Once the abdominal lymphatic channels are visualized, the patient's abdomen is prepped from the inferior costal margin to just below the umbilicus. Planning a percutaneous approach to the abdominal lymphatic channels requires careful examination of the preoperative MRI. The position of the aorta and right renal artery are referenced to bony landmarks on the scan. An inferior right lateral approach is used most often to avoid these two vascular structures. The approximate starting position is 3–5 cm to the right of midline. After local anesthesia is given, a small dermatotomy is made using a no. 11 blade. We use an Acustick II Introducer Kit (Boston Scientific, Natick, MA) to puncture and then cannulate the lymphatic system. When making the puncture and approach to the cisterna chyli, it is often useful to angle the image intensifier “along the barrel” so that the needle on fluoroscopy overlies the cisterna (Fig. 111-4). This technique helps to minimize drifting of the needle as it travels through visceral structures. Just before the needle reaches the cisterna, the C-arm is placed into an anteroposterior position. The needle can be seen “tenting” the lymphatic channels. Entry is made with a brisk and deliberate motion. Contrast material is gently injected to confirm placement, and a 0.018-inch wire then is advanced through the channel and into the lymphatic system (Fig. 111-5). Sometimes the needle travels through both walls. With gentle retraction, the needle will “pop” into the lymphatic lumen, and the wire can be advanced.