A left thoracic approach in a prone position for thoracoscopic thoracic duct ligation in a patient with post-esophagectomy chylothorax: A case report

•Early surgical treatment is recommended for chylothorax after esophagectomy.•We performed thoracic duct ligation in the left thorax in a prone position.•Fine and sharp clips crashed the thoracic duct.•In a prone position, surgeons can easily convert from a left to a right approach.•In a prone position, manual compression of lung is not necessary.•In a prone position, the leakage point is easily found as the fluid trickling. We debate whether or not to approach from right thorax for the left chylothorax after esophagectomy. A 50s-year-old female underwent right-sided thoracoscopic esophagectomy with three-field lymphadenectomy for esophageal carcinoma (type 0-IIa, 3.4×2.2cm, T1bN0M0, Stage IA), followed by reconstruction with esophagogastric anastomosis through the posterior mediastinum. The thoracic duct was excised and ligated. The left thoracic drainage increased to 2115mL/day on the fifth postoperative day. Thoracic duct injury was diagnosed, and surgery was performed on sixth postoperative day. With the patient in a prone position, the thoracic duct was ligated successfully under thoracoscopy in the left thorax. The leakage point was found in the crushed duct by 8.8-mm titanium clips. Then, we performed mass ligation of the thoracic duct with 11-mm titanium clips below the leakage point after careful dissection. The surgery took 58min, with an estimated total blood loss of 0g. Although thoracic duct is anatomically located on the right side of the descending aorta, we employed a left-sided thoracoscopic approach due to the chylous leakage in the left thorax. With the patient in the prone position, surgeons can easily convert from a left thoracic approach to a right thoracic approach immediately without postural change if the thoracic duct cannot be found in the left thoracic cavity. This technique is useful and should be considered for patients with left chylothorax.