The lymphatic territories of the upper limb: Anatomical study and clinical implications

BACKGROUND: Current understanding of the pattern of lymph channels is largely dependent on the anatomical studies of Sappey performed in the nineteenth century, when mercury was injected into human cadavers and the lymphatics were dissected. These studies have not been repeated because the use of mercury is now prohibited as a result of its toxicity. The aim of this study was to reappraise the gross lymphatic anatomy and lymph node connections using a radiologic technique. A period of 3 years was required for development of a new method. METHODS: The definitive technique used hydrogen peroxide to identify lymphatic vessels and to inflate them. The individual channels were injected with a radiopaque lead oxide mixture and recorded on x-ray film. Each channel was dissected meticulously under the surgical microscope and its course examined in relation to the regional lymph nodes. This method was then applied to 14 human cadaver upper limbs obtained from 10 different cadavers. RESULTS: The authors found that the superficial lymphatic vessels course within the subcutaneous fat in close proximity to the main subcutaneous veins. Communication between the superficial and the deep lymphatic systems was not identified in these studies. CONCLUSIONS: Most lymph vessels were seen to flow into one main (sentry) lymph node in the axillary region; however, some of the lymph vessels ran along the posterior forearm, bypassing the "sentry" node to reach other smaller nodes.