Lung Transplant Surgical Technique

Lung transplantation replaces one or both diseased native lungs with donor lungs, restoring three anastomoses per lung: the bronchus, the pulmonary artery, and a left atrial cuff carrying the pulmonary veins. It may be performed as a single-lung or bilateral sequential operation, and is the principal surgical option for selected patients with end-stage lung disease.

Definition

Lung transplant surgical technique is the implantation of one or both donor lungs by anastomosing, for each lung, the bronchus (airway), the pulmonary artery, and a left atrial cuff incorporating the pulmonary veins, performed as a single-lung transplant or as a bilateral sequential transplant.

Scope

The topic covers the single-lung and bilateral sequential implantation techniques and the three lung anastomoses, together with the surgical incisions used. Donor lung procurement and preservation, recipient selection, ex vivo lung perfusion, and rejection are addressed in neighbouring entries.

Core questions

• Which three anastomoses are required to implant each lung?
• How does single-lung transplantation differ from bilateral sequential transplantation?
• What surgical incisions and exposures are used?
• When is cardiopulmonary bypass or extracorporeal support employed?

Key concepts

• Bronchial anastomosis
• Pulmonary artery anastomosis
• Left atrial cuff (pulmonary vein) anastomosis
• Single-lung transplantation
• Bilateral sequential transplantation
• Clamshell (transverse thoracosternotomy) incision
• Extracorporeal support during implantation

Mechanisms

Each donor lung is implanted with three anastomoses: the bronchus is joined to restore the airway, the pulmonary artery is anastomosed to restore pulmonary blood flow, and a left atrial cuff incorporating the donor pulmonary veins is sewn to the recipient left atrium to restore venous return. A single-lung transplant implants one lung, usually through a posterolateral thoracotomy; a bilateral sequential transplant implants both lungs in turn, frequently through a transverse thoracosternotomy (clamshell) incision or bilateral thoracotomies, with the second lung implanted while the first supports gas exchange. The clamshell approach requires reliable sternal reapproximation, the technique of which influences healing and chest wall stability (keshavamurthy-2014). Cardiopulmonary bypass or extracorporeal membrane oxygenation may be used when the recipient cannot tolerate single-lung ventilation or clamping of the pulmonary artery (watson-dark-2012).

Clinical relevance

Lung transplantation is a surgical option for selected patients with end-stage lung disease, and the implantation technique affects airway healing, graft perfusion, and chest wall recovery. This entry describes the operation for educational reference and is not a source of operative instruction or individualized clinical guidance.

Epidemiology

Bilateral sequential transplantation is common for suppurative and many fibrotic and obstructive diseases, while single-lung transplantation may be used in selected recipients; the choice depends on the underlying disease and recipient factors (watson-dark-2012).

Evidence & guidelines

Modern isolated lung transplantation grew out of combined heart-lung transplantation, successfully reported by Reitz and colleagues for pulmonary vascular disease (reitz-1982). Contemporary single-lung and bilateral sequential techniques and the use of extracorporeal support are summarized by Watson and Dark (watson-dark-2012), and technical aspects such as sternal closure after the clamshell incision are addressed in the operative literature (keshavamurthy-2014).

History

James Hardy performed the first human lung transplant in 1963, but durable success awaited later advances; Reitz and colleagues demonstrated successful combined heart-lung transplantation in 1981 (reitz-1982), and Joel Cooper's group achieved sustained success with isolated lung transplantation in the 1980s, after which single-lung and bilateral sequential techniques were standardized (watson-dark-2012).

Debates

Single-lung versus bilateral lung transplantation

Single-lung transplantation uses fewer donor organs and a smaller operation, while bilateral transplantation is preferred for suppurative disease and may offer durability advantages in some indications; the optimal choice depends on the underlying disease and remains a clinical judgement.

Key figures

• James Hardy
• Joel Cooper
• Bruce A. Reitz

Seminal works

• reitz-1982

Frequently asked questions

What are the three connections made when implanting a lung?

For each lung, the surgeon joins the bronchus (to restore the airway), the pulmonary artery (to restore blood flow to the lung), and a cuff of left atrium carrying the pulmonary veins (to restore blood flow back to the heart).

What is a clamshell incision?

It is a transverse thoracosternotomy — a horizontal incision crossing the chest and dividing the sternum — that gives wide exposure to both pleural cavities and is often used for bilateral sequential lung transplantation.