUMAN

LYMPHATIC SYSTEM

MAURO ANDRADE AND ALFREDO JACOMO

Department of Surgery, University of Sao Paulo, Brazil

INTRODUCTION
The lymphatic system transports lymph from interstitial space in different organs
toward the base of the neck. Its pathway begins after resorption from initial lym-
phatics and lymph transport to progressively larger vessels (lymphatic collectors and
trunks), finally reaching the confluence of the internal jugular and subclavian veins
as lymphatic and thoracic ducts, respectively, at the right and left venous angles.
Even though important physiopathological and therapeutical issues may exist due to
the close anatomical, embryological, and functional relationship of blood and lymphatic
vessels, there are some marked differences between the two systems (1).
In that sense, unlike blood vessels, the lymphatic system cannot be considered as
a real circulatory system. While blood circulates in a closed circle pumped by the
heart, both in systemic and pulmonary circulation, lymph flow is unidirectional from
peripheral tissues to blood and is considered to be an open semicircular system.
The lymphatic system is ubiquitous and exists in all tissues where blood vessels are
also found, placenta being an exception. Cornea does not contain lymphatics (10).
For a long time, the existence of lymphatics in the central nervous system has been
a subject of discussion among anatomists. However, liquor is now considered as the
neuroaxis lymph and it has a clear relationship with cervical lymphatic pathways.
Study of lymphatics has always been troublesome for the anatomists due to the
small caliber of the lymphatic vessels and their transparent content. After the initial
observation of the chylous vessels by Aselli in 1627, methods were developed to
observe the lymph vessels. In the seventeenth century, mercurial injections were
56 Cancer Metastasis and the Lymphovascular System

employed and Gerota’s solution, idealized at the end of the nineteenth century, is
still in use today with some modifications (3, 6–9).

GENERAL ORGANIZATION OF THE LYMPHATIC SYSTEM

The fluid originated from capillary filtration flows preferentially through the tissue
channels, the “microcirculatory highway” of the interstitium. After absorption of
the interstitial fluid by the initial lymphatics, lymph is transported through
progressively larger and structurally more complex vessels until its final destination
into the blood system.All along the way, compact chains of capsulated lymphocytes,
the lymph nodes, filter the lymph and are responsible for another essential role of
the system: the immune response (14).
According to Kubik, lymphatic vessels can be classified in a crescent order of size
and complexity in lymph capillaries, precollectors, collectors, and trunks. The first
two are denominated initial lymphatics (12).
The structure of lymph capillaries, whose prime function is absorption of fluid and
macromolecules, differs from blood capillaries in some essential features: their format
resembles glove fingers, they have incomplete basal membrane, and are larger than the
correspondent blood capillary vessels (1).Their endothelial cells have a small number
of open junctions, not found in blood vessels (except for sinusoidal capillaries and
injured vessels). In some areas, adjacent endothelial cells partially overlap, creating a
point of entry for interstitial fluid and at the same time acting as an antireflux mech-
anism. Anchoring filaments are a unique anatomical feature presented by lymph
capillaries; these structures are extensions of the endothelial cells and originate on the
outer surface of the intercellular contact area between two adjacent cells. Their
adhesions to interstitial elastic and collagen fibers open the intercellular space when
interstitial volume increases and are a major feature of lymph absorption.
Collector vessels and trunks present structure similar to veins, even though their
three layers – intimae, media, and adventitia – are thinner and have a less evident
separation than those observed in the venous system. They have semilunar valves,
more numerous and histologically similar to the vein valves, formed by folds of
endothelium, smooth muscle, and connective tissue.There is also a valve at the lym-
phatic confluence at the jugulosubclavian junction, thus avoiding blood reflux to
the major lymphatic ducts (10).
The lymphatic system, according to its topography, can be divided into three systems:
superficial, deep, and visceral.The superficial system drains skin and subcutaneous tissue
whereas the deep lymphatic system is responsible for the subfascial tissue drainage.The
visceral system can also be considered a part of the deep system. Perforating vessels cross
the fascia and connect the superficial and deep systems. Some authors consider another
group of vessels: the communicating vessels, which communicate areas drained by dif-
ferent bundles. Lymphatic collectors of the limbs, both superficial and deep, accompany
neighboring vessels (2), the drained volume through the superficial system being far
more important to the lymphatic drainage of the extremities.
Lymph nodes consist in an agglomerate of lymphoid tissue surrounded by a capsule
of dense connective tissue and some smooth muscle fibers and their inner framework is
 5. Anatomy of the Human Lymphatic System 57

formed by trabeculae, extensions of the inner aspect of the capsule that limit lymph
follicles.After reaching the lymph node, lymph flows through its subcapsular space and is
filtered in the network formed by the trabecular and medullar sinuses. Lymph nodes are
arranged as chains found in reasonably constant areas of the body and contain a variable
number of nodes; the total number of lymph nodes in humans is estimated to be around
600–700 (13).The shape of the lymph nodes is usually spherical or round, and can vary
considerably in size, and may reach a normal diameter of up to 1 in. Structurally, they
have a small depression called the hilus and an opposite convex surface. Efferent lymph
vessels and nodal arteries and veins are found in the hilus whereas afferent lymph ves-
sels reach the lymph node in many points along its convex surface.Afferent lymph vessels
are generally smaller and more numerous than the efferent vessels (14).
The same as in lymph vessels, lymph node groups, or chains can be classified according
to their location as superficial, when they are embedded into the subcutaneous tissue,
or deep, situated under the muscular fascia or inside abdominal or thoracic cavities (2).

FORMATION OF THE MAIN LYMPHATIC TRUNKS AND DUCTS

There are 11 lymphatic trunks: gastrointestinal, lumbar, bronchomediastinal, sub-
clavian, jugular, and descending intercostals (10). All, except for the gastrointestinal
trunk, are paired.
Lumbar trunks are formed by the union of lymphatic vessels, which drain the
following regions: lower limbs, urogenital system, anatomical structures irrigated by
the inferior mesenteric artery, and the infraumbilical portion of the abdominal wall.
Efferent lymph vessels from celiac and superior mesenteric lymph nodes origi-
nate the gastrointestinal trunk.
The right and left bronchomediastinal trunks are responsible for the transport of
lymph coming from the deep layer of the superior and anterior areas of the
abdomen and thorax, the anterior portion of the diaphragm, lungs, heart, and vis-
ceral aspect of the right lobe of the liver.
The subclavian trunks are formed by lymphatic collectors draining the upper
limbs, supraumbilical area of the abdominal wall, and anterior thoracic wall.
Lymph from the head, face, inner structures of the neck, and posterior cervical
region drain toward the jugular trunks.
The descending intercostal trunks collect the lymph originated at the deep pos-
terior thoracic region, corresponding to the last five intercostal spaces.
There are two lymphatic ducts: the right lymphatic duct and the thoracic duct.
The first is formed by the confluence of the right jugular trunk, right subclavian
trunk, and right bronchomediastinal trunk; generally, this duct empties into the
right jugulosubclavian confluence.
The thoracic duct is originated from the descending intercostal trunks, the right
and left lumbar trunks, and the gastrointestinal trunk. Cisterna chyli is an ampular
dilatation frequently observed where those trunks meet and is located between the
azygous vein and aorta at the level of L2 to D12. Just after its origin, the thoracic
duct runs cranially through the aortic hiatus of the diaphragm, to the right of the
median sagittal plane, and around D5 level it turns to the left side, crossing the
58 Cancer Metastasis and the Lymphovascular System

posterior aspect of the thoracic esophagus. At the base of the neck, it reaches the
left jugulosubclavian junction and near its terminal portion receives the left jugular, left
subclavian, and left bronchomediastinal trunks.
Therefore, according to the lymphatic drainage, the body can be divided into four
quadrants and all but the upper right quadrant are drained by the thoracic duct.

ANATOMY OF THE LYMPHATICS OF THE UPPER LIMBS

The lymphatic drainage of the superior limbs has two components: a superficial
drainage and a less important one, the deep lymphatic system. Both systems anastomose
and most of the upper limb lymph has a common final destination: the axillary lymph
nodes. The superficial lymphatic system has ten bundles (Figs. 1 and 2), each one of
them with one to many lymphatic collectors.Anastomoses between bundles are frequent.

Figure 1. Anterior view of the upper limb. Schematic distribution of the superficial bundles of the forearm
and arm. Observe the epitroclear lymph node
 5. Anatomy of the Human Lymphatic System 59

Figure 2. Posterior view of the superficial lymphatic bundles of the upper limb

Didactically, the bundles can be divided into six proximal bundles in the arm and
four distal in the forearm and hand. The proximal bundles are further subdivided
into three anterior and three posterior bundles (4).
Anterior bundles are, according to their drainage area, cephalic, basilic (Fig. 3),
and prebicipital; and the posterior ones are posteromedial, posterior, and postero-
lateral.
The four bundles that drain the distal regions are divided into two anterior (ante-
rior radial and anterior ulnar) and two posterior (posterior radial and posterior
ulnar).
The deep lymphatic drainage of the upper arms has six bundles: two proximal in
the arm and four distal.The proximal bundles are denominated brachial (Fig. 4) and
deep brachial due to their anatomical relation witsh the homonymous arteries.
60 Cancer Metastasis and the Lymphovascular System

Figure 3. Basilic bundle observed after intradermal injection of Gerota’s mass in the anterior aspect of the
forearm. Impregnation of lymph nodes of the anterior and lateral lymph node groups of the axilla

The four distal comprise three anterior bundles: deep radial, deep ulnar, and ante-
rior interosseal (Fig. 5), and one posterior: posterior interosseal (6–9) (Fig. 6).
Derivative pathways are lymph collectors that do not reach the expected
drainage site at the root of the limbs. For the upper limbs, two different derivative
pathways can be identified.They are the cephalic and the posterior bundles that run
to the supraclavicular nodes and posterior scapular nodes, respectively.These deriv-
ative pathways are one of the possible explanations of why lymphedema does not
always develop after axillary resection and radiation for breast cancer treatment (4).
Lymph nodes of the upper limbs can also be classified as superficial and deep (4).
Superficial lymph nodes are found in the arm (Fig. 1) accompanying the basilic vein,
called epitroclear lymph nodes, and in the deltoideopectoral sulcus, called del-
toideopectoral lymph nodes. Deep lymph nodes (Figs. 4–6) are located in the arm and
in the forearm.Arm lymph nodes are found close to the vessels and are so denominated
brachial and deep brachial lymph nodes. In the forearm, there are anterior lymph nodes
(radial, ulnar, and anterior interosseal) and a posterior one (posterior interosseal) (6–9).
Lymph nodes in the axilla (Figs. 7–9) are organized as lymph centers or chains and
receive lymph from the following regions: upper limb, supraumbilical area up to the
clavicle, and dorsal region (10).These chains are classified according to their location in:
1. Anterior group (also pectoral or external mammary or lateral thoracic). Located at the infe-
rior border of the pectoralis major muscle and related with the lateral thoracic
artery.This chain receives lymph from most of the breast and supraumbilical region.
 5. Anatomy of the Human Lymphatic System 61

Figure 4. Schematic anterior view of the deep bundles and lymph nodes of the arm and their relationship
with the arteries

2. Posterior group (also subscapular). Situated anterior to the subscapular muscle, all
along the subscapular vessels and receives lymph from the dorsum.
3. Lateral group (or axillary).This chain accompanies the axillary vessels, situated ante-
rior, posterior, superior, and inferior to them and drains lymph from the upper
limb, except the lymph that flows through derivative pathways.
62 Cancer Metastasis and the Lymphovascular System

Figure 5. Anterior view of the deep bundles and lymph nodes of the forearm
 5. Anatomy of the Human Lymphatic System 63

Figure 6. Anterior view of the deep bundles and lymph nodes of the arm, medial and posterior to the
biceps muscle
64 Cancer Metastasis and the Lymphovascular System

Figure 7. Lymph nodes of the axilla.The anterior group is related to the lateral thoracic artery and is fol-
lowed by the lateral and posterior chains.The intermediate group receives afferent vessels from the previous
groups. Medial or apical chain is located medial to the minor pectoralis muscle

Figure 8. Basilic bundle and lateral lymph nodes of the axilla after injection in the hand
 5. Anatomy of the Human Lymphatic System 65

Figure 9. Lymphatic drainage of the breast to the lymph nodes of the axilla and internal mammary chain

4. Intermediate group (or central).This is also located following the axillary vessels but
is immediately medial to the previous group, receiving lymph from efferent ves-
sels of the lateral chain.
5. Medial group (or apical).This last group is situated medial to the pectoralis minor
muscle, receives efferent vessels from the intermediate group and from this group,
efferent vessels form the subclavian trunk that flows to the lymphatic duct on the
right side and thoracic duct on the left.

ANATOMY OF THE LYMPHATICS OF THE LOWER LIMBS

The lymphatic drainage of the lower limbs also consists of two different systems:
the deep and the superficial system (2).
The superficial system has six different bundles (11) (Figs. 10–12), two distal in the
foot and in the leg, named according to the main vein they follow: great saphenous
bundle (or ventromedial) and lesser saphenous (or posterolateral) bundle. The other
four proximal bundles are located in the thigh and are subsequently divided in two
anterior and two posterior bundles.The anterior bundles are the anteromedial of the
thigh (or ventromedial or great saphenous bundle) and anterolateral of the thigh.The
posterior bundles of the thigh are denominated posteromedial and posterolateral.
The great saphenous bundle of the leg extends upward and continues as the
anteromedial bundle of the thigh.These lymphatic vessels converge posterior to the
medial condilum of the femur to reach the thigh. The great saphenous bundle of
66 Cancer Metastasis and the Lymphovascular System

Figure 10. Anterior view of the lower limb. Schematic distribution of the superficial bundles of the leg and
thigh. Observe that the accessory saphenous bundle is restricted to the thigh

the leg receives anastomotic vessels from the lesser saphenous bundle.The antero-
lateral bundle of the thigh, also called the accessory saphenous bundle, originates in
the thigh so there is no direct connection between this bundle and the lymphatics
of the leg (5) (Fig. 10). It is also important to notice the close relationship between
the great saphenous vein and the accompanying lymphatic bundle, especially in the
 5. Anatomy of the Human Lymphatic System 67

Figure 11. Posterior view of the lower limb. Observe the superficial popliteal lymph node

knee area, which makes the latter susceptible to trauma in operations for saphenous
harvest to aortocoronary bypass and some surgical procedures for varicose veins (2).
The deep lymphatic drainage of the lower limb has five lymphatic bundles, being
three distal (leg and foot) and two proximal in the thigh.
The deep lymphatic bundles of the foot and leg are divided in one anterior
(Fig. 13) and two posterior (Fig. 14). The anterior bundle is named anteromedial
68 Cancer Metastasis and the Lymphovascular System

Figure 12. Superficial inguinal lymph nodes and their relationship with the branches of the great saphenous
vein after injection in the foot

bundle or anterior tibial and the posterior ones are called posteromedial or poste-
rior tibial, and the last one posterolateral or fibular bundle.
In the thigh, the deep lymphatic bundles accompany the femoral artery and the
deep femoral artery (Fig. 15) and drain into the deep inguinal lymph nodes (6–9).
Lower limbs also have deep and superficial lymph nodes (3). Superficial lymph
nodes are found in the subcutaneous of the inguinal (Figs. 13 and 15) and popliteal
regions (Fig. 14). Inguinal lymph nodes are related to the superficial regional veins:
great saphenous, accessory lateral saphenous, superficial circumflex iliac, superficial
epigastric, and external pudenda.
The superficial inguinal lymph nodes are named according to their anatomical
relationship with the neighboring vein (Fig. 16). There are six superficial nodal
chains: three of them are located inferiorly and contain one single node (great
saphenous, lateral accessory saphenous, and intersaphenous) and the remaining
three are cranial to the saphenofemoral junction, and usually multinodal (superfi-
cial circumflex iliac, superficial epigastric, and external pudenda).
Usually, the lymphatic drainage of the lower limbs reaches the inferior inguinal
lymph nodes (great saphenous, lateral accessory saphenous, and intersaphenous),
while superior ones receive lymph from infraumbilical abdominal area, gluteus,
external genitalia, and part of the uterus.The major labia of pudendum have both
homolateral and contralateral drainage (6–9) (Figs. 16 and 17).
 5. Anatomy of the Human Lymphatic System 69

Figure 13. View of the anterior deep bundle and lymph node of the leg

Superficial inguinal lymph nodes, mainly the inferior nodes, can be severed dur-
ing great saphenous vein stripping and dissections of the inguinal area, due to their
relationship with saphenofemoral junction, which may lead to lymphatic blockage
and edema of the lower limb.
70 Cancer Metastasis and the Lymphovascular System

Figure 14. View of the posterior deep bundles of the leg accompanying the posterior tibial and fibular arteries

In the popliteal region, the superficial popliteal node is commonly unique and
receives lymph from the posterolateral bundle of the leg (Fig. 18).
Concerning deep lymph nodes, they are located in the leg, popliteal, and inguinal
regions.
 5. Anatomy of the Human Lymphatic System 71

Figure 15. Superficial inguinal lymph nodes and superficial bundles of the lower limb and their relation-
ship with the great saphenous vein

Deep leg lymph nodes are usually situated near to the origin of the arteries, thus
anterior tibial, posterior tibial, and fibular, and they receive lymph from the leg and
foot (11). Deep popliteal chain (Fig. 19) usually contains ten lymph nodes and has
the following distribution, according to their position regarding the popliteal ves-
sels: one is anterior to the popliteal artery (anterior popliteal or prearterial); the
nine lymph nodes remaining are related to the popliteal vein. Of those, three are
72 Cancer Metastasis and the Lymphovascular System

Figure 16. Superficial inguinal lymph nodes after injection in both feet and left major labium with masses
of different colors. Lymphatic drainage of the genital area injected goes to both inguinal areas

Figure 17. Schematic distribution of the lymphatic drainage of the major labia of the pudendum

situated lateral to the vein and three are medial. They have the denomination of
superior, median, and inferior in each side, considering their location related to the
joint.The three deep posterior lymph nodes (retropopliteal) receive their denomi-
nation according to their position cranial or caudal to the lesser saphenous popliteal
 5. Anatomy of the Human Lymphatic System 73

Figure 18. Superficial popliteal lymph node and posterolateral bundle of the leg after injection in the
lateral aspect of the foot

junction as two suprasaphenous and one infrasaphenous (2, 3, 11).This entire group
drains lymph from subfascial portions of the leg and foot and can also receive
lymph from the superficial area through perforator vessels.
Deep inguinal lymph nodes are located medial to the femoral vein and deep to
saphenous femoral junction. There are fewer nodes as compared to the superficial
chain and one of them, always present, lays near to the lacunar ligament and is called
74 Cancer Metastasis and the Lymphovascular System

Figure 19. Deep popliteal lymph nodes and their relationship with the popliteal vessels

Cloquet’s lymph node (2, 3). This chain receives lymph from efferent vessels that
accompany the femoral artery and also from the superficial area.
After the inguinal lymph nodes, lymph of the lower limbs reaches external iliac
and common iliac lymph nodes. Subsequently, it passes through lumbar aortic
lymph nodes that form the lumbar trunks and finally drain into the thoracic duct.
 5. Anatomy of the Human Lymphatic System 75

ANATOMY OF THE LYMPHATICS OF THE PELVIS

Pelvic lymph nodes receive their denomination according to their topographic
relationship to the iliac vessels as external, internal, and common iliac lymph nodal
chains (10).
The external iliac chain, which follows inguinal lymph nodes, is subdivided into lat-
eral, intermediate, and medial.The lateral lymph nodes are located at the lateral aspect
of the external iliac artery and are superficial to the psoas muscle. The intermediate
chain is found between the artery and the vein, and its more cranial lymph node is
found near the common iliac artery bifurcation and is closely related to the ureter.
Medial external iliac lymph nodes are found medial to the external iliac vein and
near the obturator nerve. Its more caudal node has a close relationship with
Cloquet’s node (2, 3).
The internal iliac chain lies near to the internal iliac artery and its branches and
has parietal and visceral lymph nodes.
The parietal nodes are superior and inferior gluteal, lateral sacral, and obturators.
The visceral are lateral, anterior and posterior vesical, rectal, and uterine.As visceral
internal iliac lymph nodes are closely related to the pelvic organs, they are usually
the first to be reached by lymphatic metastasis.
The common iliac lymph chain is located along the homonymous artery, and
medial, lateral, and intermediate lymph nodes can also be identified. The medial
one is the most cranial of them and sometimes is included in the subaortic lymph
nodes group.
Thorough comprehension of lymphatic vessels and nodes of the pelvis, particularly
those of the uterus, is very important due to the incidence of uterine carcinoma.
Thus, the fundus and upper part of the uterine body drain through lymphatic
vessels of the round ligament to the superficial inguinal lymph nodes. Laterally, on
the superior region of the broad ligament, its lymphatic drainage follows that of the
uterine tube and ovary, accompanying the ovarian vessels to the lumbar aortic
chain. On the other hand, the lymphatic drainage of the inferior portion of the
uterine body and neck goes mainly to the pelvic lymph nodes, external, internal,
and even common. Because of this massive spread of the cervical lymph drainage,
complete removal of pelvic lymph nodes is sometimes required for the treatment
of cervical carcinoma.

ANATOMY OF THE LYMPHATICS OF THE ABDOMEN

Lymph node chains of the abdominal cavity are retroperitoneal and are divided
into aortoceliac and aortolumbar, respectively, superior and inferior to the left
renal vessels.The first will form the gastrointestinal trunk and the latter the lumbar
trunks (10).
The celiac aortic lymph nodes have three different chains:
1. Left aortoceliac, located between the lateral aspect of the aorta and the left
diaphragmatic pillar
76 Cancer Metastasis and the Lymphovascular System

2. Right aortoceliac, between the right side of the aorta and the right diaphrag-
matic pillar
3. Anterior aortoceliac, near the superior mesenteric artery origin
These three chains receive lymph from the spleen, pancreas, abdominal esopha-
gus, liver, gallbladder, stomach, small intestine, cecum, ascending colon, and proxi-
mal two-thirds of the transverse colon.Also, some vessels from the left colic flexure
and distal third of the transverse colon drain to this chain.
Aortolumbar lymph nodes are divided into three groups: preaortic, left aortic or left
lateral aortic, and right aortic. Some authors describe a posterior aortic chain, which
we believe does not exist because aortic pulse against the vertebra could damage them.
The preaortic chain is located anterior to the abdominal aorta and its lymph
nodes are around the inferior mesenteric artery origin up to the inferior aspect of
the left renal artery. This chain receives efferent lymph vessels from the left colic
flexure, distal third of the transverse colon, descending colon, sigmoid and most of
the rectum. Therefore, the distal part of the transverse colon and the left flexure
have double lymphatic drainage.
The left aortic chain is located between the lateral aspect of the aorta and the
psoas muscle.This chain collects lymph from the kidney, suprarenal gland, left com-
mon iliac chain, testicle or ovary, uterine tube, left superior portion of the uterus,
and deep layer of the abdominal wall.
The right aortic chain is divided into precaval, interaortocaval, laterocaval, and
retrocaval.The precaval group is represented by lymph nodes situated from the ori-
gin of the inferior cava vein until the inferior border of the right renal vessels.The
interaortocaval group is found between the inferior cava vein and abdominal aorta
until the inferior border of the left renal vessels.The laterocaval group is situated to
the right of the vein and the retrocaval group is found posterior to the cava, ante-
rior to the psoas muscle. These four lymph nodal groups receive the lymphatic
drainage from the kidney, suprarenal gland, testicle or ovary, uterine tube, superior
and lateral portion of the uterus, deep layer of the abdominal wall, and right com-
mon iliac chain.
The aortolumbar chains join at the median line and the main efferent lymph ves-
sels from either side form two lumbar trunks that join with the gastrointestinal
trunk to form the thoracic duct.

ANATOMY OF THE LYMPHATICS OF THE HEAD AND NECK

The lymphatic drainage from the head is made through four pathways (10):
1. Anterior or facial vessels. It receives the drainage from the frontal area and anterior
portion of the face, except for the chin and inferior lip (that drain to the sub-
mental lymph nodes) and subsequently drains to the submandibular lymph
nodes.
2. Parotideal. It receives the lymphatic drainage from the lateral aspect of the face,
including the eyelid, flowing to parotideal lymph nodes.
 5. Anatomy of the Human Lymphatic System 77

3. Retroauricular. It receives lymph from the parietal and temporal areas and drains
to the mastoid or retroauricular lymph nodes.
4. Occipital. It receives lymph from the occipital region and drains to the occipital
lymph nodes.
Superficial cervical lymph nodes are distributed along the external jugular vein,
superficial to the sternocleidomastoid muscle, and their efferent vessels reach the
deep cervical lymph nodes.
Deep cervical lymph nodes accompany the internal jugular vein, beneath the ster-
nocleidomastoid muscle; some of these lymph nodes run posteriorly together with
the accessory nerve and others run downward along with the subclavian vessels.
One lymph node located deep to the posterior body of the digastric muscle is
denominated jugulodigastric and another, located superiorly to the tendon of the
omohyoid muscle, is called juguloomohyoid.
Efferent lymph vessels from submental, submandibular, parotideal, retromandibu-
lar, and occipital reach the deep cervical lymph nodes (jugulodigastric), located cra-
nial to the internal jugular vein. The jugular trunk is formed by lymphatic vessels
coming from deep cervical lymph nodes and flows to the thoracic duct on the right
and to the thoracic duct on the left (10, 14).

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