Laparoscopic Management of Chylous Leakage Using a Direct Lymph Node Injection with Methylene Blue as a Leakage Point Location Strategy in a Patient with Retroperitoneal Extragonadal Seminoma

Background: The first-line treatment in cases of chylous leakage is conservative, and operation should be considered only in patients who fail to respond to this treatment. The main clinical concern is the difficulty of intraoperative localization of the site of leakage that can affect surgical outcome. Case Presentation: A 33-year-old man presented with a 4-month history of abdominal pain and weight loss. CT scan revealed enlarged retroperitoneal lymph nodes. Retroperitoneal lymph node biopsy was performed owing to the suspicion of lymphoproliferative disease, with a pathological result of nonspecific adenitis. Because of persistence of pain, an abdominal CT scan showed a large left retroperitoneal fluid collection that was found to be compatible with chyle after drainage. Conservative treatment was established, but because of its failure, surgical management was attempted by the laparoscopic approach. Intraoperative direct lymph node injection of methylene blue was used as a leakage point location strategy that allows selective ligation of the site of leakage. Thereafter a gradual reduction in chyle output to zero was observed. Conclusion: The laparoscopic approach could be a feasible and successful method for the management of chyle leakage in patients refractory to conservative treatment. Intraoperative direct lymph node injection of methylene blue could be a useful technique to facilitate detection of the site of leakage during operation.