Clinical Scorecard: Evaluating the Safety and Practicality of Bilateral Lung Transplantation via Video-Assisted Thoracic Surgery

At a Glance

Key Highlights

• Clamshell incision provides excellent exposure but is associated with high rates (7-30%) of sternal wound complications and delayed recovery.
• VATS approach preserves sternal integrity, avoids rib cutting, and uses mini-thoracotomies with thoracoscopic visualization and specialized instruments.
• Intraoperative ECMO support reduces the need for full mediastinal exposure, facilitating less invasive surgical approaches.

Guideline-Based Recommendations

Diagnosis

• Select patients undergoing bilateral lung transplantation with ECMO support for surgical approach evaluation.

Management

• Use VATS with bilateral mini-thoracotomies and thoracoscopic instruments to perform bilateral lung transplantation while preserving sternal integrity.
• Employ intraoperative ECMO (central or peripheral cannulation) to support cardiopulmonary function during transplantation.
• Avoid cardiopulmonary bypass and single-lung or multi-organ transplantation in this VATS protocol.
• Exclude patients unable to tolerate peripheral ECMO or achieve adequate lung deflation for thoracoscopic manipulation.

Monitoring & Follow-up

• Monitor for sternal wound complications, chest wall stability, and postoperative pulmonary function recovery.
• Assess intraoperative vascular control and adequacy of thoracoscopic visualization during implantation.

Risks

• Potential limited mediastinal exposure and restricted angles for hilar dissection with VATS approach.
• Technical challenges in vascular control and implantation through limited incisions.
• Risk of sternal wound complications and chest wall instability with clamshell incision.

Patient & Prescribing Data

Patients undergoing bilateral lung transplantation with ECMO support at a tertiary care center

VATS approach introduced as default surgical strategy since April 2024, except for patients with contraindications; aims to reduce operative trauma and improve early postoperative outcomes compared to clamshell incision.

Clinical Best Practices

• Preserve internal thoracic artery and vein by avoiding rib cutting during mini-thoracotomy.
• Use endoscopic vascular clamps and thoracoscopic instruments for pulmonary artery and left atrial control.
• Employ a soft tissue wound protector and avoid sustained rib spreading to minimize chest wall trauma.
• Introduce donor lung using a sterile insertion device to facilitate atraumatic implantation.
• Apply thoracoscopic visualization as primary view with adjunct direct visualization as needed.

References

• Sternal complications in clamshell incision
• Thoracotomy approaches preserving sternum
• Previous VATS lung transplantation technique
• ECMO use reducing need for full mediastinal exposure