Background: Injury to the thoracic duct (TD) and resulting chyle fistula conveys a high degree of morbidity and is a frequent complication after thyroid surgery. Performance of lymphangiography using indocyanine green (ICG) was recently established as an acceptable modality to identify the TD during neck dissection. This report describes the first clinical experience using intraoperative ICG lymphangiography to facilitate identification of a cervical TD injury in a re-operative field following neck surgery.

Methods: One patient who underwent total thyroidectomy and central lymph node dissection for medullary carcinoma developed a chyle fistula within the first week postoperatively. A decision was made for re-exploration in attempt to identify and ligate/repair the injured TD. 5-mg of ICG was injected in the dorsum of the left foot 60 minutes before imaging. Intraoperative imaging was performed with a hand-held near infrared (NIR) camera (Hamamatsu, PDE-Neo, Hamamatsu City, Japan). Results During initial operative exploration, NIR fluorescence confirmed presence of a chyle fistula. After neck washout, NIR fluorescence identified the primary injured TD branch, as well as smaller leaking branches. Surgical clips were placed and the area reimaged with NIR fluorescence, demonstrating persistent leak. Thus, selected clips were removed and the TD branch was suture repaired. NIR fluorescence confirmed chylostasis. Postoperatively, the patient recovered without complication.

Conclusion: This is the first described application of ICG lymphangiography to intraoperatively identify a TD injury after neck surgery facilitating efficient repair and allowing confirmation of chylostasis. This technique may be an important adjunct for the surgeon encountering this challenging problem.