Dr. Luis Iván León Ortega & Joel Cazares - Best of the Best in Pediatric Surgery 2025

We're going to move on now to the uh, the next presentation. Um, the next presentation is from the Mexican Pediatric Surgical Society uh, and we have Luis Ivan Leon Ortega, who's talking about initial experience with the use of intraoperative fluorescence with indocyanine green in minimally invasive surgery for thoracic duct ligation in pediatrics and he's coming from the University of Monterrey, Nuevo Leon in Mexico. Hello, I'm Dr. Leon, it's a pleasure for me to have this space and share our research with you all. Chylothorax is the presence of Kyle in the plural space, which may be of either congenital of acquired origin. It is associated with significant respiratory morbidity, thoracic cavity compromise, nutritional deficiencies and immuno suppression. Surgical options include pleurodesis, thoracic duct ligation using an open approach, thoracoscopic surgery and the creation of a pluroperitoneal shunt. Our objective is to share our experience with the use of indocyanine green fluorescence in thoracoscopic thoracic duct ligation for patients with chylothorax. We conduct a retrospective, longitudinal and descriptive study by reviewing medical records from June 2020 to December 2023. A total of four patients were included, all diagnosed with chylothorax, refractory to medical treatment and treated with thoracoscopy using indocyanine green. After the anesthetic procedure, 0.5 milligrams per kilogram of ICG is instilled percutaneously into the inguinal lymph nodes under ultrasound guidance. The patient is positioned in prone with the lateral edge of the surgical table aligned and an elevation of the right side to achieve an ergonomic setup. A 5 mm port is used for a 30 degree optic inserted through an incision posterior to the tip of the scapula in the fifth intercostal space. A pneumothorax is induced with a pressure of 6 to 8 millimeters of mercury and a CO2 flow rate of 1 to 2 liters per minute. Under direct visualization two additional working ports are placed, a 5 mm port, two to three intercostal spaces below the camera port along the posterior axillary line and a 3 mm port, one to two intercostal spaces above the camera port along the mid axillary line. Deflation allows for exposure of the inferior pulmonary ligament, which is divided to provide excellent visualization of the posterior mediastinal structures. The right lung is reflected to enable identification of the esophagus and thoracic aorta. Patch pleuritis is frequently observed, owing to the presence of Kyle or a history of chest to placement, necessitating adhesion release when required. An infrared light filter is applied to facilitate visualization of the duck beneath the pleura. A window is created above the thoracic duct, extending from the diaphragm to approximately three vertebral bodies cephala. Once identified, the duct is isolated and ligated with clips at multiple points along its trajectory. This multiple ligation technique ensures definitive control of any leakage. Finally, a chest tube is placed through the orvus of most caudal 5 millimeter working port. We observed an improvement in surgical time as the learning curve progressed with an average duration of 75 minutes, ranging from 65 to 85. The causes of chylothorax were as follows: two cases of congenital idiopathic chylothorax, one case of pulmonary lymphangiectasia and one iatrogenic case related to plural neurtication performed for complicated pneumonia. In our series, chylothorax was observed on the right side in three patients and on the left side in just one patient. During follow up, the patients demonstrated both clinical and radiological progress with no recurrences and minimal nearly perceptible scarring. Identification of the thoracic duct in pediatric patients represent a significant challenge due to anatomical variability among individuals as well as factors such as medianitis and patch pleuritis are associated with chylothorax. Our experience with interoperative fluorescence has significantly facilitated identification and terruption of the thoracic duct, achieving successful ligation in 100% of our cases. Ultrasound guided installation of ICG directly into the lymph nodes is a safe and effective method for visualizing the thoracic duct. The use of this technology has enabled us to reduce surgical time without complications resulting in shorter hospital stays. Conclusion, our experience suggests that the use of ICG is a safe and effective tool for identifying the thoracic duct during minimally invasive surgery, thereby facilitating its ligation. We aim to achieve even better outcomes as the number of cases increases. Thank you very much for your attention. Very presentation, that's a great technique for a very frust sometimes incredibly frustrating problem. I I think I understand well and it looks great for the genic, but I was surprised that you had cases where it was congenital. Um, lesions and did you find the same thing? Was it was it ligating the thoracic duct or did you have to ligate other places and identify other sources using the ICG? Yeah, thank you. Thank you very much. Excellent question. Um, we we only have one patient with congenital. So we did the same technique, uh, we open open a window into the plura and then make a, we saw the the portion of the thoracic duck where is leaking, then we decide to make multiple, um, apply multiple clips for uh, try to, um, to obstruct any branch that may have. Um, a couple of questions, we have uh, one from the chat and then, so I, first of all, you had much I've tried this for genic ones and it, it was a lot not as yours. Um, what uh, there's a question about what lab what technology do you needs from an imaging standpoint? Do you have uh a special system or a laparoscope for that. And then there was a question about how long before the operation do you actually give the ICG. Yeah, I think that that is a really good question and unfortunately the platform that we may use, I think there's one is one of the most important variables. So we don't have nothing to disclose. So but but we use the the system from striker the with the ICG camera 5 millimeters uh laparoscope. And uh and the dose is 0.5 milligram per kilo and we apply around 45 minutes uh prior uh the the position and and starting the surgery. Um, it might have been a uh an issue from technical factors because uh talking with some colleagues they don't have the same um the results. Yeah. Well, thank you so much. It's a very important presentation. Thank you. Thank you very much.