1. Chylothorax: Surgical Ligation of the Thoracic Duct Through Thoracotomy 
Robert A. Meguid, MD, MPH, FACS 
Operative Techniques in Thoracic and Cardiovascular Surgery 
Volume 21, Issue 2, Pages (June 2016)
DOI: /j.optechstcvs
Copyright © 2016 Elsevier Inc. Terms and Conditions

2. Figure 1
The thoracic duct runs as a plexus of valved lymphatics in the soft tissue anterior to the vertebral bodies. In the most common anatomical pattern the thoracic duct arises from the cisterna chyli below the diaphragm and ascends into the posterior right mediastinum. It travels up the posterior mediastinum between the descending thoracic aorta, the esophagus, and the azygos vein. The thoracic duct crosses from the right to the left posterior mediastinum typically between T5 and T6 vertebral bodies, posterior to the heart. It then continues to ascend on the left and drains posteriorly into the confluence of the left subclavian and internal jugular veins as they become the innominate vein. Although the most common pattern of anatomy includes a main thoracic duct, the anatomy of the thoracic duct varies from this description in half of individuals. Most common variations are collateral branches from the thoracic duct to veins in the chest (including intercostal, lumbar, and the azygous vein), and bilateral or multiple ducts traversing the diaphragm as they enter the chest.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2016 Elsevier Inc. Terms and Conditions

3. Figure 1
The thoracic duct runs as a plexus of valved lymphatics in the soft tissue anterior to the vertebral bodies. In the most common anatomical pattern the thoracic duct arises from the cisterna chyli below the diaphragm and ascends into the posterior right mediastinum. It travels up the posterior mediastinum between the descending thoracic aorta, the esophagus, and the azygos vein. The thoracic duct crosses from the right to the left posterior mediastinum typically between T5 and T6 vertebral bodies, posterior to the heart. It then continues to ascend on the left and drains posteriorly into the confluence of the left subclavian and internal jugular veins as they become the innominate vein. Although the most common pattern of anatomy includes a main thoracic duct, the anatomy of the thoracic duct varies from this description in half of individuals. Most common variations are collateral branches from the thoracic duct to veins in the chest (including intercostal, lumbar, and the azygous vein), and bilateral or multiple ducts traversing the diaphragm as they enter the chest.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2016 Elsevier Inc. Terms and Conditions

4. Figure 2
The patient is intubated with a double-lumen endotracheal tube to provide isolation of the right lung from the ventilator circuit. After placement of monitoring lines and large bore intravenous access by the anesthesiology team, the patient is positioned in left lateral decubitus position. The patient is positioned on a bean bag on the operating table such that the break in the table falls between the iliac crest and the costophrenic angle. An arm holder is used to support the right arm (A).
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2016 Elsevier Inc. Terms and Conditions

5. Figure 2
Continued (B) The patient is secured to the flexed table on top of the bean bag. Lower and upper body warming devices are placed. The right chest from shoulder to abdomen and from spine to nipple are prepared in a sterile manner. The right lung is isolated from the ventilator circuit while the patient is prepped for surgery, to allow time for the right lung to deflate fully.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2016 Elsevier Inc. Terms and Conditions

6. Figure 3
A right lateral thoracotomy via the seventh intercostal space is performed. The tail of the latissimus dorsi and the serratus anterior muscles are divided. The right chest is entered via the seventh intercostal space laterally.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2016 Elsevier Inc. Terms and Conditions

7. Figure 4
The rib on the inferior aspect of the incision is dissected circumferentially from the neurovascular bundle posteriorly, and then 1 cm section is removed to allow for retraction and adequate visualization of the right posterior mediastinum. A Finochietto rib retractor is placed into the thoracotomy to provide retraction.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2016 Elsevier Inc. Terms and Conditions

8. Figure 5
With the right lung isolated from the ventilator, it is reflected anteriorly. The esophagus is identified via placement of an orogastric tube by the anesthesiologist during the procedure. The location of the descending thoracic aorta is confirmed with palpation. Additional exposure to the distal posterior mediastinum can be achieved via retraction of the right hemidiaphragm inferiorly. This can be achieved via placement of a figure of eight 2-O absorbable suture into the central tendon of the right hemidiaphragm. This is then retracted anteriorly and inferiorly through a separate stab incision through the chest wall at the reflection of the diaphragm anteriorly.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2016 Elsevier Inc. Terms and Conditions

9. Figure 6
Elevation of the soft tissue intervening between the esophagus on the right, the azygos vein on the left and the descending thoracic aorta and vertebral column deep to the operative field is performed with a Debakey forceps. It is this intervening tissue which contains the thoracic duct, including a plexus of lacteals. This soft tissue is then ligated in 3 positions at 2 cm increments starting approximately 2 cm above the esophageal hiatus of the diaphragm.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2016 Elsevier Inc. Terms and Conditions

10. Figure 7
Ligation is performed with O silk sutures (A and B). The esophagus, containing an orogastric tube, is reflected toward the left chest. Sutures are placed medially to laterally, superficially to deep to minimize risk of injury to the esophagus and aorta (B). Great care is taken not to involve or injure the esophagus or the aorta during placement of the sutures. Some surgeons advocate administration of heavy cream or methylene blue-stained milk products through the orogastric tube, to improve visualization of the thoracic duct in the chest. The fat from this is emulsified and absorbed into the lacteals. This then travels up the thoracic duct through the chest and aids in identification of the thoracic duct plexus. Application of fibrin glue sealant on top of the ligated thoracic duct may promote sealing of the area of leak and prevent further leakage from the duct ligation procedure itself. I consider both of these maneuvers optional.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2016 Elsevier Inc. Terms and Conditions

11. Figure 7
Ligation is performed with O silk sutures (A and B). The esophagus, containing an orogastric tube, is reflected toward the left chest. Sutures are placed medially to laterally, superficially to deep to minimize risk of injury to the esophagus and aorta (B). Great care is taken not to involve or injure the esophagus or the aorta during placement of the sutures. Some surgeons advocate administration of heavy cream or methylene blue-stained milk products through the orogastric tube, to improve visualization of the thoracic duct in the chest. The fat from this is emulsified and absorbed into the lacteals. This then travels up the thoracic duct through the chest and aids in identification of the thoracic duct plexus. Application of fibrin glue sealant on top of the ligated thoracic duct may promote sealing of the area of leak and prevent further leakage from the duct ligation procedure itself. I consider both of these maneuvers optional.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2016 Elsevier Inc. Terms and Conditions

12. Figure 8
The right hemithorax is drained with a single 28 Fr chest tube positioned posteriorly along the mediastinum, to facilitate complete evacuation of any fluid accumulation in the chest.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2016 Elsevier Inc. Terms and Conditions