Routine preoperative laboratory studies and a chest radiograph are ordered on the day of the transplant procedure. Blood pressure monitoring is achieved by an arterial line placed prior to induction of anesthesia.

Operative informed consent should include a clear statement regarding the possibility of transmission of infectious disease or malignancy from the donor as well as whether the donor is considered a Centers for Disease Control and Prevention (CDC) high-risk donor.

Standard operative risks should be discussed, including but not limited to bleeding, infection, immunosuppression
complications, allograft dysfunction, airway or vascular anastomotic complications, need for prolonged mechanical ventilation and tracheostomy, acute and chronic rejection, need for mechanical circulatory support such as extracorporeal membrane oxygenation (ECMO), and death.

In patients who are certain to require cardiopulmonary bypass (CPB) during the operation, a single lumen endotracheal tube can be used. Patients undergoing lung transplantation without CPB are typically intubated with a left-sided, double lumen endotracheal tube to allow for selective lung ventilation during the procedure.

A Swan-Ganz pulmonary artery (PA) catheter with an introducer sheath for large-volume resuscitation is placed following induction of anesthesia, usually via the right internal jugular vein. The tip of the PA catheter is advanced just beyond the pulmonary valve, so as not to interfere with stapling of the PA at the time of recipient pneumonectomy. The presence of pulmonary hypertension may warrant CPB for the operation’s safe conduct. The perfusion team should be present in the operative suite throughout the procedure, as CPB may be needed emergently at any time.

A transesophageal echocardiogram is performed routinely in all patients to assess ventricular function, rule out associated cardiac anomalies, assist in de-airing at the end of the procedure, and assessing the vascular anastomoses.

A Foley urinary catheter is placed.

Perioperative antibiotics are center-specific. We typically employ cefuroxime for perioperative coverage in addition to vancomycin on a selective basis. Postoperative antibiotics are chosen based on donor and recipient airway cultures.

One gram of methylprednisolone is administered prior to reperfusion of the right lung allograft.

Position the patient with both arms tucked. In the case of the clamshell incision, a vertical back roll is placed in order to further elevate the lateral chest off the operative table.

Mark the proposed incision on the patient. In the case of the clamshell approach, the 4th intercostal space is marked as well as the inframammary crease, particularly in women. In the case of a median sternotomy approach, the central part of the sternum is marked. Both femoral arteries are marked in case the patient requires postoperative ECMO support.

Widely prep and drape the chest, abdomen, pelvis, groins, and legs. The prep should extend laterally to the midaxillary line for the clamshell approach. An iodine-impregnated drape is placed over the skin.

A cell saver is used in all cases. This is helpful in blood salvage prior to and following CPB. A separate “dirty” suction catheter is used to suction the bronchus of airway secretions.

Especially in the case of inflammatory lung disease such as cystic fibrosis or bronchiectasis, frequent bronchoscopic suctioning of the airways by the anesthesia team is necessary.

Our institutional preference is to perform bilateral sequential lung transplantation through either a trans-sternal bilateral anterolateral thoracotomy “clamshell” incision (FIG 1) or a median sternotomy, depending on surgeon preference. Alternatively, bilateral anterolateral thoracotomy incisions through the 4th intercostal space can be made, avoiding the need for sternal division (FIG 2). This limits surgical exposure but results in superior sternal stability. Two perpendicular retractors are used per side to expose the hilar structures. In the absence of sternal division, if CPB is needed, then either peripheral groin cannulation can be used or central cannulation of the right atrium and ascending aorta through the right thoracotomy.

In women, the anterolateral thoracotomy incision should be in the inframammary crease. Flaps should be elevated to allow entry into the 4th intercostal space. In large
breasted women, a retraction stitch is sometimes placed through the breast tissue and secured superiorly to the drape to allow better exposure.

In the setting of single lung transplantation, the 4th intercostal space is typically used. Due to anatomic differences between the right and left hilum, a posterolateral approach offers some advantage on the left side, whereas an anterior thoracotomy is almost always preferable on the right side.

In the case of a clamshell incision, following entry into the pleural space, the intercostal muscles are incised laterally with electrocautery to the paraspinal ligaments to allow less traumatic opening of the thoracotomy retractor. Both internal mammary artery pedicles are clipped, divided, and oversewn. Both pleural spaces are entered and bilateral thoracotomy retractors are placed.

Mediastinal structures should be mobilized prior to heparinization and CPB. Pericardial stay sutures are placed and the right and left pulmonary arteries and the right-sided pulmonary veins are mobilized.

The routine use of CPB in bilateral lung transplantation is controversial. Most centers rarely use it for single lung transplantation unless there is intraoperative hemodynamic instability. In the setting of bilateral lung transplantation, some centers use CPB selectively and others routinely.

We prefer to use CPB for the majority of bilateral lung transplants. We believe this results in more stable hemodynamics, faster recipient pneumonectomy and implantation, quicker blood salvage through cardiotomy suckers, and avoidance of exposure of the ischemic first lung allograft to the entire cardiac output while the second lung allograft is implanted. Disadvantages include the potential for systemic inflammatory response, the need for arterial and venous cannulation, and the potential for increased postoperative bleeding from acquired coagulopathy and increased transfusion requirement.

The use of a median sternotomy incision, in contradistinction to a clamshell incision, requires CPB in all cases because exposure of the left hilum is otherwise impossible without decompression of the heart. Likewise, if concomitant cardiac surgical procedures are to be performed, then CPB is necessary.

The institution of CPB should be done when the procurement team is en route to the operative suite. After full heparinization, arterial cannulation is accomplished through the ascending aorta. Venous cannulation is via a two-stage cannula in the right atrial appendage or via bicaval cannulae in the superior and inferior vena cava, depending on surgeon preference.