Sternum Sparing Thoracotomy Incisions in Lung Transplantation Surgery a Superior Technique to the Clamshell Approach

Abstract

Objective Bilateral anterior transsternal thoracotomy incision (clamshell technique) is the standard approach used for bilateral sequential lung transplantation (LTX). The morbidity and wound complications of this large incision can be considerable and costly. Muscle sparing anterior thoracotomies without division of the sternum may lead to decreasing the sequelae of wound complications. The objective of this study was to determine the rate of wound complications in the nonsternal incising lung transplant patients. Methods We used the single-institution-based transplant data bank, phone questionnaire, and ambulatory care unit follow-up data to investigate retrospectively the incidence of wound healing complications following muscle and sternum sparing and mammary artery protecting limited access small submammary anterior thoracotomy incisions (AT) for LTX surgery. In the need for cardiopulmonary bypass, the femoral artery and vein were cannulated. Results After exclusion of seven clamshell operations for LTX combined with cardiac surgery, 91 recipients (65% male), aged 19 to 68 years (mean, 54 ± 8 years), underwent 84 AT and 48 lateral thoracotomies (LT) for idiopathic pulmonary fibrosis (IPF) (48%), obstructive disease (40%), cystic fibrosis (CF) (5%), and pulmonary arterial hypertension (PAH) (7%). AT ranged from 5.5 to 26 cm (mean, 20.3 ± 4.8 cm) and LT from 12 to 25 cm (mean, 19.8 ± 2.4 cm) and was not significantly different (P = 0.37). Warm ischemic times ranged from 30 to 92 minutes (mean, 56 ± 11 minutes). Four patients required rethoracotomy for bleeding/hematoma formation. Cardiopulmonary bypass/intraop extracorporeal membrane oxygenation (ECMO) was used in 64%. Superficial wound infection and subsequent drainage/care was needed in four LTX incisions. Reoperation for lung herniation using patch repair technique for thoracic wall stabilization was required in two AT and three LT. Conclusions Sternum sparing and mammary artery protecting limited access submammary anterior and lateral thoracotomy incisions for LTX surgery are safe and effective. This approach avoids complications related to sternal transaction and may minimize the development of severe wound complications following LTX surgery.