Single port thoracoscopic treatment of thoracic duct injury after thyroidectomy with neck dissection

Chylous leakage is a complication of thyroidectomy accompanied by bilateral neck dissection with incidence of 0.5-6.2%. A 51-year-old female patient underwent total thyroidectomy, bilateral and central neck dissection for papillary thyroid carcinoma. In post-operative 4^th day, left sided chylous leakage was observed as 1,500 cc/day through neck drain. Leakage did not cease after 1-month conservative treatment so single port thoracoscopic intervention was performed. Under general anesthesia, patient was placed in left lateral decubitus position. An Alexis^® retractor was placed through sixth intercostal space. Thoracic cavity was visualized with 30º scope. Posteroinferior edge of lower lobe was retracted superior posteriorly with a Foerster clamp to display inferior pulmonary ligament, which was then divided with electrocautery. Posterior mediastinal pleura between azygous vein and chest wall was incised to mobilize the vein. After that, mediastinal pleura between azygous vein and esophagus was cut longitudinally and esophagus was retracted anteriorly to dissect towards aorta. By dissection, thoracic duct was revealed as a thin tubular structure with occasional peristalsis. After isolation of the duct, it was clipped using Hem-o-lok^®. Finally, fibrin sealant was applied to decrease risk of recurrence. One chest tube was placed to ensure adequate drainage of thoracic cavity and complete re-expansion of lung. Neck drain and chest tube was extracted in postoperative second and fourth day respectively and patient was discharged at 8^th day. Single port thoracoscopy is a safe choice for treatment of chylous leakages due to cervical ductus thoracicus injury with faster recovery.