Laparoscopic Repair of Chylous Ascites

Abstract

A 44-year-old female underwent hand assisted laparoscopic left donor nephrectomy. The procedure was uneventful and the kidney was successfully transplanted into the biological son. The initial postoperative period was unremarkable. The patient was discharged home on postoperative day 2. She complained of nausea and lack of appetite after discharge from the hospital. Two weeks later she complained of mild increase in abdominal girth. On physical examination she had a moderately distended abdomen, with dullness to percussion. Diagnostic paracentesis was performed in the office, and 120 cc milky white, odorless fluid was aspirated. Laboratory analysis of the fluid was consistent with chylous ascites, and cultures were negative. All other laboratory tests were normal. Computerized tomography of the abdomen with oral and intravenous contrast material confirmed the presence of a large volume of ascites (fig. 1). The patient was rehospitalized and put on a low fat diet and medium chain triglyceride supplementation for 1 week. Management was then changed to total parenteral nutrition and subcutaneous somatostatin for 1 week. Both regimens of conservative treatment failed to improving the condition. Hand assisted laparoscopic exploration was elected. The patient was given a high fat breakfast 6 hours before the operation to increase the chyle flow. On entering the abdomen 12 l chyle was aspirated. The colon was mobilized and the left renal bed was explored. A streak of white chyle was immediately visible (fig. 2). Further dissection showed that the leak was coming from a 1 mm hole in one of the lymphatic channels on the lateral wall of the aorta. The tract was sutured laparoscopically and the surrounding lymphatics were cauterized with bipolar electrocautery. Finally, oxidized regenerated cellulose with fibrin glue was applied to the area. The patient was started on a low fat diet, did well and was discharged home on postoperative day 4. At 1-month followup she was following a regular diet and was asymptomatic. Examination revealed no evidence of ascites, and serum electrolytes, creatinine and proteins were within normal limits.