Bilateral sequential lung transplantation: technical aspects

Abstract

The surgical technique for lung transplantation has evolved dramatically over the last three decades. Significant improvements in short term outcomes in the early years of lung transplantation were due, in large part, to techniques developed to reduce airway anastomotic complications in single lung transplantation. Following development of the technique of en bloc double lung transplantation, evolution to the bilateral sequential technique further reduced airway complications for double lung transplantation.More recently, some programs have utilized the en bloc double lung transplant technique with bronchial artery revascularization to aid airway healing and potentially improve short-and long-term outcomes. The experience with bronchial artery revascularization remains limited to a few series, with the technique having not been widely adopted by most lung transplant programs. With the implementation of priority allocations schemes in many countries, patients with higher risk profiles are being prioritized for transplantation which results in more complex procedures in fragile recipients with multiple comorbidities. This includes the increased need for concomitant cardiac procedures as well as performing lung transplantation after prior cardiothoracic surgery. Different surgical approaches have been described for bilateral sequential lung transplantation with or without intra-operative mechanical circulatory support (MCS), such as sternotomy, clamshell (bilateral anterior thoracotomies with transverse sternotomy), and bilateral thoracotomy incisions.Herein, we aim, not only to describe the various surgical approaches for double lung transplantation, but to provide a comprehensive review of other aspects related to the recipient pathology and different anatomical variants as well as handling technical challenges that might be encountered during the procedure.

Lung Transplantation for Pulmonary Artery Hypertension

“…We routinely use clamshell incision (bilateral anterior thoracotomy with transverse sternotomy) for access [25,77] though many centers prefer median sternotomy [78]. The clamshell incision offers excellent exposure but can be painful and affect chest wall mechanics.…”

“…The operative techniques of LT have been well described [77,25,86,87]. Only those aspects of operative technique with more than one way of performing and that significantly impact outcomes are elaborated here in greater detail.…”

Risk factors associated with surgical site infections in patients undergoing cardiothoracic surgery: A systematic review and meta‐analysis

“…Moreover, the median sternotomy technique minimises pulmonary impairment by avoiding extensive rib spreading and intercostal muscle dissection, which are often necessary in lateral thoracotomy approaches 3 . This reduced trauma to the chest wall and surrounding musculature results in less post‐operative pulmonary function compromise, a crucial advantage for patients with pre‐existing pulmonary conditions 4 . Despite the rapid advancement and adoption of minimally invasive techniques, these often cannot replace the median sternotomy in surgeries requiring complex reconstructions, such as extensive coronary artery bypass grafting involving multiple vessels, combined valve repairs with aortic reconstruction and complex congenital cardiac repairs, as well as in scenarios necessitating multiple simultaneous procedures 5–7 .…”

“… 3 This reduced trauma to the chest wall and surrounding musculature results in less post‐operative pulmonary function compromise, a crucial advantage for patients with pre‐existing pulmonary conditions. 4 Despite the rapid advancement and adoption of minimally invasive techniques, these often cannot replace the median sternotomy in surgeries requiring complex reconstructions, such as extensive coronary artery bypass grafting involving multiple vessels, combined valve repairs with aortic reconstruction and complex congenital cardiac repairs, as well as in scenarios necessitating multiple simultaneous procedures. 5 , 6 , 7 For these reasons, the median sternotomy remains an indispensable surgical approach, granting cardiac surgeons' comprehensive access to both the cardiac and vascular systems for effective surgical intervention.…”