Indocyanine green-guided video-assisted thoracoscopic surgery thoracic duct ligation and talc pleurodesis for refractory chylothorax after Ivor Lewis oesophagectomy

Refractory chylothorax following oesophagectomy is a challenging complication, often requiring surgical re-intervention. We describe a standardized technique for thoracic duct ligation using indocyanine green (ICG) fluorescence guidance. A 62-year-old male presented with high-output chylothorax 40 days after a minimally invasive Ivor Lewis oesophagectomy, refractory to conservative management. The procedure involved pre-operative bilateral inguinal lymph node injection of ICG. A right-sided three-port VATS approach was utilized. Intra-operatively, a provocative fatty meal test (cream and olive oil) was administered via the nasogastric tube. Using near-infrared fluorescence, the thoracic duct was rapidly identified. The technique included meticulous dissection, mass ligation with silk sutures, and reinforcement with polymer clips. Chemical pleurodesis with talc was added to ensure pleural symphysis. The patient was discharged on post-operative Day 5 with no recurrence at 30-day follow-up. This video tutorial demonstrates that ICG-guided VATS ligation, combined with inguinal lymph node injection, provides a safe, reproducible, and highly effective strategy for managing complex post-oesophagectomy chylothorax.