Thoracic duct visualisation with subcutaneous administration of indocyanine green dye during minimally invasive oesophagectomy

Introduction: Chylothorax is a rare complication of oesophagectomy with an incidence of 2%–12%, resulting in high mortality. Accurate identification of the course of the thoracic duct (TD) intraoperatively may help prevent injury to this vital structure. Techniques to visualise the TD during oesophagectomy have evolved over the years. The various routes of indocyanine green (ICG) administration to visualise TD include superficial inguinal lymph nodal injection, injection into the toe web space and small bowel mesentery. Of these, the image-guided injection into the inguinal nodes is the most popular technique. In this study, we introduce a novel and simpler technique of pre-operative subcutaneous administration of ICG in the inguinal region (without image guidance). Patients and Methods: This is a single-arm clinical trial amongst patients undergoing thoracolaparoscopic and robotic oesophagectomy for oesophageal cancer. ICG was injected subcutaneously into the bilateral inguinal regions, 10–12 hours, before the surgery. Intraoperatively, visualisation of the TD under near-infrared spectroscopy, and any anatomical variation was noted. Results: Amongst the 38 patients included in the study, TD was visualised in 35 patients (92%). Five patients had anatomical variations, and 3 had intraoperative injury, which was identified and dealt with by clipping. Conclusion: Visualisation of the TD during oesophagectomy using subcutaneous administration of ICG is a simplified, non-demanding technique with comparable results to those of image-guided groin node injection. This simple technique of ICG administration, which has been standardised in this study, can be safely incorporated into routine practice for oesophageal resections.