Single-lung and double-lung transplantation: technique and tips

Abstract

The first successful single-lung and double-lung transplantations were performed in the eighties. Since then both surgical and anesthesiological management have improved. The aim of this paper is to describe the surgical technique of lung transplantation: from the anesthesiological preparation, to the explantation and implantation of the lung grafts, and the preparation of the donor lungs. We will also describe the main surgical complications after lung transplantation and their management. Each step of the surgical procedure will be illustrated with photos and videos.

Keywords: Double-lung transplantation; bronchial anastomosis; single-lung transplantation; surgical technique.

Figure 1

Anesthesiologic preparation. 1, double-lumen tube; 2, central venous catheter; 3, Swan-Ganz probe; 4, invasive blood pressure/arterial catheter.

Figure 2

Installation. Arms spread.

Figure 3

Clamshell incision. (A) Cutaneous incision; (B) surgical view after opening the chest.

Figure 4

Double anterior thoracotomy. (A) Cutaneous incision. The right side is opened first; (B) breast tissue is pulled upward.

Figure 5

Lung dissection. The lung is gently divided from the mediastinum. The main PA and the mediastinal artery are dissected and encircled with loops, as well as the upper and middle lobes veins. The inferior vein is not seen on the video. Before explantation, a clamping test on the PA is performed, while the anesthesiologist checks hemodynamic tolerance and possible rise in pulmonary arterial pressures (8). Available online: http://www.asvide.com/article/view/24494

Figure 6

Preparation of the graft. The bronchus is cut one ring above the secondary carina to prevent ischemic necrosis. The artery is cut to avoid excessive length and later plicature of the anastomosis. The atrium cuff is made as regular as possible. All the removed pieces of the vascular structures are kept for eventual reparation of anastomotic leak (9). Available online: http://www.asvide.com/article/view/24495

Figure 7

Preservation of the lung. (A) The graft is preserved at 4 °C in three bags containing respectively cold preservation fluid, cold physiological serum and ice, and air. The nurse opens the first bag, and the surgeon takes under sterile conditions the second bag inside. (B) Preservation with an OCS device (Transmedics^®, Andover, MA, USA).

Figure 8

Explantation of the native lung. The vessels, pulmonary artery and pulmonary veins, are cut with a stapling device first. The bronchus is seen afterward, and opened with a sharp bistouri. From this moment the suction device must be changed, and the cell-saver cannot be used any longer until the bronchial anastomosis is done. The last adherences are cut, the native lung is removed from the chest cavity and sent for pathological examination (10). Available online: http://www.asvide.com/article/view/24496

Figure 9

Preparation of the hilum. The bronchial stump is shortened until the main bronchus is reached. Careful haemostasis of the bronchial arteries must be performed, as they will be on the posterior part of the lung when the implantation is over. The arterial stump is divided as far as possible below the vena cava. Pericardial fluid can be seen when the pericardium is opened. After the dissection, a clamp is put on the main artery to check the safety of the anastomosis. Similarly, the veins are divided as far as possible. A suture of prolene is used to pull the phrenic nerve upward, and avoid traction and trauma during the implantation (11). Available online: http://www.asvide.com/article/view/24497

Figure 10

Bronchial anastomosis. The first stitch between the two bronchial stomps is placed at the upper corner.

Figure 11

Bronchial anastomosis. A PDS 3.0 is placed at the upper corners of the two bronchial stumps. The length of each side must be carefully assessed. The membranous part of the anastomosis is sutured with a running suture. Each side of the suture is used to perform a running stitch one from the upper corner towards the middle of the anterior side of the anastomosis, and one from the lower part. The congruence of the anastomosis must be checked, a flap can be placed on the anastomosis (pericardial tissue, fat tissue, …) (17). Available online: http://www.asvide.com/article/view/24498

Figure 12

Arterial anastomosis.

Figure 13

Arterial anastomosis. The length of the arterial stump is checked. The running suture starts at the upper end of the anastomosis with a non-absorbable suture of 5.0. Care should be taken to avoid transluminal stitches. Once the anterior wall is finished, both sides of the stitch are placed on a clamp and will be tied after the flush (20). Available online: http://www.asvide.com/article/view/24499

Figure 14

Atrial anastomosis.

Figure 15

Atrial anastomosis. The two extremities of the recipient veins are opened, a dissector is placed between them and the opening is completed. With a technique similar to the one used for the artery the anastomosis is performed with a running stitch of non resorbable 4.0 suture (21). Available online: http://www.asvide.com/article/view/24500

Figure 16

Retrograde flush. A small opening of the running stitch on the anterior part of the arterial anastomosis is created while the atrial clamp is gently opened. Once the vascular structures are filled, the arterial suture is tied (22). Available online: http://www.asvide.com/article/view/24501

Figure 17

Techniques of atrial reparation. (A) The atrial cuff is too short. A pericardial patch is placed partially or totally on the circumference of the cuff; (B) the veins have been split accidentally. A running suture is performed for reconstruction of the cuff; (C) the veins have been split with an associated defect of length. Both veins are sutured to a cuff of pericardium; (D) one vein has been shortened. It is reconstructed with a pericardial bridge.