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Video-Assisted Thoracoscopic Thoracic Duct Ligation with Indocyanine Green Fluorescence Imaging

Tuesday, November 28, 2023

Cavadas C, Dambrosio P, Terra R, Lauricella L. Video-Assisted Thoracoscopic Thoracic Duct Ligation with Indocyanine Green Fluorescence Imaging. November 2023. doi:10.25373/ctsnet.24650040

This video is the second-place winner from CTSNet’s 2023 Innovation Video Competition. Watch all entries into the competition, including the other winning videos.

The near-infrared fluorescence imaging system is an innovative technology that can help surgeons to easily and safely perform video-assisted thoracoscopic thoracic duct ligation for the treatment of chylothorax. This video presents two cases using this method.

The first case presents a fifty-five-year-old male patient who underwent a total thyroidectomy due to a papillary thyroid carcinoma with radical neck dissection. He developed a cervical lymphatic fistula, which had no response to clinical treatment after fourteen days, with indication of thoracic duct ligation. 

The surgery began with an USG scan of the inguinal area and bilateral injection of indocyanine green in the lymph nodes cortical spaces. The femoral artery was avoided. Intubation was completed and a nasogastric tube was placed, which was then used to infuse 200 ml of olive oil to help ingurgitate the thoracic duct. 

Next, a right VATS procedure began with an anterior traction of the lung, exposing the posterior pleural space between the spine and the esophagus. The near-infrared fluorescence imaging system was then turned on, which helped to easily identify the thoracic duct. Surgeons began pleural dissection anterior and posterior to the duct. They could see the thoracic duct almost completely dissected. After complete dissection, the esophagus was visible anteriorly. Next, ligation of the structure with metal clips began. After ligation, no transection was needed. This was the final aspect, and an ingurgitated thoracic duct was established.

The second case presents a sixty-five-year-old male patient who underwent a bilobectomy to treat a squamous cell carcinoma of the lung with systematic lymphadenectomy. He had a prolonged hospital stay due to an air leak, with diagnosis of chylothorax fourteen days after surgery. He had no response to clinical treatment after seven days and surgery was indicated. 

The same approach was used, administering an indocyanine green injection and olive oil through a nasogastric tube. In this case, a pleural cavity full of fibrins and adherences was found due to the previous surgery. A lymphatic leak was also detected. The cavity was aspirated, and the team searched for the site of the leak. 

The site of leak was then easily detected as the paratracheal lymph node dissection area. The near-infrared fluorescence imaging system was kept on to guide the dissection of the thoracic duct. It could be identified even between multiple adherences. The thoracic duct dissection was then carefully proceeded. Isolation of the thoracic duct was reached with a vessel loop. Surgeons confirmed its intimal relation with the esophagus and azygos vein and proceeded with ligation with metal clips. After conclusion of the procedure, no lymphatic leak was detected. 

Both patients were discharged from the hospital four days after surgery with no complications.


  1. Bibas BJ, Costa-de-Carvalho RL, Pola-dos-Reis F, Lauricella LL, Pêgo-Fernandes PM, Terra RM. Video-assisted thoracoscopic thoracic duct ligation with near-infrared fluorescence imaging with indocyanine green. J Bras Pneumol. 2019;45(4):e20180401.
  2. Londero F, Grossi W, Vecchiato M, Martino A, Ziccarelli A, Petri R and Morelli A. Fluorescence-Guided Identification of the Thoracic Duct by VATS for Treatment of Postoperative Chylothorax: A Short Case Series. Front. Surg. 9:912351.
  3. Hashimoto, T., Osaki, T., Oka, S. et al. Effective application of indocyanine green for visualization of the thoracic duct during video-assisted thoracoscopic surgery for chylothorax: a case report. Gen Thorac Cardiovasc Surg Cases 2, 68 (2023).


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Hello, Eitan! Thanks for your question. The Indocyanine Green for injection powder should be dissolved with the Sterile Water for injection provided for this product. We use a total of 1-2ml of this solution distributed by 2-3 lymph nodes each side, just before the anaesthesia induction, under sterile conditions. Hope it was helpful!

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