What is the recommended surgical incision for a patient undergoing a double lung transplant?

Surgical Incision for Double Lung Transplantation

The median sternotomy is the recommended surgical approach for double lung transplantation, as it provides equivalent or superior outcomes to the traditional clamshell incision while significantly reducing operative time, cardiopulmonary bypass duration, and wound complications. 1, 2

Primary Surgical Approach

Median sternotomy should be the default incision for bilateral sequential lung transplantation because it offers:

• Shorter operative time and reduced cardiopulmonary bypass duration compared to clamshell thoracotomy, which directly impacts perioperative morbidity 1
• Equivalent short-term and long-term survival to clamshell incision (no statistical difference in overall survival, P = 0.61) 1
• Superior access for mechanical circulatory support and concurrent cardiac procedures if needed 2
• Earlier extubation and fewer transfusion requirements compared to clamshell approach 2
• Avoidance of sternal nonunion and wound complications that are inherent to transverse sternotomy 3

Alternative Approaches and Their Indications

Clamshell Incision (Bilateral Anterior Thoracotomy with Transverse Sternotomy)

This approach should be reserved for specific anatomical challenges:

• Extensive lower lobe disease requiring superior exposure 4
• Combined pulmonary and mediastinal disease with hemithoracic extension 4
• Bilateral pulmonary metastases requiring comprehensive bilateral access 4

The clamshell provides excellent exposure to all areas of the mediastinum, pericardium, pleura, and lung, but comes at the cost of:

• Longer operative time and cardiopulmonary bypass duration 1
• Higher risk of sternal override and wound infection (though modern fixation techniques with K-wire stents or Steinmann pins have improved outcomes) 4
• Increased postoperative morbidity related to sternal transaction 5

Video-Assisted Bilateral Anterior Thoracotomy (Without Sternotomy)

Sternum-sparing bilateral anterior thoracotomies represent an emerging superior alternative to clamshell:

• Eliminates sternal division complications while maintaining bilateral access 3, 5
• Minimal wound complications (superficial infection rate of only 4.4% in one series of 91 recipients) 5
• Preserves internal mammary arteries and chest wall integrity 5
• Safe and effective with warm ischemic times comparable to other approaches (mean 56 ± 11 minutes) 5

This approach uses muscle-sparing submammary anterior thoracotomies (mean 20.3 cm) with femoral cannulation for cardiopulmonary bypass when needed 5.

Critical Technical Considerations

Phrenic nerve preservation is mandatory during dissection, particularly emphasized in heart-lung transplantation guidelines but equally applicable to double lung transplantation 6, 7

High-volume center expertise is essential - lung transplantation should only be performed at experienced centers due to the complexity of bilateral sequential implantation and cardiopulmonary bypass management 7

Common Pitfalls to Avoid

• Do not default to clamshell incision based on historical precedent alone - median sternotomy provides equivalent outcomes with less morbidity 1, 2
• Do not underestimate wound complications with clamshell - even with modern fixation techniques, sternal nonunion remains a significant risk 3
• Do not choose incision without considering need for concurrent cardiac procedures - median sternotomy provides superior access if cardiac intervention is anticipated 2
• Avoid inadequate sternal fixation if clamshell is used - augment standard pericostal sutures and sternal wires with K-wire stents or Steinmann pins to prevent override 4

Algorithmic Decision Framework

1. Standard bilateral sequential lung transplant without anatomical complexity → Median sternotomy 1, 2

2. Extensive lower lobe disease or hemithoracic mediastinal involvement → Clamshell incision 4

3. Desire to minimize sternal complications while maintaining bilateral access → Video-assisted bilateral anterior thoracotomy without sternotomy 3, 5

4. Anticipated need for mechanical circulatory support or cardiac procedures → Median sternotomy 2