Azygos vein arch injury caused by an ultrasonic scalpel during lung cancer surgery

Unexpected azygos vein injury during thoracoscopic lung resection is rare. Here, we describe a case of azygos vein arch injury caused by an ultrasonic scalpel. The patient underwent segmentectomy for right upper lobe lung cancer. The ultrasonic scalpel was activated while its blade tip was inadvertently grasping the vascular wall of the azygos vein arch during management of bleeding from the pulmonary artery stump, resulting in injury to the azygos vein arch. Because the injury site was temporarily sealed, it was not initially detected. When the right upper lobe was retracted ventrally to dissect the upper lobe bronchus, tension was applied to the injured site of the azygos vein arch, leading to massive haemorrhage. Conversion to thoracotomy was required, and haemostasis was achieved using a fibrin sealant patch. The azygos vein is a low-pressure system; most injuries can be managed with a fibrin sealant patch.