Identification of the Thoracic Duct Using Indocyanine Green During Cervical Lymphadenectomy



Injury to the thoracic duct (TD) is the most common complication after a left lateral neck dissection, and it carries a high degree of morbidity. Currently, no routine diagnostic imaging is used to assist with TD identification intraoperatively. This report describes the first clinical experience with lymphangiography using indocyanine green (ICG) during lateral neck dissections.


In six patients undergoing left lateral neck dissection (levels 2–4) for either thyroid cancer or melanoma, 2.5–5 mg of ICG was injected in the dorsum of the left foot 15 min before imaging. Intraoperative imaging was performed with a hand-held near infrared (NIR) camera (Hamamatsu, PDE-Neo, Hamamatsu City, Japan).


In five patients, the TD was visualized using NIR fluorescence, with a time of 15–90 min from injection to identification. Imaging was optimized by positioning the camera at the angle of the mandible and pointing into the space below the clavicle. No adverse reactions from the ICG injection occurred, and the time required for imaging was 5–10 min. No intraoperative TD injury was identified, and no chyle leak occurred postoperatively. For the one patient in whom the TD was not identified, it is unclear whether this was related to the timing of the injection or to duct obliteration from a prior dissection.


This is the first described application of ICG lymphangiography to identify the thoracic duct during left lateral neck dissection. Identification of TD with ICG is technically feasible, simple to perform with NIR imaging, and safe, making it a potential important adjunct for the surgeon.

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Author information

JC, RS, JEP: Study design. JC, LAS, AMT, JEP: Data acquisition; JC, JEP: Data analysis/interpretation; JC, LAS, AMT, RS, JEP: Manuscript preparation/approval.

Correspondence to John E. Phay MD.

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The authors declare that they have no conflict of interest.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

VIDEO S1 Near-infrared imaging of the thoracic duct in patient 4. Live action of the images from Fig. 2 is shown. (WMV 11800 kb)

VIDEO S2 Near-infrared imaging of the thoracic duct in patient 5. Live action of the images from Fig. 3 is shown. (WMV 17741 kb)

VIDEO S1 Near-infrared imaging of the thoracic duct in patient 4. Live action of the images from Fig. 2 is shown. (WMV 11800 kb)

VIDEO S2 Near-infrared imaging of the thoracic duct in patient 5. Live action of the images from Fig. 3 is shown. (WMV 17741 kb)

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Chakedis, J., Shirley, L.A., Terando, A.M. et al. Identification of the Thoracic Duct Using Indocyanine Green During Cervical Lymphadenectomy. Ann Surg Oncol 25, 3711–3717 (2018).

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