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16 Aortic Arch andAscending Aorta Replacement
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121
vein over a guidewire is performed, or cannulation of the
superior vena cava using a three-stage cannula achieves
excellent venous drainage. The patient is cooled to 32°C,
and the pericardial eld ooded with CO2. Cold blood cardioplegia is delivered intermittently both ante- and
retro-gradely.
The diseased aorta is excised taking great care not to damage the right pulmonary artery which is frequently adherent
to the back of the aorta. In this eventuality, repair of a damaged pulmonary artery is best done using a pericardial patch
rather than direct approximation. A suitably sized vascular
graft is chosen and cut to an appropriate length. A 4/0 prolene
suture is used to construct the proximal and distal anastomoses. The needle is mounted forehand, and suturing of the
proximal anastomosis begins at 4 o’clock on the graft, passing the needle from outside to inside. The suture length is
equalised, and the distal end pinned to the drapes using a
rubber-shod. Suturing continues with the needle mounted
forehand, passing from native aorta to graft, until about 10
o’clock. The other needle is then used to complete the anas-
tomosis using a forehand suture technique throughout. The
distal aortic suture line is constructed in a similar fashion,
but starting with the needle passing outside to inside of the
native aorta. As this distal anastomosis is coming to a
conclusion, the left ventricular vent is switched off to allow
passive lling of the heart. A ‘Y’-cannula is placed in the
graft and used for venting and delivering a hotshot prior to
clamp removal so the anastomotic patency can be conrmed.
Any remedial sutures are placed if needed, and then after a
thorough de-airing drill, the cross-clamp is removed.
Suggested Reading
Cooley DA. A brief history of aortic aneurysm surgery. Aorta
(Stamford). 2013;1(1):1–3.
Coselli JS. Evolution of aortic arch repair. Tex Heart Inst J.
2009;36(5):435–7.
Xydas S, Mihos CG, Williams RF, LaPietra A, Mawad M, Wittels SH,
et al. Hybrid repair of aortic arch aneurysms: a comprehensive
review. J Thorac Dis. 2017;9(Suppl 7):S629–34.
Part VI
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Surgery of the Failing Heart
Cardiopulmonary Transplantation:
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AnOverview
MariusBerman
17
Heart Transplantation
The rst interhuman, orthotopic, heart transplant was performed by Dr. Christiaan Nethling Barnard at the Groote
Schuur hospital in Cape Town 1967. The patient survived for
18days.
In the current era, there are approximately 5000 transplants performed worldwide each year. The outcomes are
excellent.
The most signicant development in the past 10years is
the advent of hearts that have become usable after circulatory
(DCD) death. It requires utilisation of novel technologies,
with in- or ex situ organ perfusion, to resuscitate and assess
the quality of the heart. The outcome of heart transplantation
with DCD hearts is equal to heart transplantation after brain
death (DBD) [1].
The indication, contraindications [2], and outcomes are as
follows.
Indications
Ambulatory
• Patients on optimal medical therapy with symptoms on
exertion
• More than 2 hospitalisation episodes/year
• Deterioration of renal function or inability to clear heart
failure congestion
• Worsening right ventricular function with rising pulmo-
nary artery pressure
• High natriuretic peptide
• Ventricular arrhythmias
• Anaemia, weight loss, hyponatremia, or liver dysfunction
attributable to heart failure
M. Berman (*)
Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
e-mail: Marius.berman@nhs.net
Urgent Inpatient Referral
• The inability to wean inotropic support
• Mechanical circulatory support for cardiogenic shock
• Pulmonary oedema and ventilation
• Refractory ventricular arrhythmias
Contraindications
• Active infection
• Symptomatic cerebral or peripheral vascular disease
• Diabetes mellitus with end-organ damage
• Current or recent neoplasm
• Forced expiratory volume in 1 s (FEV1) or forced vital
capacity (FVC) <50%
• Irreversible kidney or liver dysfunction (In selected
cases, there is a potential option of combined organ
transplantation)
• Recent pulmonary thromboembolism
• Pulmonary hypertension; systolic pulmonary pressure
>60mmHg, transpulmonary gradient >15 mmHg and/or
pulmonary vascular resistance >5 Wood units. Suitability
is assessed with pharmacological management or bridging with mechanical circulatory support.
• Psychological factors
• Obesity (BMI >35kg/m2)
Outcomes
The outcomes are largely dependent on donor and recipient
factors—to name some—donor age, ischemic time, recipient
pathology, previous surgery, institution volume, geographical region, and many others (Figs.17.1 and 17.2). The full
report is published on a yearly basis by the International
Society of Heart and Lung Transplantation [3].
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. C. Wells (ed.), Atlas of Cardiac Surgery, Springer Surgery Atlas Series, https://doi.org/10.1007/978-3-031-43195-1_17
125
126
ab
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M. Berman
Fig. 17.1 Adult heart recipient survival by era (a) and by region (b). DCM dilated cardiomyopathy, ICM ischaemic cardiomyopathy, HCM hyper-
trophic cardiomyopathy, RCM restrictive cardiomyopathy, CHD congenital heart disease. (From Perch etal. [3]; with permission)
(DCD). This potentially requires in situ or exvivo organ perfusion and ventilation to assess its quality. The matching of
donor and recipient is affected by multiple variables.
Indications
This is a multidisciplinary decision. Patients must meet the
following criteria [4]:
• High (>50%) risk of death due to lung disease within
2years if lung transplantation is not performed.
• High (>80%) likelihood of surviving at least 90days after
Fig. 17.2 Adult heart transplant recipient survival by pathology. DCM
dilated cardiomyopathy, ICM ischaemic cardiomyopathy, HCM hypertrophic cardiomyopathy, RCM restrictive cardiomyopathy, CHD congenital heart disease. (From Perch etal. [3]; with permission)
Lung Transplantation
Lung transplantation progressed signicantly in the past
10 years. Vast majority are performed without mechanical
support, with some units using extracorporeal membrane
oxygenation (ECMO) or cardiopulmonary bypass. The
access is via thoracotomy, sternotomy, or clamshell with
recently reports of robotic-assisted lung transplants. One of
the major developments in lung transplantation is the increasing use of organs from donation after circulatory death
lung transplantation.
• High (>80%) likelihood of 5-year post transplant survival
from a general medical perspective provided adequate
graft function.
Contraindications
• A recent history of malignancy; 5-year disease free interval required
• Poorly controlled signicant dysfunction of another organ
• Coronary disease, non-amenable to revascularisation
• An uncorrectable bleeding disorder
• Poorly controlled infection
• Chest wall or spinal deformity which will affect graft
function
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127
• BMI >35kg/m
2
• Noncompliance with medication
• Psychological factors
• Illicit substance abuse or dependence
Outcomes
Outcomes of Chronic Obstructive Pulmonary Disease
(COPD) recipients are better than other pathologies
(Fig.17.3). In addition, the prognosis of double lung transplantation is better compared to single lung transplantation
(Fig.17.4). The report is published on a yearly basis by the
International Society of Heart and Lung Transplantation.
Fig. 17.3 Adult lung transplant outcome by diagnosis. (From Perch
etal. [3]; with permission)
Fig. 17.4 Adult lung transplant outcome of single versus double lung
transplant. COPD chronic obstructive pulmonary disease, other—
A1ATD alpha 1 antitrypsin deciency, CF cystic brosis, IPAH idio-
pathic pulmonary hypertension, IPF interstitial pulmonary brosis,
retransplantation. (From Perch etal. [3]; with permission)
Conclusion
Cardiopulmonary transplantation has become a fully
accepted therapy with excellent results. Organ donation
remains the rate limiting step but has been enhanced by
recent changes in the law to an opting out system and the
advent of the availability of DCD organs. Until genetically
engineered xenotransplantation becomes a reality and/or
mechanical replacement comes of age, human organ donation will be the mainstay of treatment for cardiopulmonary
failure.
References
1. Messer M, Cernic S, Page A, et al. A 5-year single-centre early
experience of heart transplantation from donation after circulatory
death donors. J Heart Lung Transplant. 2020;39(12):1463–75.
2. Bhagra S, Pettit S, Parameshwar J. Cardiac transplantation: indications, eligibility and current outcomes. Heart. 2019;105:252–60.
3. Perch M, Hayes D, Cherikh WS, Zuckermann A, Harhay MO,
Hsich E, International Society for Heart and Lung Transplantation,
et al. The international thoracic organ transplant registry of the
International Society for Heart and Lung Transplantation: thirtyninth adult lung transplantation report-2022; focus on lung transplant recipients with chronic obstructive pulmonary disease. J Heart
Lung Transplant. 2022;41(10):1335–47. https://doi.org/10.1016/j.
healun.2022.08.007.
4. Weill D.Lung transplantation: indications and contraindications. J
Thorac Dis. 2018;10(7):4574–87.
Lung Transplantation
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PradeepKaul, LuWang, andMohamedOsman
18
Procurement
Lungs are susceptible to damage and injury stemming from
resuscitation, ventilator-associated infection, barotrauma,
and brainstem death process. Therefore, lung allografts have
the lowest utilisation rate for transplantation among all the
solid organs. Due to the increasing disparity between waiting
list and lung transplant activities and change in donor demographics, the donor selection criteria have evolved over time.
Table 18.1 summarises the ideal and extended criteria and
contraindications for donor selection.
Once donor lungs are provisionally accepted by a
transplant centre, donor operation proceeds at a time
agreed by the retrieval teams and donor hospital. Donor
operation is a continuous process of allograft optimisation
and procurement.
Table 18.1 Main donor selection criteria for lung transplantation
Ideal donor Extended-criteria donor Contraindication
Age 25–45years 45–75years >75years
Cause of death No chest trauma
No aspiration
Past medical history Non-diabetic Diabetes mellitus Severe lung pathology
Social history No smoking history <20 pack years history of smoking >20 pack years history of smoking
Ventilation <5days 5–7days
Oxygenation
Bronchoscopy • Clear bronchoscopy • Small amount of white secretion
Chest X-ray Clear chest X-ray Minimal opacity Severe opacity in large proportion of lung eld
Ischaemic time <4h
a
PaO2/FiO2 ratio after at least 10min of ventilation with FiO2 100% and positive end-expiratory pressure (PEEP) of 5–10 cmH2O
a
>350mmHg 200–350mmHg <200mmHg
• Mild inammation in airway
The steps for procurement of a lung block are as follows:
1. Median sternotomy is the commonest incision for cardiothoracic organ procurement. The pericardium is then
opened with an inverted “T” shaped incision.
2. Two or three pericardial stay sutures are placed on each
side of the opened pericardium. The stay sutures are
secured with artery forceps for easy mobilisation of the
pericardium to facilitate access to the bilateral pleural
spaces. Both pleurae are opened, and the lungs are
inspected for the nal component of allograft assessment.
Table18.2 lists the main considerations of the intraoperative evaluation.
If the recipient centre formally accepts the lung allograft
with the nal piece of information, the retrieval team can
proceed to dissection in preparation for lung procurement.
Aspiration pneumonia
• Large amount of secretion or blood
• Secretion reaccumulating
• Gross contact bleeding from airway
• Abnormal bronchial tree anatomy
P. Kaul (*)
Royal Papworth Hospital, Cambridge, UK
e-mail: pradeep.kaul@nhs.net
L. Wang · M. Osman
Transplant Surgery, Royal Papworth Hospital, Cambridge, UK
e-mail: lu.wang@nhs.net; mohamed.osman2@nhs.net
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. C. Wells (ed.), Atlas of Cardiac Surgery, Springer Surgery Atlas Series, https://doi.org/10.1007/978-3-031-43195-1_18
129
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a
b
e
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Table 18.2 Intraoperative ndings for donor lungs assessment
• Palpate to assess adhesions—Adhesion should be safely divided
before lungs are mobilised for inspection to avoid parenchymal
injury, which can compromise donor lung preservation and lead to
prolonged air leak post-transplant.
• Inspect the colour of the lungs—Anthracotic pigment on the
pleural surfaces is expected due to exposure to air pollution and
smoking.
• Inspect for bullae, blebs and scarring—A few bullae or blebs in the
apices are acceptable.
• Examine any parenchymal injury– Contusion or penetration injury
can occur in trauma cases or donors who received aggressive
cardiopulmonary resuscitation.
• Inate the lungs to recruit the atelectatic areas —If atelectasis
recurs, repeat bronchoscopy to remove any secretion reaccumulated
in the airway.
• Deate the lungs—Once lungs are fully recruited, ask the
anaesthetist to deate the lungs at the point of full ination. A
quick collapse of the lungs excludes any airway obstruction.
• Palpate for lung nodules—While the lungs are deated, palpate for
any nodules or mass. If there is a positive nding, biopsy and
frozen section should be performed immediately if possible. All the
transplant centres receiving organs from this donor should be
informed of this nding and the histopathology results.
• Perform differential blood gases—The lungs should then be
ventilated with FiO2 100% and PEEP 5–10 cmH2O for at least
10min before blood samples are collected from each of four
pulmonary veins and an arterial line for systemic gases.
P. Kaul et al.
b
3. Divide the aortopulmonary fold and use blunt dissection
to separate the ascending aorta from the pulmonary artery
(PA) trunk as well as the right PA.
4. Divide the pericardium on top of superior vena cava
(SVC) and isolate it from the surrounding connective tissue and right PA. Place a black silk tie with snugger
loosely around the SVC.
5. Lift the SVC gently and use blunt dissection to isolate
azygos vein which drains into the posterior aspect of
SVC. Place two black silk ties loosely around azygos
vein.
6. Carefully divide the pericardial reection between inferior vena cava (IVC) and right inferior pulmonary vein.
7. Isolation and even division of innominate vein is optional,
but this step helps provide better access to trachea later
during the explant.
The cardiothoracic retrieval team must remain in theatre
while waiting for the abdominal team to complete their dissection in case the donor becomes haemodynamically unstable. Once both the retrieval teams are ready and a cross-clamp
time is agreed with the recipient centres, 300units/kg donor
bodyweight of heparin is given via a central venous line.
8. While waiting for heparin to be circulated in the donor’s
cardiovascular system, insert a 4-0 proline purse-string
suture at the PA bifurcation and the ascending aorta.
9. Place the respective perfusion catheters and secure them
with the purse-string sutures. The perfusion tubing is
c
Fig. 18.1 The surgical steps prior to organ explant. (a) separate
ascending aorta from pulmonary artery trunk, (b) isolate superior vena
cava, (c) dissect around inferior vena cava, (d) insert cardioplegia cannula into ascending aorta, (e) secure perfusion catheter into pulmonary
artery at the level of bifurcation (From Sundaresan et al. [1]; with
permission)
handed out, primed with pulmonary ush solution and
cardioplegia, and connected to the respective perfusion
catheters (Fig.18.1) [1].
10. Use a pair of dissecting scissors to develop the
Waterston’s groove between the left and right atria,
about 1cm anterior and medial to the conuence of the
right superior and inferior pulmonary veins.
Conrm with the abdominal team about the cross-clamp
and venting strategies. It is preferable to cross-clamp the
supradiaphragmatic descending aorta and vent the abdominal organs below the diaphragm. If the abdominal team
requests to cross-clamp the descending aorta above the diaphragm, use blunt dissection to isolate the descending aorta
at the level of diaphragm. If the abdominal team requests
c
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venting to be performed above the diaphragm, prepare
another pool sucker to collect blood and abdominal organ
ush solution returning from the IVC.
Once all the parties are ready for organ explant and the
donor is fully heparinised,
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11. Tie the silk ligatures around the azygos vein and ask the
central venous lines to be withdrawn out of the SVC.
12. Inject 250 mcg of Prostacyclin (PGE1) directly into the
PA trunk to dilate the pulmonary vascular system and
facilitate distribution of the pulmonary ush solution.
13. Tighten the snugger around the SVC to occlude the
venous return from the upper body.
14. Place an angled DeBakey clamp on the IVC just above
the diaphragm to occlude the venous return from the
lower body.
15. Partially divide IVC and left atrial appendage to vent the
heart.
16. Apply a cross-clamp at the distal ascending aorta just
inferior to the innominate artery and deliver the
pulmonary ush solution and cardioplegia through the
perfusion catheters. Make sure the PA pressure does not
exceed 15–20mmHg by placing the cold ush solution
bags about 30–60cm above the donor. During lung perfusion, the tidal volume should be set at 6–8mL/kg ideal
bodyweight, FiO2 at 50% and ination pressure at 15–20
cmH2O.Cover both the heart and lungs with some cold
saline to swiftly reduce the organ temperature and thus
their metabolic rate (Fig.18.2) [1].
17. After the cardioplegia and antegrade pulmonary ush
solution are delivered, the donor heart is retrieved rst.
Make three stabbing incisions into the left atrium at the
appropriate level, one in the middle of the developed
Waterston’s groove, one in the middle of the left atrium
base at 1.5 cm from the coronary sinus by lifting the
ventricles up superiorly, and the last one at the base of
the left atrial appendage.
18. Divide the IVC fully. Extend the stabbing incision in the
Waterston’s groove superiorly towards the base of SVC
and inferiorly to connect to the stabbing incision in the
left atrial base. Continue excising the left atrium towards
the third stabbing incision at the base of the left atrial
appendage and complete the excision by dividing the
left atrial roof.
19. Remove the perfusion catheters. Fully divide the ascending aorta at the level just inferior to the cross-clamp.
Open the pulmonary artery trunk by extending the incision made for the perfusion catheter. Disconnect the PA
trunk from the right and left PA at the level of the bifurcation. Remove the snugger around the SVC and transect the SVC just inferior to the innominate vein. Divide
the azygos vein in between the two sutures. At this point,
cardiectomy is completed (Fig.18.3) [1].
a
b
Fig. 18.2 The surgical steps at the initial stage of organ explant. (a)
Inject Prostacyclin into pulmonary artery, (b) snug superior vena cava,
(c) clamp and divide inferior vena cava, partially divide left atrial
appendage, clamp distal ascending aorta, deliver cardioplegia, and pulmonary ush solution. (From Sundaresan etal. [1]; with permission)
Fig. 18.3 The nal steps for cardiectomy. Divide ascending aorta
close to the cross-clamp, separate pulmonary artery trunk from right
and left pulmonary arteries at the level of bifurcation, and divide superior vena cava. Lower image shows pulmonary venous cuff. (From
Sundaresan etal. [1]; with permission)
20. Deliver 250–500mL of the cold pulmonary ush solution retrogradely into each of the pulmonary vein orice. Make sure the balloon of the retrograde perfusion
catheter seals the pulmonary vein ostium tightly to minimise the ush solution leakage. The retrograde perfu-
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sion can be stopped once the perfusion solution returning
from the respective pulmonary artery is clear without
blood clots.
21. Remove the pericardium anterior to the phrenic nerves
on both sides and inferior to the inferior pulmonary
veins in the mediastinum. Lift the right lung out of the
right pleural space. Complete the division of the right
inferior pulmonary ligament up to the base of the right
inferior pulmonary vein. Dissect the mediastinal pleura
posterior to the right hilum and the connective tissues in
the pre-oesophageal plane from the inferior end until the
azygos vein is encountered. Use blunt dissection as
much as possible to avoid damaging the oesophagus at
this stage. Divide the azygos vein. Place the right lung
back into the right pleural cavity. The same steps are
performed on the left side, except the descending part of
the aortic arch which is divided at this time.
22. During the retrograde perfusion and lung dissection process, the lungs should be continuously ventilated.
23. Pull the aortic arch down and divide it from the three neck
arteries. Clear the tissues in the para-tracheal space bilaterally to isolate the trachea circumferentially. Care shall be
taken to prevent injury to membranous trachea. At this
point, the lung block is only connected to the donor by the
trachea. Ask the anaesthetist to partially retract the endobronchial tube to ensure there is adequate length of trachea
on the lung block side. Place a TA stapler as superior as
possible around the trachea (Fig.18.4). The lungs are ventilated with a peak pressure of 20 cmH2O.When the lungs are
inated, re the TA stapler. Place another stapler proximal
to the rst one. Divide the trachea between the staple lines.
Proximal prevent the spillage of secretion from the upper
airway.
P. Kaul et al.
Fig. 18.5 Package of the lungs
24. Transfer the lung block from the chest cavity to the back
bench. Make a nal inspection of the lungs for parenchymal injury and residual atelectasis. It is possible to
repeat ination or perfusion at this stage. Once the lungs
are ready for package, place them in three sterile bags
each lled with 2L of cold saline or pulmonary ush
solution. Remove all the air from the bags before tying
them with heavy strings (Fig.18.5). The lung block is
then placed into an icebox together with the donor’s
blood samples, lymph nodes, bronchoalveolar lavage
sample, a piece of spleen, and documents. The icebox is
then transported to the transplant centre without unnecessary delays.
Fig. 18.4 Division of trachea and and the left atrial cuff after donor
cardiectomy
Special Considerations if Heart Is Retrieved
forTransplantation
If heart is also retrieved for transplant, use the angled
DeBakey clamp to slightly push against the diaphragm
before occluding the IVC to ensure that there is adequate
IVC on the heart side. This helps avoid damage the coronary
sinus when dividing the IVC. Pay special attention when
separating the left atrium from the cuff around the pulmonary veins. Make sure that there is adequate left atrial cuff
for anastomosis during the heart implantation.
Special Considerations intheDonation After
Circulatory Death Donors
For the donation after circulatory death (DCD) donors, a
futility of continued treatment statement is required to
replace the certicate of brainstem death.
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1. After the retrieval teams are ready, the patient is transferred to the operation theatre or the anaesthetic room of
the theatre where withdrawal of life sustaining treatment
takes place.
2. The patient is positioned with the head of the bed up at
30°. Once ventilation and inotrope support are withdrawn, the patient’s vital signs are closely monitored and
recorded every 5minutes initially. Once the arterial pressure trace becomes a at line (mechanical asystole) and
no respiratory effort is observed, a 5-minute stand-off
period starts.
3. At the end of this stand-off period, circulatory death is
conrmed by an anaesthetist and the donor is expeditiously prepared for organ donation. While the donor is
being cleaned and draped, re-intubation and
bronchoscopy are performed at the same time. After a
rapid sternotomy and opening of the pericardium,
25,000 units/kg of heparin is injected into the PA. A
purse-string suture and pulmonary ush perfusion catheter are placed on the main PA.
4. At 10minutes from the mechanical asystole, a single tidal
breath is given.
5. The SVC, IVC, descending aorta, and ascending aorta are
clamped in sequence. Once the aorta is clamped, ventilation can be re-started.
6. The left atrial appendage is amputated to facilitate venting. The antegrade pulmonary ush perfusion is then
delivered.
7. The donor lung assessment is performed after the antegrade perfusion completes.
8. If the lungs are accepted for transplant, lung block explant
and preservation are carried out in the same way as for the
brainstem death donors.
Implantation
Some lung recipients’ clinical condition deteriorates since
they are listed for transplantation. Therefore, patient reviews
immediately before the operation is important.
Once the donor lungs are formally accepted after the
additional information from the retrieval team’s assessment
is gathered, the recipient can be sent to theatre for anaesthesia. A double lumen endotracheal tube, ideally a left sided
one, is placed to facilitate single lung ventilation during the
operation. In addition to the central venous catheter and arterial line, it is preferrable to have a pulmonary artery catheter
inserted via recipient’s right internal jugular vein, transoesophageal echocardiography probe ready for cardiac function assessment, and cerebral saturation monitoring set up to
observe cerebral perfusion throughout the procedure.
The recipient is placed in a supine position, with arms
either tucked in loosely or secured to the armrests in the
extended position away from the body, to facilitate surgical
exposure to the mid-axillary lines. To improve surgical
access during the operation, rolls or pneumatic bags can be
placed under the chest to push the operative side up. In addition, the operative table can be rotated, provided the recipient
is securely strapped to the operating table.
The common incisions for lung transplantation are clamshell or transverse thoraco-sternotomy, anterolateral thoracotomy, and median sternotomy (Fig. 18.6). Individual
transplant centres have described video-assisted thoracoscopic surgery and robotic-assisted approaches with smaller
incisions, such as mini-anterior thoracotomies.
The choice of incision depends on the indication for
transplantation, requirement of mechanical circulatory support, and surgeon’s personal experience and preference.
For clamshell incision,
1. Mark the second to sixth ribs on both sides.
2. Make a skin incision in the sub-mammary fold simulta-
neously on both sides and join them across the sternum
at the level of fourth intercostal space.
3. Dissect into the retro-mammary plane and raise a ap.
4. Enter the pleural cavities through the fourth intercostal
space.
5. Identify and ligate the internal mammary arteries on
both sides as the dissection approaches towards the
sternum.
6. Make a transverse sternotomy at the level of fourth inter-
costal space.
7. Divide the mediastinal pleura to the level of
pericardium.
8. Place a Finochietto retractor on each side and open them
simultaneously.
9. Divide the intercostal muscles at the top of the bottom
rib. In each opened space, this helps in avoiding rib fractures whilst opening the retractor for access.
10. The serratus muscle bres can be prized apart without
dividing.
11. Latissimus dorsi muscle is spared.
For anterior thoracotomy incision, the skin incision is also
made in the sub-mammary fold and a ap is raised as the
dissection proceeds in the retro-mammary plane. The pleural
cavity is entered via the fourth or fth intercostal space. It is
certainly preferred over the clamshell incision in the cases of
single lung transplantation. In bilateral sequential lung transplantation, it does avoid the sternal related complications
like malunion. It also allows better respiratory effort in the
immediate post-operative period. However, the recipient’s
groin areas need to be prepared to establish extra-corporeal
membrane oxygenation via femoral cannulation in case
mechanical circulatory support is required during the
operation.
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