Surgical Aspects of Lung Transplantation

The main surgical issues facing lung transplant surgeons today are access to the thorax, anastomotic problems and size mismatch of the lungs. As double lung transplantation becomes more popular, with survival advantage being demonstrated for more conditions, the clam shell incision is being increasingly utilized. However,problems with healing of the transverse sternotomy, particularly in immunocompromised patients, is a significant source of post operative morbidity. This chapter will review various techniques to improve sternal apposition and healing and discuss alternatives to the clam shell incision. Dealing with anastomotic size discrepancy, and avoiding problems intra-operatively are of paramount importance when performing lung transplantation. This chapter will review techniques for dealing with inadequate cuffs at the venous and arterial anastomsoses and techniques for performing the bronchial anastomosis. Size mismatch between donor and recipient is an important issue with paediatric and small adult recipients being disadvantaged on the waiting list. The use of lobar transplantation, non anatomical cut down and split lung transplantation has allowed larger donor lungs to be downsized for use in smaller recipients. There are also instances during surgery when donor lungs are larger than expected for the recipient and size reduction is required for an ideal fit. This chapter discusses the sizing issues that impact on outcomes in this group of patients.