ICG for Intraoperative Thoracic Duct Lymphangiogram in VATS Thoracic Duct Ligation
Thoracic duct ligation is a proven, established procedure for chylothorax management refractory to medical management. However, intraoperative localization of the thoracic duct course or leakage is difficult, and there is a lack of consensus on the best intraoperative modality to visualize a thoracic duct. This video proposes that ICG can be used as the modality of choice for intraoperative localization of the thoracic duct.
A forty-two-year-old man presented after sustaining bilateral pneumothoraces and multiple fractures. He was taken to the OR for VATS hemothorax evacuation and chest wall stabilization. His recovery was uneventful, and he was discharged on postoperative day six with no issues.
The patient presented five days later with a large right pleural effusion. Thoracentesis drained four liters of chylous fluid consistent with chylothorax. The patient was started on medical management with NPO and Octreotide and subsequently underwent three talc pleurodeses to close the leak, but they were all unsuccessful and surgical management was indicated.
ICG is a water-soluble molecule with fluorescence in the near-infrared light spectrum. It is inexpensive to manufacture and nontoxic, even in large amounts. The near-infrared signal can be overlaid with the white light camera image to produce an image of real time fluorescence in the surgical field. In this procedure, ICG was administered immediately after intubation and about one hour was allowed for peak fluorescence to develop while the patient was prepped and draped.
As the camera was advanced into the chest, the team observed an abundance of adhesions and plaques from the previous talc pleurodeses procedures. The adhesions were lysed, and the right lung was displaced to reveal a collection of serous fluid underneath it. That fluid was suctioned up and blunt dissection attempted to locate the leakage. SPY imaging was then turned on, and the fluorescent imaging was overlaid on top of the normal camera image.
On the posterior of the right lung was a collection of fluorescent lymphatic fluid. This was the first time lymphatic fluid being ejected from the thoracic duct lesion into the chest was directly visualized. The SPY gain was then reduced to determine exactly where the fluid was coming from. With the SPY gain turned off, it was nearly impossible to distinguish the fluorescent lymphatic fluid, which became clear, from the serosanguinous fluid in the field.
Next, the team began suturing the visceral pleura of the lung to the parietal pleura of the chest wall in an attempt to close the tissue on top of itself and prevent additional leakage. While it may have been standard procedure to perform an en masse ligation of the thoracic duct, it was not possible in this case because of fibrosis and inflammation secondary to the previous talc pleurodeses.
As the final portion of the suture was tied down and cut, there was no additional leakage out of the thoracic duct opening. A layer of bioglue sealant was applied and talc pleurodesis was performed so fibrosis and inflammation would prevent additional leakage in the future.
Compared to the large amounts of preoperative chylous drainage on medical management, there was minimal postoperative drainage on a low-fat diet. In conclusion, ICG can be considered a practical, safe, and reproducible method of intraoperative lymph angiography.
1. Arshava EV, Parekh KR. Thoracoscopic Thoracic Duct Ligation: How I Teach It. The Annals of Thoracic Surgery. 2020;109(5):1330-1334. doi:10.1016/j.athoracsur.2020.01.004
2. Meester R, QUEST MEDICAL IMAGING. Fluorescence Imaging Enters the Surgical Suite. Accessed January 15, 2023. https://www.photonics.com/Articles/Fluorescence_Imaging_Enters_the_Surgical_Suite/a61927
3. Chakedis J, Shirley LA, Terando AM, Skoracki R, Phay JE. Identification of the Thoracic Duct using Indocyanine Green During Cervical Lymphadenectomy. Ann Surg Oncol. 2018;25(12):3711-3717. doi:10.1245/s10434-018-6690-4
4. Kamiya K, Unno N, Konno H. Intraoperative indocyanine green fluorescence lymphography, a novel imaging technique to detect a chyle fistula after an esophagectomy: Report of a case. Surg Today. 2009;39(5):421-424. doi:10.1007/s00595-008-3852-1
5. Matsuura Y, Ichinose J, Nakao M, Okumura S, Mun M. Recent fluorescence imaging technology applications of indocyanine green in general thoracic surgery. Surg Today. 2020;50(11):1332-1342. doi:10.1007/s00595-019-01906-6
6. Morales-Conde S, Licardie E, Alarcón I, Balla A. Indocyanine green (ICG) fluorescence guide for the use and indications in general surgery: recommendations based on the descriptive review of the literature and the analysis of experience. Cirugía Española (English Edition). 2022;100(9):534-554. doi:10.1016/j.cireng.2022.06.023
7. Newton AD, Predina JD, Nie S, Low P, Singhal S. Intraoperative Fluorescence Imaging in Thoracic Surgery. J Surg Oncol. 2018;118(2):344-355. doi:10.1002/jso.25149
8. Okusanya OT, Hess NR, Luketich JD, Sarkaria IS. Infrared intraoperative fluorescence imaging using indocyanine green in thoracic surgery. European Journal of Cardio-Thoracic Surgery. 2018;53(3):512-518. doi:10.1093/ejcts/ezx352
9. Vecchiato M, Martino A, Sponza M, et al. Thoracic duct identification with indocyanine green fluorescence during minimally invasive esophagectomy with patient in prone position. Diseases of the Esophagus. 2020;33(12):doaa030. doi:10.1093/dote/doaa030