Safety and Feasibility of Bilateral Lung Transplantation via VATS Approach

Overview

This study evaluates a novel video-assisted thoracic surgery (VATS) technique for bilateral lung transplantation, comparing it to the conventional clamshell incision. The VATS approach demonstrated feasibility and safety while preserving sternal integrity and potentially reducing wound-related morbidity.

Background

Bilateral lung transplantation traditionally uses a clamshell incision, providing excellent exposure but associated with significant morbidity such as sternal wound complications and delayed recovery. Alternative thoracotomy approaches preserving the sternum have been proposed but are limited by technical challenges and exposure issues. The increasing use of extracorporeal membrane oxygenation (ECMO) has reduced the need for full mediastinal exposure, enabling exploration of less invasive surgical strategies like VATS. This study presents a retrospective analysis comparing perioperative and early postoperative outcomes of VATS versus the clamshell approach.

Data Highlights

The study included patients undergoing bilateral lung transplantation with ECMO support from August 2017 to March 2025. The VATS approach was introduced in April 2024 and adopted as the default surgical strategy except for specific contraindications. The VATS technique utilized bilateral mini-thoracotomies with endoscopic vascular clamping and thoracoscopic instruments, avoiding rib cutting and preserving internal thoracic vessels. Incision lengths decreased from approximately 13 cm initially to under 10 cm in recent cases. Specialized thoracoscopic instruments facilitated vascular control and implantation through limited access incisions.

Key Findings

• The VATS approach preserves sternal integrity by using a mini-thoracotomy working window without rib cutting.
• Endoscopic vascular clamps and thoracoscopic instruments enable effective pulmonary artery and left atrial control despite limited access.
• Incision size was reduced over time, with recent cases requiring less than 10 cm for donor lung insertion.
• The use of ECMO intraoperatively reduces the necessity for full mediastinal exposure, facilitating minimally invasive techniques.
• Temporary rib spreading was only used during donor lung insertion and removed immediately, minimizing chest wall trauma.
• The VATS technique potentially reduces wound-related morbidity compared to the conventional clamshell incision.

Clinical Implications

The VATS approach for bilateral lung transplantation offers a less invasive alternative that preserves sternal stability and may reduce postoperative wound complications. Surgeons can consider this technique in patients eligible for peripheral ECMO support and adequate lung deflation, potentially enhancing recovery and pulmonary function post-transplant. Adoption requires familiarity with thoracoscopic instruments and endoscopic vascular control.

Conclusion

Bilateral lung transplantation via VATS is a feasible and safe technique that maintains sternal integrity and may reduce morbidity associated with traditional clamshell incisions. This approach represents a promising minimally invasive alternative in selected patients undergoing ECMO-supported lung transplantation.

References

1. Seoul National University Hospital Institutional Review Board 2025 -- Study Protocol Approval H-2505–194-1646
2. Previous Reports 2010-2023 -- Thoracotomy Approaches Preserving Sternum
3. Authors' Prior Work 2024 -- Introduction of Bilateral VATS Lung Transplantation Technique
4. ECMO Usage Trends 2023 -- Impact on Surgical Exposure Requirements