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 Table of Contents  
Year : 2020  |  Volume : 6  |  Issue : 3  |  Page : 278-291

Lung Transplantation: The Indian Experience and Suggested Guidelines Part II A: The Technique of Lung Transplantation

1 Department of Heart and Lung Transplantation, Apollo Hospitals, Chennai, Tamil Nadu, India
2 Department of Cardiothoracic Surgery, All India Institute of Medical Sciences, New Delhi, India
3 Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India

Date of Submission18-Nov-2020
Date of Decision22-Nov-2020
Date of Acceptance22-Nov-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. Thirugnanasambandan Sunder
Department of Heart and Lung Transplantation, Apollo Hospitals, 21 Greams Lane, Off Greams Road, Chennai - 600 006, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcs.jpcs_108_20

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Background: A series of lectures and workshop on lung and heart–lung transplantation were organized by the Departments of Cardiology and Cardiothoracic Surgery at All India Institute of Medical Sciences, New Delhi, and the Department of Heart and Lung Transplantation at Apollo Hospitals, Chennai. The 1st day workshop on preoperative workup part was published as Part-I in this journal in August 2018. The hands-on cadaveric workshop conducted on May 20, 2018, forms the basis of the first section of the second part (Part II a) which deals with the technique of lung transplantation. The techniques of lung transplantation and Indian scenario are also reviewed. Methodology: The technique practiced by the transplant team at Apollo Hospitals, Chennai, was used for the demonstration of donor lung, heart–lung block harvest and implanting lungs, heart–lung block, while also discussing other possible techniques. Human cadavers were used, and live high-definition audio–video transmission to the lecture hall was made. Results: Accurate figures regarding lung transplantation in India are still not available. However, as per the Indian Society for Heart and Lung Transplantation, current data suggest that overall, about 1050 heart transplants and 310 lung transplants have been done in India. Of these, it is anticipated that national data regarding number of single-lung transplants, double-lung transplants, and heart–lung transplants will be available soon. The Department of Heart and Lung Transplantation at Apollo Hospitals, Chennai, has performed a total of 69 hearts and 149 lungs in 119 patients in various combinations: isolated heart transplants (40 patients), double-lung transplantation (DLT) (43 patients), single-lung transplantation (7 patients), heart and DLT (27 patients), en bloc heart and liver transplantation (1 patient), and combined heart–lung and kidney transplantation (1 patient). While the survival data for India are not currently available, our 3-year survival for DLT is 76.2%. Conclusions: While the surgical technique demonstrated is used in most of our cases, at times, different techniques have had to be adopted based on challenges confronted on the operating table. However, we have found that developing surgical protocols and maintaining consistency in the operative techniques translates into good surgical outcomes.

Keywords: Bronchial anastomosis, clamshell incision, lung transplantation

How to cite this article:
Sunder T, Ramesh PT, Kuppuswamy MK, Choudhary SK, Hote MP, Devagourou V, Rajashekar P, Singh SP, Seth S. Lung Transplantation: The Indian Experience and Suggested Guidelines Part II A: The Technique of Lung Transplantation. J Pract Cardiovasc Sci 2020;6:278-91

How to cite this URL:
Sunder T, Ramesh PT, Kuppuswamy MK, Choudhary SK, Hote MP, Devagourou V, Rajashekar P, Singh SP, Seth S. Lung Transplantation: The Indian Experience and Suggested Guidelines Part II A: The Technique of Lung Transplantation. J Pract Cardiovasc Sci [serial online] 2020 [cited 2022 Jan 21];6:278-91. Available from: https://www.j-pcs.org/text.asp?2020/6/3/278/304520

  Introduction Top

As a continuation of the first workshop on lung transplantation,[1] the second hands-on human cadaveric workshop on lung transplantation was jointly organized by the Departments of Cardiothoracic Surgery and Cardiology, All India Institute on Medical Sciences (AIIMS), New Delhi, and the Department of Heart and Lung Transplantation, Apollo Hospitals, Chennai, on May 20, 2018. This interactive workshop was organized at the state-of-the-art facility in AIIMS Trauma Centre at the Advanced Trauma Skills and Simulation Facility [Figure 1]. This center has modern lecture hall [Figure 2] and fully equipped dissection theater. The real-time high-definition audio–video transmission from dissection room to the lecture hall enabled live discussions between the audience and operating team. This article is illustrated with images which are captured from the high-definition video during the workshop. We have used the technique that we routinely use at our Department of Heart and Lung Transplantation, Apollo Hospitals, Chennai.
Figure 1: Hands-on workshop team at advanced trauma skills and simulation facility at AIIMS, New Delhi.

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Figure 2: Lecture hall at the facility which is online with dissection theater.

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The second section of the second part (Part IIb) deals with surgical aspects of heart–lung transplantation (HLT). The third part deals with the postoperative management of lung and HLT.

  Methodology Top

Three well-preserved, fresh, human cadavers were organized at the above facility which was fully equipped with all surgical instruments, sutures, and high-definition video recording apparatus [Figure 3] with capability of live transmission to the lecture hall. In two cadavers, the technique of harvesting the lungs and heart–lung block was demonstrated via midsternotomy. In the third cadaver, the access to chest via clamshell incision and technique of native lung explant and implant of donor lung was demonstrated. High-quality audio transmission enabled real-time live discussions. The technique practiced by the transplant team at Apollo Hospitals, Chennai, was used, while also discussing other methods during the workshop. The other techniques are mentioned at appropriate places with references for further reading.
Figure 3: High-definition video equipment recording the procedure in dissection theater for live transmission to the lecture hall.

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Full approval from the Institutional Ethics Committee (dated 31 Jul 2020 for IEC Application No: AMH-C-S-016/07-20) was obtained for retrospective review of outcomes of lung transplantation performed in our unit. The outcomes after double-lung transplantation (DLT) have been analyzed retrospectively.

Indian data on lung transplantation

Compilation of data about heart and lung transplantation has been a challenge in India. The Indian Society of Heart and Lung Transplantation (INSHLT) has embarked on the arduous task of collecting data and building a database for patients requiring isolated heart, isolated lung, combined heart–lung transplantation, and mechanical circulatory support and to maintain an Indian Transplant Registry. Data collection and compilation is in its initial stages.

Although accurate figures are still not available, as per the INSHLT, current data suggest that over 1050 heart transplants and about 310 lung transplants have been done in India. While heart transplantation is being done in 65 centers across India, lung transplants were done in only 15 centers in different states of India. Of 15 centers, 9 centers have done <10 lung transplants each. The remaining 6 centers have done more than 10 lung transplants each. However, currently, the data are crude with no distinction between single-lung transplant, DLT, and heart–lung transplantation. The INSHLT is in the process of collecting in-depth data to enable generation of reports pertaining to the Indian scenario.

Data from the Department of Heart and Lung Transplantation, Apollo Hospitals, Chennai

The Department of Heart and Lung Transplantation at Apollo Hospitals, Chennai, has assessed a total of 350 patients and transplanted 218 organs in 119 patients. This includes 69 hearts and 149 lungs. The transplantations were in various combinations: 40 patients had isolated heart transplantation, 43 patients underwent double-lung transplantation (DLT), 7 patients had single-lung transplantation (SLT), 27 patients had HLT and DLT, 1 patient underwent en bloc heart and liver transplantation, and finally, 1 patient had a combined heart–lung and kidney transplantation. Since 2017, we have standardized each step of our technique of DLT and established that it gives consistently good results. Analysis of overall survival for double-lung transplants after our standardization has shown a 3-year survival of 76.2% [Figure 4].
Figure 4: Kaplan–Meier curve showing 3-year survival of 76.2% after double-lung transplantation.

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While a lot of advancements and rapid strides have been made in the field of lung transplantation in areas such as donor management, ex vivo perfusion, immunosuppression, and understanding of molecular basis of rejection, the surgical techniques of lung transplantation have had only minor modifications in the recent years.[2] Hence, articles on surgical techniques are infrequently published.

Technique of lung transplantation

Surgical strategy

For DLT, we routinely use extracorporeal membrane oxygenation (ECMO) support in a central venoarterial (V-A) configuration with bicaval venous drainage and arterial return to the ascending aorta. However, since early times, many centers have done bilateral sequential lung transplantation without using cardiopulmonary bypass, reserving its use only if needed.[3]

For SLT, we plan for an operation without any ECMO support. If the patient tolerates trial clamping of the pulmonary artery (PA) with collapse of ipsilateral lung for 5 min and the contralateral lung can maintain oxygenation with stable hemodynamics, we proceed without ECMO. The perfusionist is always, however, available in theater ready to go on in a matter of minutes, should the need arise.

Anesthesia and lines

Surgical team should be present right from induction. A perfusionist is always in theater with the ECMO circuit assembled and primed before induction.

Induction is done with fentanyl and midazolam. Rocuronium is the preferred muscle relaxant. Inhalation agents used are sevoflurane with oxygen mixture. Nitrous oxide is avoided due to its effect of raising pulmonary vascular resistance. Anesthesia is maintained with fentanyl infusion and rocuronium infusion. A nasogastric tube is placed under vision with laryngoscope just before endotracheal intubation. A single-lumen endotracheal tube (ET) is used for DLT and a left endobronchial double-lumen tube is used for SLT. Monitoring lines include right radial and left femoral arterial lines. Central venous cannulation of right internal jugular vein (IJV) and right femoral vein (RV) is done, which facilitates easy placement of ECMO venous cannula, should ECMO support be needed postoperatively. Wide bore venous access is available for rapid infusion, if needed. A nasopharyngeal temperature probe and Foley's indwelling urinary catheter are also sited.

Perioperative immunosuppression

Induction therapy with 20 mg of basiliximab given intravenously 20 mg over 20 min. Furthermore, 500 mg of methyl prednisolone is given intravenously over ½ h. Pantoprazole is given as a single bolus dose of 40 mg intravenously followed by a continuous infusion at 8 mg/h.

Extracorporeal perfusion considerations

The ECMO circuit is assembled in a V-A configuration and primed before induction. It is assembled as a closed circuit with reservoir incorporated but excluded or bypassed from the circuit using tubing clamps. Thus, there is no reservoir in the active circuit and hence activated clotting time (ACT) can be maintained at relatively lower levels (160 to 180 s). Incorporation of a reservoir during circuit assembly and then excluding from the circuit by tubing clamps is a safety measure in case of venous air lock or surgical mishap. In such cases, it is a simple matter of letting the reservoir in by unclamping the tubes. In such an emergency, no extra heparin is needed since heparin is added previously into the reservoir. Once the emergent situation is tackled, the reservoir is excluded as before using tubing clamps and the ACT is allowed to spontaneously fall and is maintained between 160 and 180 s.

Position of the recipient

  • DLT: Supine position with arms abducted 90 degrees at the shoulder
  • SLT: Lateral position.


Double-lung transplantation

We routinely use bilateral anterior thoracotomy with transverse sternotomy (clamshell incision) though some centers use a median sternotomy.[4] In 2020, Shudo et al. from Stanford Group compared median sternotomy with clamshell incision in 192 patients and did not find any statistically significant difference between the two approaches in terms of survival or postoperative morbidity.[5] The clamshell incision offers excellent exposure, but can be painful and affects chest wall mechanics. Sternotomy, on the other hand, is less painful, but the exposure is limited, especially for the pulmonary vein (PV) anastomosis on the left side.[6] Some centers recommend bilateral anterior thoracotomy without sternal split.[7] Minimally invasive video-assisted approach has also been described for DLT.[8]

Single-lung transplantation

We use a posterolateral thoracotomy.

Steps of the double-lung transplant procedure

  1. Clamshell incision
  2. Mediastinal dissection
  3. Institution of central V-A ECMO
  4. Native right lung explant
  5. Bench work: Donor right lung hilar preparation
  6. Donor right lung implant
  7. Reperfusion of the implanted right lung
  8. Left side procedure
  9. Separation from V-A ECMO
  10. Hemostasis
  11. Closure of clamshell.

Steps of clamshell

We have described this method in detail since this is not a commonly performed incision. The sternal  Angle of Louis More Details which corresponds laterally to the second costal cartilage is palpated, and the spaces are counted down to the fourth space [Figure 5] on both sides and spaces marked.
Figure 5: Fourth intercostal space being palpated.

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The skin incision is a curved one with concavity upward extending from the anterior axillary line and is over the 4th intercostal space until the lateral sternal border on either side. The medial ends of the incision are then joined [Figure 6]. In female patients, a submammary skin incision is used, and the breast tissue mobilized superiorly. The spaces are then counted and the fourth space on both sides located and marked with cautery.
Figure 6: Skin incision.

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Entering the pleural cavity

The pectoralis muscle is incised along the proposed incision with diathermy. The fourth intercostal muscle is carefully dissected off the superior border of the 5th rib at one point until the parietal pleura is reached. After a period of hyperoxygenation for 3 min, the anesthetist is asked to disconnect the ET for a brief period to allow the lungs to deflate and fall away from the chest wall. The parietal pleura is then incised at one point and a finger inserted to ensure that the lungs are away. The finger is then inserted fully along the superior border of the 5th rib, and the 4th space is opened using diathermy on the superior border of the 5th rib using the finger as a guard against injuring the underlying lung [Figure 7]. This step is important in patients with interstitial lung disease (ILD) because the lungs are fibrotic and noncompliant and any injury to the lung will preferentially allow escape of tidal volume leading to inability to ventilate and dangerous hypoxia.
Figure 7: Finger inside pleural cavity guarding the lung beneath while entering the pleural cavity.

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As the intercostal muscle division approaches the lateral end of the sternum, care is taken to divide only the muscle and stop short just superficial to internal mammary artery (IMA) pedicle. In patients with wide spaces and wide subcostal angles, the IMA pedicle can be seen and is controlled with large Ligaclips or suture and divided in between. In some patients, due to significant crowding of ribs and costal cartilages, it may not be possible to see the IMA. Use of harmonic scalpel to coagulate and divide is appropriate. At times, if the pedicle cannot be secured, the same can be secured after transverse sternotomy and under vision. Transverse sternotomy using a sternal saw is performed with the saw tilted at an angle [Figure 8]. This results in beveled sternal edges which help in secure sternal approximation and better healing.
Figure 8: Sternal saw held at an angle to have beveled sternal edges to aid approximation.

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Opening of the clamshell incision is done [Figure 9] gradually using two retractors on either side, opening equally on both sides. Care is taken to avoid rapid spreading of retractors which can cause rib fractures, especially on those with osteoporotic ribs (prolonged steroid therapy). The divided ends of the IMA are inspected on both sides and secured if necessary.
Figure 9: Open clamshell incision.

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Mediastinal dissection

The thymus gland is divided in the midline until the innominate vein is visible. The pericardium is incised longitudinally from the superior pericardial reflection down until the diaphragm. This incision is to the right of the midline [Figure 10], so that there is enough pericardium covering and protecting the heart during left-sided manipulations and implantation of the donor left lung. Lower end of the incision is extended laterally on both sides converting it into an “inverted T” incision.
Figure 10: Opening pericardium to the right of midline.

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Institution of V-A ECMO: Systemic heparinization is given aiming for an ACT of 160–180 s. Concentric purse-string sutures are placed on the ascending aorta, superior vena cava (SVC), lower lateral wall of the right atrium (RA), and main PA (MPA). Care is taken during placement of purse strings to site them in areas of thick-walled RA to ensure airtight snugging of the venous cannula. This is important because entraining air can cause venous airlock leading to stopping of the pump. Central V-A ECMO is established using bicaval venous cannulation and ascending aortic cannulation. A vent is sited in the PA, which is connected to the venous line and V-A ECMO is initiated.

Recipient native right lung explantation (recipient right pneumonectomy)

Once ECMO is established with full flows, the ventilator is disconnected from the ET tube and this allows collapse of lungs. The pericardial stay sutures on the right side are swung over to the left side after moving all the venous pipes to the left side. This maneuver frees up the right pleural cavity. The pleura is widely opened longitudinally from the top at the level of root of neck down to the diaphragm.

Mobilizing the lung off the chest wall, mediastinum, and diaphragm

With lung collapsed on full flows with ECMO, the right lung is carefully mobilized off the chest wall, apex, diaphragm, and medially from the mediastinal pleura. In virgin chests, the lung surfaces are often free with occasional flimsy adhesions. Previous thoracotomy, surgical lung biopsy, or intercostal drainage sites may have adhesions. These adhesions are to be carefully divided ensuring hemostasis, since these adhesions can be vascular and cause troublesome bleeding later.

Identification of phrenic nerve from apex of chest to diaphragm

This is an important step and is done to prevent any inadvertent injury during later dissection and its importance cannot be overemphasized. The nerve is seen coursing caudally, lying on the mediastinal pleura on lateral surface of the SVC, and as it reaches the hilum, it runs on the mediastinal pleura over the pericardium traveling anterior to the hilum [Figure 11] until it reaches the diaphragm. Excessive mediastinal adipose tissue due to chronic steroid therapy is often encountered, which obscures the phrenic nerve. In such scenarios, it is prudent to stay as close to the hilar vessels and use diathermy at as low settings as possible.
Figure 11: The right phrenic nerve is seen on the pericardium and the surgeon's hand is seen retracting the right lung laterally.

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Division of the inferior pulmonary ligament

The inferior pulmonary ligament is attached to the posteromedial border of the lower lobe and is divided under vision with diathermy. There is a constant spurter, which needs to be cauterized well. The assistant retracts the heart gently with his right hand toward himself and uses a Deaver's retractor with his left hand over the dome of the diaphragm (keeping a sterile pad on the diaphragm) and retracts the right dome of the diaphragm caudally. The surgeon then holds the right lower lobe taut and pulls it toward himself. This maneuver will put the inferior pulmonary ligament to a stretch, and it can be easily divided using diathermy under vision.

Right hilar dissection

Once the lung is freed all around, attention is turned to the hilum of the right lung. The pleura overlying the hilum is incised with diathermy at low setting anteriorly keeping away from the previously identified phrenic nerve. Sometimes, hilar nodes can be troublesome obscuring view and are often vascular. The trick here is to avoid grasping the node with forceps, which will result in bleeding and to hold only the perinodal tissue [Figure 12]. With gentle maneuvering, nodes are best excised in toto, just enough for dissection of hilar structures, so that anastomoses can be safely performed. No attempt is made to do extensive lymphadenectomy.
Figure 12: Hilar node is being dissected off the right superior pulmonary vein. Note that it is held by perinodal tissue with forceps. The phrenic nerve and right superior pulmonary vein are also seen.

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Dissecting the right pulmonary artery

The right pulmonary artery (RPA) exits the pericardium just posterior to the SVC and enters the right hilum. Most often, a tributary of the right superior PV (RSPV) is seen crossing it anteriorly, and once this is divided between ligatures, the RPA is easily seen. With the assisting gently retracting the SVC toward the left and the surgeon gently pulling the right upper lobe (RUL) toward himself, the RPA can be seen. Sharp dissection helps and we need to be in the correct plane to go around the RPA [Figure 13]. For this step, the RPA is dissected anteriorly away from SVC, superiorly below the azygous vein as it arches to enter the SVC and inferiorly from the RSPV. Once the RPA is encircled with a tape, sharp dissection distally is done toward its branches which are ligated and divided. We always divide the recipient PA at its branches and not the MPA, because in case there is gross size mismatch with aneurysmal PA, the donor PA can be anastomosed to one of the branches of the recipient PA.
Figure 13: Right pulmonary artery dissected and about to be encircled with umbilical tape.

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Dissecting the pulmonary veins

Both the RSPV [Figure 12] and right inferior PV (RIPV) can be dissected from the front. The tributaries from the RUL and right middle lobe to the RSPV are divided between ligatures or Ligaclips. This step opens the hilum anteriorly, and with the lower lobe retracted toward the right, the RIPV can be seen and its tributaries can be divided between ligatures. If the vein is not clearly visible anteriorly, the assistant with his left hand retracts the entire right lung to the left and the pleura is incised posteriorly, exposing the RIPV, which is then dissected and divided between ligatures. The next step is to mobilize cut ends of both RSPV and RIPV and their confluence into the left atrium (LA). Intrapericardially, the interatrial groove (Sondergaard's groove) is developed by sharp dissection as is done before standard left atriotomy for mitral procedures.[9] The pericardium is then incised very close to the PV anteriorly (taking care to avoid phrenic nerve which runs closely). The pericardium is carefully incised circumferentially around the PV to free up and mobilize the PV-LA cuff adequately enough to facilitate placement of Satinsky side biting clamp.

Dissection of right main bronchus

Attention is now turned to the bronchus. The bronchus being a posterior structure is best tackled from behind. The assistant retracts the entire lung anteriorly and toward the left to expose the posterior mediastinum. If not already incised, the posterior mediastinal pleura is incised close to the hilum. The azygous vein can be seen ascending upward in the posterior chest wall and curving anteriorly to enter the SVC, just medial to the RUL bronchus. This landmark is useful in locating both the RUL bronchus just lateral to the azygous vein, with the right main bronchus (RMB) lying deep in the concavity of the azygous vein. Nodes encountered here need to be appropriately excised carefully. The bronchial arteries can be large and hypertrophied and can usually be seen. These are carefully secured with Ligaclips. The RMB, RUL bronchus, and bronchus intermedius (BI) are dissected and umbilical tapes passed around them [Figure 14]. It is particularly important to leave plenty of peribronchial tissue around and not to denude the bronchus with a view to aid healing bronchial anastomosis. The RUL bronchus and BI are stapled and divided using endoscopic liner cutter stapler [Figure 15].
Figure 14: Bronchial dissection right upper lobe and BI are looped with umbilical tapes, ready to be stapled.

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Figure 15: Right upper lobe bronchus is being stapled and divided by endoscopic linear cutter stapler.

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Identification of vagus nerve

Sometimes, the vagus nerve can be seen coursing posterior to the hilum on the esophagus [Figure 16]. Care must be taken to avoid dissection close to the vagus. In patients with ILD typically with a very contracted chest, the vagus may not be easily visible and the best approach in such cases would be to stay as close to the hilum as possible. Vagal nerve damage, either by neuropraxia due to stretching, thermal injury due to conducted heat from diathermy, or direct nerve injury, can cause significant gastroparesis and paralytic ileus, leading to significant morbidity and is best prevented.
Figure 16: The forceps points at the vagus nerve coursing downward on the esophagus posterior to the hilum which is retracted anteriorly and to the left by the assistant. The right lung has been removed.

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Removal of the native right lung and hemostasis

The right chest cavity is now empty after the native right lung is removed [Figure 17], which is sent for histopathological examination. The chest wall is carefully examined for bleeding and all points secured. When dense adhesions are encountered, bleeding from the chest wall can be troublesome, especially on ECMO. Argon plasma coagulator helps in securing bleeding points from areas of diffuse recalcitrant ooze.
Figure 17: Empty Recipient right chest. The stapled ends of the bronchi are seen. A hilar node obscures the cut ends of the pulmonary vein cuff. Cut end of right pulmonary artery has retracted behind the superior vena cava and hence not seem.

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Mobilizing recipient hilar structures: Bronchus, artery, and vein

The recipient hilum is then prepared for graft implant. This means all the three structures, the bronchus, PA, and PV-LA cuff, need to be freed and mobilized enough to securely apply clamp before vascular anastomosis. The stapled ends of the bronchi are left for now [Figure 18], but bronchus is carefully freed up without excessive denuding. The PA stump must be freed up fully [Figure 19] and adequate length mobilized to facilitate application of vascular clamp. The PV-LA stump must be freed from pericardium all around [Figure 20] to facilitate application of Satinsky side biting clamp.
Figure 18: The stapled cut end of the right main bronchus is held with forceps. The pulmonary artery is retracted anteriorly. Subcarinal nodes are seen in the inferior aspect of the right main bronchus. These tissues are only sparingly excised, just enough for safe anastomosis.

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Figure 19: Mobilized, ligated stump of pulmonary artery which is gently pulled from under the superior vena cava to bring it to view.

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Figure 20: The ligated stumps of the pulmonary vein confluence with pulmonary artery is seen mobilized and freed up.

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Separation of donor lungs

While hemostasis of the empty right chest cavity is underway, the donor lung block is carefully opened taking care to maintain sterility. The lungs are transported en bloc in an inflated condition. The two lungs are separated as follows: the posterior pericardium is incised in the midline from below up to the carina. The MPA from the bifurcation is usually present. The right PA is divided about 1 cm beyond the bifurcation. Other tissues are divided, and a bronchial stapler is applied obliquely at the junction of RMB and carina. Then, the RMB is cut flush distal to the stapler with a 11-blade. Sterile swabs are kept ready to collect secretions from the cut end of the RMB and are immediately sent for grams stain and culture.

This technique keeps the left lung inflated, which is then quickly kept back in a sterile bag with sterile cold solution and triple bagged and kept in ice to help continue and maintain the cold ischemic time for the left lung.

Bench work: Preparation of the donor right lung hilar structures

Preparing donor bronchus

The aim is to keep as short donor bronchial length as possible and to divide the donor RMB 1 or 2 rings proximal to the origin of the RUL bronchus. Using a 11-blade knife, the cartilaginous wall of the RMB is incised, after carefully marking the site of division as described above, circumferentially [Figure 21]. The membranous wall is then cut using a Potts scissor.
Figure 21: Bench work: Fashioning the donor right main bronchus – Division just 1 or 2 rings proximal to the origin of right upper lobe bronchus.

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Bench work: Preparing the donor right pulmonary artery

The donor right PA is then dissected free [Figure 22] from surrounding structures taking care to avoid “button-holing” the PA. The ideal site of division is just proximal to the take-off of the first branch of the PA. However, at this time, a little excess PA is retained, the final site of incision being made at the time of anastomosis.
Figure 22: Bench work: Fashioning the donor pulmonary artery.

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Bench work: Preparation of the pulmonary vein-left atrium cuff

The donor LA cuff with the confluence of both RSPV and RIPV is mobilized by dissecting it off from the surrounding tissues, taking great care to avoid any injury to the lung parenchyma or button-holing the cuff [Figure 23].
Figure 23: Preparing donor left atrium cuff.

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Implantation of the donor right lung in the recipient

Anastomosis of the right main bronchus

The stapled end of the recipient RMB is divided just proximal to the take-off of the RUL bronchus. A 11-blade knife is used to cut the cartilaginous portion and Potts scissor is used to trim the membranous portion. Care is taken not to denude the bronchial wall. Any secretions are carefully sucked out. The prepared right lung is then lowered into the recipient right pleural space aligning anterior and posterior surfaces correctly [Figure 24]. The ends of both donor and recipient bronchi are carefully aligned opposite each other. All the surfaces of the lung except the hilum are kept covered in sponges soaked in cold saline.
Figure 24: The donor right lung is being lowered and aligned in the recipient right pleural cavity. The fashioned cut end of the recipient right main bronchus is seen.

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Technique of bronchial anastomosis

We use a continuous suture to approximate the posterior membranous wall [Figure 25] and [Figure 26] and simple interrupted sutures for the anterior cartilaginous wall, ensuring that the suture includes a cartilaginous ring on either end [Figure 27]. We use either a 3/0 or 4/0 Prolene suture based on the tissue quality. End-to-end anastomosis is our preferred technique, especially when both bronchi are of the same size and it often results in perfect approximation once the anastomosis is complete [Figure 28] and [Figure 29]. Only when the bronchial size mismatch is significant, we use a “telescoping” technique where the smaller bronchus is telescoped into the larger ones by appropriately placed interrupted sutures in the cartilaginous wall.
Figure 25: The two bronchi are aligned close to each other and the first stitch is being taken on the donor cartilaginous wall.

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Figure 26: The posterior continuous layer approximating the membranous portion is seen.

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Figure 27: Interrupted stitches are being taken on the cartilaginous anterior wall of the bronchi.

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Figure 28: The anterior interrupted sutures are being tied with perfect juxtaposition of bronchi.

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Figure 29: Completed bronchial anastomosis.

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Variations in technique of bronchial anastomosis

The technique of bronchial anastomosis plays a vital role in the operation. Airway complications after lung transplantation, to a large extent, depend on the surgical technique of bronchial anastomosis and are common causes of post-LT morbidity and mortality.

Preferences for each technique vary among different centers.[10] There are reports which claim superior results with techniques which “telescope” the bronchial ends.[11] Furthermore, there are reports which suggest that the complication rates are higher with “telescoping” technique.[12],[13],[14] Some centers use a single layer of continuous suture to anastomose the bronchial ends.[15] A recent article from Vienna, in 2020, reports excellent long-term results with an anastomotic complication of only 0.8% in the period from 2014 to 2017 and recommend this technique for bronchial anastomosis.[16]

Variations in the suture material used for bronchial anastomosis

While we use non-absorbable monofilament Prolene routinely for the bronchial anastomosis, there are many centers that have used Vicryl[17] and absorbable monofilament PDS suture.[4]

Bronchial artery revascularization

This was a technique practiced earlier by anastomosing a previously harvested pedicled mammary artery to the aortic cuff around the origin of bronchial artery or as a free pedicle.[18],[19] While some reports claimed superior outcomes, this practice currently has been given up in many centers due to similar outcomes in patients without bronchial artery revascularization (BAR).[4] However, a recent report from combined Copenhagen and Cleveland Clinic, in 2019, suggests superior 5-year survival with BAR and highlights the need for larger multicenter study.[20]

Covering the bronchial anastomosis

We use an autologous pericardial patch to cover the anterior bronchial wall with loose interrupted sutures. Pleural flaps, pericardial fat tissue, peribronchial tissue, and omental patches mobilized from the abdomen have been used to cover bronchial anastomosis.[21] We have used pedicled vascularized intercostal muscle flap to wrap the bronchial anastomosis in SLT.

Anastomosis of the pulmonary artery

Attention is then turned to the recipient PA. A vascular clamp is applied extrapericardially after gently pulling the recipient PA stump, ensuring adequate length for tension-free anastomosis [Figure 30]. Sometimes, if the length of PA is not sufficient, the clamp can be used intrapericardially between the aorta and SVC, after carefully dissecting and mobilizing the RPA at that point and using an umbilical tape to go around it to help apply the vascular clamp safely. The recipient PA is then cut marking the point [Figure 31] aligning to the origin of upper lobe branch. The appropriate-length recipient PA and donor PA [Figure 32] are fashioned and the cut ends of both donor and recipient PA are approximated aligning the site of upper lobe branch of each of the PAs. This step is important to prevent torsion of the anastomosis. A 5/0 Prolene suture is used in a simple continuous fashion [Figure 33],[Figure 34],[Figure 35] for the PA anastomosis. Once the anastomosis is complete, the ends are not tied but held together with rubber-shod straight forceps to help de-airing.
Figure 30: The recipient pulmonary artery stump is clamped with a vascular clamp and length of stump being measured.

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Figure 31: The recipient pulmonary artery stump is cut at desired point.

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Figure 32: The donor pulmonary artery is fashioned and aligned.

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Figure 33: The posterior wall of the pulmonary artery anastomosis done.

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Figure 34: The anterior wall of pulmonary artery being sutured.

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Figure 35: Completed pulmonary artery anastomosis. The pulmonary artery is left clamped and sutures untied for de-airing later.

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Assessment of adequacy of pulmonary artery anastomosis

After completion, the PA anastomosis is carefully examined for torsion at the anastomosis, redundant PA with likelihood of kinking or a tight anastomosis under tension. Any revision is best done at this stage. Kinking of the PA due to redundancy may need excision of appropriate segment and reanastomosis. Torsion may require take down of anastomosis, realign properly, and reanastomosis. Anastomosis under tension is best redone with interposition autologous pericardial graft.

Anastomosis of the pulmonary vein-left atrium cuff

When this last anastomosis is about to start, the anesthetists are requested to start intravenous infusion of 250 mg methyl prednisolone to be given intravenously over 20 min. A Satinsky side biting clamp is then applied onto the previously mobilized and ligated recipient PV. The ligatures on the cut ends of RSPV and RIPV are then removed and cut ends opened. The bridge of tissue between the RSPV and RIPV is divided making it into a single large opening. The edges are then fashioned well, leaving adequate cuff for the anastomosis. The donor LA cuff is aligned carefully and a single running continuous suture with 4/0 Prolene is used for anastomosis, taking care to approximate endocardium and avoid any LA muscle into the suture line [Figure 36]. This is important to prevent nidus for clots and subsequent systemic embolization. The posterior layer is completed first and the sutures are continued onto the anterior wall [Figure 37]. Like PA anastomosis, after completion, the cut ends are not tied, but held together in a rubber shod hemostat, in preparation for de-airing. Inadequate PV-LV cuff may be repaired with autologous or donor pericardial patches.[22],[23]
Figure 36: The donor pulmonary vein–left atrium cuff is aligned with the clamped recipient pulmonary vein-left atrium cuff.

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Figure 37: The pulmonary vein–left atrium anastomosis in progress.

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Order of performing anastomoses

The bronchus being posterior is the first anastomosis to be performed. After the bronchus, we perform the PA anastomosis followed by the PV-LA cuff anastomosis. However, some centers perform the PV-LA first followed by the PA anastomosis.

Check list and controlled reperfusion of the right lung

After completion of all anastomosis, preparations are made for de-airing and controlled reperfusion to let the new lung into circulation. The first step is to ensure full delivery of the second dose IV methyl prednisolone which was started at the time of last anastomosis. A check bronchoscopy is then done to look at the adequacy of the anastomosis and thoroughly toilet the bronchial tree sucking out all blood clots and secretions. The anesthetist gently inflates the lung and flow is reduced to let blood into the right lung. The PA suture is tightened but not tied and PA clamp is gradually released in stages over 4 min, keeping the LA clamp in place and the sutures in LA cuff loosened to thoroughly de-air. After adequate antegrade de-airing, further deairing is done retrogradely – this time tightening LA suture, clamping PA, and loosening PA suture. The LA clamp is slowly released, so that blood is de-aired via the PA. After thorough de-airing, both PA and PV sutures are securely tied down. The lung is kept ventilated until the left main bronchus is to be divided, at which time the ventilation is stopped.

Left-sided procedure: Left native lung explantation and left donor lung implantation

As with the right side, the recipient native left lung is explanted, and stumps fashioned. The bench work on the donor left lung hilar structures is as done on the right side. The donor lung is similarly implanted as on the right side. Great care must be taken to keep the left bronchial tree free of blood during the anastomosis. As on the right side, a 3rd dose of IV methyl prednisolone is given during the last anastomosis. Check bronchoscopy is done to evaluate left bronchial anastomosis and importantly to clear both lungs of spilled blood and secretions. Finally, controlled reperfusion is done as for the right lung.

We do explantation of both lungs first, since we use ECMO support for all our DLT and then implant right lung first followed by left lung implantation. However, in centers performing bilateral sequential lung transplantation, the right donor lung is implanted first while relying on native left lung for gas exchange. Then, the native left lung is explanted relying on the right transplanted lung for gas exchange. The donor left lung is then implanted. Obviously, there is always an ECMO/Cardiopulmonary bypass available, should the need arise.

Hemostasis and weaning off veno arterial extracorporeal membrane oxygenation

After confirming hemostasis, good gas exchange, and hemodynamics, all anastomoses are checked again paying special attention to the vascular anastomoses. Any revision of vascular anastomosis, if needed, is best addressed now. The patients are gradually separated from ECMO support. Appropriate vasopressors are commenced, if needed. The least possible FiO2 is used. Heparin is reversed with appropriate dose of protamine. The pericardium is loosely tacked covering the heart with one or two stitches.


Each side has two drains sited about 2 inches below the incision. The medial drain is placed anterior to the hilum with its tip lying close to the apex of the pleural cavity. The lateral drain is sited to lie on the diaphragm pointing toward the base of the pleural cavity.

Pacing wire

We place a single RV epicardial pacing wire brought out below the incision.

Chest closure

Pericostal sutures with No. 5 Ethibond are used for rib approximation. The sternum is approximated tightly with 2 stainless steel wires. The pectoral muscles are approximated with 1/0 Vicryl. In obese patients and women, subcutaneous layer may be approximated with 2 layers using 2/0 Vicryl taking care to obliterate spaces and prevent collection, which may get infected later. We routinely use subcutaneous vacuum drain (Romovac drain size 16) on either side to prevent subcutaneous collections. The skin is either stapled or closed with a subcuticular stitch using 3/0 Monocryl.

A portable bedside chest X ray done on arrival to transplant ICU after DLT is shown [Figure 38] to demonstrate the bilateral apical and basal drains, transverse sternal wires, and transverse row of skin staples used for closure of the clamshell incision. ET and right IJV lines are seen. The lungs fields are clear.
Figure 38: Portable chest X-ray on arrival to intensive care unit following double-lung transplantation.

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  Discussion Top

The present article discusses the technique that we follow for DLT using deceased donor organs. Living-donor lobar lung transplantations (LDLLT) are also performed in some centers in the world. The vexing issue of size mismatch in LDLLT is discussed in a recent article, which describes novel techniques to resolve the issue.[24]

Indian experience

Following the Transplantation of Human Organ Act which was passed in 1994, the first bilateral lung transplantation and heart–lung transplantation was performed by Dr. KM Cherian at Madras Medical Mission.[1] While heart transplantation in India was being done in increasing numbers, lung transplantation took longer to be done regularly. After the initial sporadic efforts, the first SLT was done simultaneously at Global Hospital and Apollo Hospital, Chennai, in 2011, but was first reported by Global Hospitals in 2013.[25] There have been case reports from our country about LT, including LT in rare conditions such as in Hermansky Pudlak Syndrome[26] and pulmonary alveolar microlithiasis.[27] Anesthetic and donor management in LT have also been reported.[28],[29] The first attempt at lung transplantation, albeit unsuccessful, in a public sector was reported in 2019.[30] The same group also reported on the underutilization of donor lungs[31] and patient characteristics and outcomes of patients referred for LT in North India.[32]

The apex body in India for transplantation is National Organ and Tissue Transplant Organization headquartered in New Delhi. The Regional Organ and Tissue Transplant Organization (ROTTO) and State Organ and Tissue Transplant Organization (SOTTO) oversee the transplant process.

Tamil Nadu is one of the states in India where high numbers of thoracic organ transplantation occur. We have discussed the factors responsible for the success of Tamil Nadu model at Annual Conference of the International Society for Heart and Lung Transplantation in 2015.[33] We have chronicled the historical events which unfolded from the start and led to the current functioning of Transplant Authority of Tamil Nadu which functions both as ROTTO and SOTTO.[34]

Gradually, over the years, the number of lung transplantation increased and currently LT is being done in 15 centers in India. Of the 15 centers performing LT in India, the great majority are being done by 6 centers. The remaining 9 centers, as on date, are low-volume centers having done <10 lung transplantations.

The current global pandemic due to coronavirus disease 2019 (COVID-19) has created numerous challenges. The INSHLT has formed a task force which has provided recommendations for thoracic organ transplantation during COVID times in India.[35] The pandemic has resulted in significant reduction in deceased organ donations, leading to increased mortality on the waiting list or deterioration requiring ECMO with a view to “bridging” to transplantation. LT has been reported for end-stage lung disease resulting from COVID-19.[36],[37] COVID has also been reported to affect recipients after transplantation.[38],[39] There have been anecdotal media reports of LT being performed for end-stage lung disease due to COVID in our country in the last few months. Cypel and Keshavjee have provided suggestions regarding decision-making before lung transplantation for end-stage lung disease due to COVID-19.[40]

Ethics clearance

Full approval from the Institutional Ethics Committee (dated 31 Jul 2020 for IEC Application No: AMH-C-S-016/07-20)was obtained for retrospective review of outcomes of lung transplantation performed in our unit.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27], [Figure 28], [Figure 29], [Figure 30], [Figure 31], [Figure 32], [Figure 33], [Figure 34], [Figure 35], [Figure 36], [Figure 37], [Figure 38]


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