Authors: Samina Park (Korea)
Categories: How-to-Do-It, Lung transplantation, Video-assisted thoracic surgery, Thoracotomy
Source: Journal of Chest Surgery
Doi: 10.5090/jcs.24.115
Authors: Samina Park
Lung transplantation remains the only curative option for patients with end-stage, medically refractory respiratory failure. Traditionally, the clamshell incision has been the primary surgical approach, as it provides extensive access to the mediastinum and bilateral pleural cavities. However, it is also associated with notable drawbacks, such as an increased risk of sternal nonunion and wound complications, which can impede postoperative recovery. This article introduces an alternative approach—double lung transplantation using video-assisted bilateral anterior thoracotomy. We present a detailed step-by-step surgical guide, offer practical tips, and highlight the advantages of this method over the conventional clamshell incision.
The global incidence of lung transplantation is rising, including in countries such as South Korea, driven by increased awareness and resources for managing respiratory failure [1,2]. Traditionally, the clamshell incision has been the preferred approach for double lung transplantation because it offers excellent exposure to the mediastinum and both pleural cavities, making it suitable for complex transplant procedures [3]. However, it also has significant drawbacks, such as an increased risk of sternal nonunion and wound complications, which can prolong recovery and lead to higher postoperative morbidity [4].
Thoracotomy was first proposed as an alternative approach for lung transplantation nearly 24 years ago [5]. Early concerns about inadequate lung preservation and limited exposure hindered its wider adoption. In Western countries, the primary indication for lung transplantation is chronic obstructive pulmonary disease/emphysema, and these patients often have larger thoracic cavities that can accommodate the thoracotomy approach. In contrast, in South Korea, the main indication for lung transplantation is interstitial lung disease, particularly idiopathic pulmonary fibrosis (IPF) [2]. This condition leads to a restrictive lung pattern and reduces thoracic cavity space, potentially limiting visibility and access during a thoracotomy. Moreover, IPF patients often present in severe clinical conditions with significant pulmonary hypertension, requiring cardiopulmonary support during transplantation to maintain hemodynamic stability. Given these challenges, thoracoscopy can help address the limitations of thoracotomy by improving visibility and safe access within the thoracic cavity. To capitalize on these benefits, our center has adopted a bilateral anterior thoracotomy approach under video assistance for double lung transplantation, increasing precision and offering adequate exposure even in patients with restrictive lung disease.
This article provides a detailed guide on performing double lung transplantation via video-assisted bilateral anterior thoracotomy, along with practical tips for managing potential challenges. We also highlight the advantages of this approach over the conventional clamshell incision, particularly focusing on the initial setup.
The patient is placed in the supine position with a shoulder pad to enhance comfort and facilitate surgical access. Both arms are secured on arm boards, taking care to avoid shoulder hyperextension. Standard draping exposes the chest and bilateral inguinal areas. The surgeon or first assistant enters the pleural cavity through an incision in the fourth intercostal space, preserving the internal thoracic artery and vein. This incision is typically about 13 cm long, though it may be adjusted to accommodate lung insertion (Fig. 1). The intercostal muscle is divided to the posterior wall, and no rib cutting is necessary.
Simultaneously, a veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO) support is prepared on bilateral inguinal vessels, if needed (Fig. 2). VA ECMO is generally preferred for patients with IPF, although in cases of mild pulmonary hypertension, VV ECMO or no circulatory support may suffice. North-South syndrome can occur in patients with good left ventricular function during peripheral VA ECMO, but once the first donor lung is implanted and ventilated, hypoxia typically improves gradually. If a single venous cannula does not provide sufficient flow, an additional venous cannula can be placed in the contralateral femoral vein. If the patient remains unstable on peripheral ECMO, cardiopulmonary bypass or central ECMO should be initiated immediately. If the native lung cannot be sufficiently deflated, limiting space in the thoracic cavity, thoracotomy may be inappropriate. Under the thoracotomy, video assistance is used in all cases to improve visualization and surgical precision during lung transplantation. A thoracoscope is utilized throughout the procedure, including the explantation and implantation phases, to compensate for the limited exposure available to assistants and nurses. Patients often present with diffuse pleural adhesions, making video assistance vital for thorough adhesiolysis, since the anterior thoracotomy approach alone offers limited visibility in the thoracic cavity. A camera port may be inserted in the 6th or 7th intercostal space, as needed. Additionally, for IPF patients with an elevated diaphragm—particularly on the right side—the anterior portion of the diaphragm may be plicated to create additional space for the donor lung. In some instances, the surgeon may choose to sit for better visualization, given the slightly lateral placement of the thoracotomy window.
Hilar dissection is generally straightforward under direct visualization by the surgeon. However, the assistant on the opposite side may have limited visibility of the hilum and posterior mediastinum. To address this, a second assistant controls the thoracoscopic camera, providing a clear view to the entire operating room team, including the anesthesiologist and nurses. This approach ensures that everyone remains engaged and can anticipate each step, thereby improving procedural efficiency and reducing the risk of miscommunication.
Before introducing the donor lung, hemostasis must be fully secured.
At our center, anastomoses are performed in the following bronchus, pulmonary artery, and then the left atrial cuff (Supplementary Video 1) [3]. The bronchus is anastomosed with a single continuous 4-0 polydioxanone suture. Next, the pulmonary artery is anastomosed with 6-0 polypropylene, using either an endoscopic or traditional Satinsky vascular clamp, depending on the vessel’s length and the thoracic cavity dimensions. Finally, the left atrium is anastomosed with a 5-0 polypropylene suture under the same type of clamp. Because the thoracotomy window offers limited space, 2 vascular clamps may not fit comfortably. In such cases, an endoscopic clamp inserted through the camera port helps reduce crowding in the surgical field. Once all anastomoses are completed, the pericardium, intercostal muscles, and inferior pulmonary ligaments of both donor and recipient lungs are secured. After completion of the anastomoses and confirmation of hemostasis, 2 chest tubes and a Jackson-Pratt drain are placed in each thoracic cavity. The thoracotomy wound is closed in stages, regardless of arterial blood gas analysis results, while the team assesses the patient’s readiness for ECMO weaning. If the femoral artery was accessed, a preplaced Perclose ProGlide suture-mediated closure system allows rapid closure of the artery post-transplant. If ECMO support is still required after surgery, the patient remains on ECMO during transport to the intensive care unit (ICU). For patients who need prolonged ECMO support in the ICU, the femoral artery is surgically repaired.
Video-assisted thoracotomy offers multiple advantages over the clamshell incision. It can significantly reduce operative time and minimize bleeding from bony and chest wall structures by limiting the incision to the intercostal muscles. This approach also permits sufficient visualization of the posterior mediastinum, while the video-assisted setup allows the entire operating room team to view the surgical field, enhancing communication and workflow. It is particularly beneficial for training residents and nurses, who can better anticipate each step and identify potential issues in real time. A key advantage of the video-assisted thoracotomy approach is that it preserves the sternum, providing important benefits during the immediate postoperative period. If respiratory difficulties arise, an intact anterior chest wall offers more robust support for inspiratory effort, thereby reducing the risk of flail chest. Preserving the sternum also avoids complications associated with sternal nonunion, such as chronic wound problems, sternal override, delayed healing, and persistent pain. We also emphasize that cardiopulmonary support strategy influences the choice of surgical approach. Some highly experienced centers have adopted central ECMO for lung transplantation via thoracotomy [6]. Nonetheless, patient safety is paramount. If unstable hemodynamics necessitate central ECMO or cardiopulmonary bypass, immediate conversion to a clamshell incision is performed to stabilize the patient.
Minimally invasive methods are already widely employed in thoracic surgery and the learning curve for video-assisted thoracotomy is not particularly steep. We also view this approach as a key step toward fully minimally invasive lung transplantation. However, an experienced scopist is essential for smoothly implementing this technique, as high-quality thoracoscopic visualization is critical.
Thoracotomy for lung transplantation was initially reported roughly 20 years ago, but its adoption was limited by poor exposure. Only recently have significant improvements in surgical technique and technology emerged [7]. Anterior thoracotomy with video assistance, as described in this article, may signal an important move toward using minimally invasive approaches in lung transplantation. In other areas of organ transplantation, such as kidney and liver, minimally invasive techniques—whether laparoscopic or robotic—are now commonly performed. Although lung transplantation has lagged behind because of its unique challenges, the success of anterior thoracotomy and early robotic cases suggests that progress is accelerating. As technology and expertise continue to develop, minimally invasive techniques will likely assume a growing role in lung transplantation, potentially improving outcomes, shortening recovery times, and expanding available treatment options for patients.
Supplementary materials can be found via https://doi.org/10.5090/jcs.24.115. Supplementary Video 1. Right lung implantation under video-assisted thoracic surgery.