Double Lung Transplant Surgical Incisions
The bilateral transverse thoracosternotomy (clamshell incision) has traditionally been the standard surgical approach for double lung transplantation, though median sternotomy and bilateral anterior thoracotomies are increasingly used alternatives. 1, 2
Primary Surgical Approach: Clamshell Incision
The clamshell incision consists of bilateral anterior thoracotomies connected by a transverse sternotomy, typically performed at the fourth or fifth intercostal space. 1, 3 This approach provides:
- Excellent exposure to all areas of the mediastinum, pericardium, pleura, and both lungs simultaneously 1
- Superior access to lower lobe disease and hemithoracic extension compared to median sternotomy 1
- Optimal visualization for bilateral sequential lung implantation 2, 3
Technical Closure Details
Closure requires pericostal sutures and sternal wires, often augmented with K-wire stents or Steinmann pins to prevent sternal override. 1 A modified figure-of-8 configuration with monofilament metal wire plus two longitudinal wires across the sternal division provides greater stability and equally distributed tension. 2
Alternative Approach: Median Sternotomy
Median sternotomy has emerged as a viable alternative with specific advantages:
- Lower morbidity than clamshell incision, particularly reduced risk of sternal nonunion and wound complications 4, 5
- Earlier extubation and fewer transfusions in contemporary series 5
- Better access for mechanical circulatory support and concurrent cardiac procedures 3, 5
- Equivalent short-term outcomes to clamshell approach 5
This approach is particularly advantageous when cardiopulmonary bypass or extracorporeal membrane oxygenation support is anticipated. 3, 5
Emerging Technique: Video-Assisted Bilateral Anterior Thoracotomy
Recent reports describe double lung transplantation using bilateral anterior thoracotomies without transverse sternotomy, employing video-assistance. 4 This technique avoids sternal division entirely while maintaining adequate exposure, though experience remains limited. 4
Critical Considerations for Approach Selection
Patient-specific factors determine optimal incision choice:
- Prior cardiothoracic surgery may favor sternotomy due to adhesions 3
- Need for concurrent cardiac procedures (valve repair, coronary bypass) mandates sternotomy access 3, 5
- Anticipated need for mechanical circulatory support favors sternotomy 3, 5
- Severe pulmonary hypertension requiring cardiopulmonary bypass benefits from sternotomy 3
Common Pitfalls and Complications
The clamshell incision carries specific risks that must be anticipated:
- Sternal nonunion remains the most significant complication, requiring reinforced closure techniques 2, 4
- Wound infections occur but are uncommon with proper technique 1
- Phrenic nerve injury must be avoided during dissection, particularly in heart-lung transplantation 6
Important caveat: Despite theoretical concerns about morbidity, prospective studies of 90 patients showed no deaths or significant morbidity from clamshell incisions, with excellent cosmetic results and no late sternal override during 2-33 months follow-up. 1
Surgical Expertise Requirements
Regardless of approach selected, lung transplantation should only be performed at high-volume centers with experienced thoracic surgeons. 6 The complexity of bilateral sequential implantation, management of cardiopulmonary bypass, and handling of fragile recipients with multiple comorbidities demands specialized expertise. 3