Case Report

A 38-year-old gentleman was admitted for transthoracic endoscopic sympathectomy (TES) for palmar hyperhydrosis. The procedure was carried out using two 5mm ports in the subaxillary position. One litre of carbon dioxide was introduced into the hemithorax to facilitate collapse of the ipsilateral lung. The sympathetic trunk is usually easily identified and ablation diathermy is carried out at the level of T2 and T3. However on this occasion, the right sympathetic trunk was obscured due to a pleural adhesion from the apex preventing collapse of the lung. After careful visualization, it was noted that this was infact an aberrant vessel arising from the right subclavian artery feeding the apical segment of the right upper lobe (Figure 1). This vessel was diathermied (Figure 2) and facilitated collapse of the lung allowing good visualization of the sympathetic trunk (Figures 3&4). The procedure was carried out uneventfully.

Figure 1

Figure 1: Aberrant vessel form subclavian artery preventing collapse of right upper lobe.

Figure 2

Figure 2: Vessel after diathermy.

Figure 3

Figure 3: Release of right upper lobe allowing better visualization.

Figure 4

Figure 4: Inspection of divided vessel to ensure haemostasis.

The occurrence of pleural adhesions and aberrant vessels seen during TES is 2.45% and 0.14% respectively (₁). We perform routine preoperative chest x-rays as the presence of apical bullae usually signifies adhesions in this area.

Conclusion

This may be a branch of an important vessel, as in the case illustrated above, and therefore extreme care during dissection of such adhesions should be practised to avoid catastrophic bleeding.

Correspondence to

Mr.R.Jeganathan, Thoracic Surgery, Ward 4A, Royal Victoria Hospital, Grovenor Road, Belfast BT12 6BA N.Ireland, United Kingdom Tel: 0044-2890-633222 / 0044-2890-632016 E-mail: reubenj@hotmail.com