Robotic-assisted thoracic duct ligation surgery guided by intralymphatic injection of indocyanine green

Post-operative chyle leak is an uncommon but significant complication that can delay recovery and increase morbidity. Thoracic duct ligation is a recognized treatment option but may be technically challenging due to poor intraoperative visualization and numerous anatomical variations. This case report describes the use of indocyanine green (ICG) administered via intralymphatic injections, facilitating intraoperative guidance for precise thoracic duct localization and ligation in a complex patient who developed a chyle leak following a bilateral neck dissection. The Da Vinci Surgical System fluorescence imaging enabled real-time visualization of the thoracic duct, allowing for accurate clip ligation. ICG revealed significant anatomical variation of the thoracic duct, underscoring its value. Fluorescence guided lymphatic mapping reduced uncertainty and minimized the need for histological confirmation of lymphatic structures. Intraoperative ICG fluorescence represents a valuable adjunct for thoracic duct identification, particularly in anatomically complex cases, and may improve the success rate of surgical management of chylothorax.