Yoshiya Toyoda, Marco Zenati, Christian Bermudez, Brack Hattler, Kenneth McCurry.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
OBJECTIVE: A minimally invasive approach for lung transplantation is developed that achieves full access to the entire chest cavity, allows the use of standard operative instruments and techniques, and preserves internal mammary arteries and the sternum.
METHODS: With the patient in supine position and the axilla exposed, a limited (8-12cm) skin incision is made beginning at the anterior axillary line extending towards the axilla along the inframammary crease. A retrospective analysis was performed for consecutive lung transplants from 11/2006 to 11/2007. This antero-axillary approach was applied for 50 patients by a single surgeon (Group A). The outcome was compared to patients with conventional approaches including clamshell, posterior or anterior thoracotomy, and median sternotomy (Group B, n=82).
RESULTS: There were no significant differences between group A vs. B in the recipient age (58±2 vs. 55±2 years), diagnosis (emphysema/fibrosis: 18/21 vs. 33/22), lung allocation score (41±2 vs. 44±2), mean pulmonary artery pressure (28±2 vs. 31±2 mmHg), double vs. single lung transplant (D/S: 31/19 vs. 59/23), use of cardiopulmonary bypass (32 vs. 37%), cardiopulmonary bypass time (225±22 vs. 253±19 min), allograft ischemic time (343±10 vs. 353±9.0 min), and the donor age (37±2 vs. 40±2 years). Preoperative recipient body mass index was higher (p=0.03) in group A vs. B (27±1 vs. 25±1). No recipients required extracorporeal membrane oxygenation perioperatively in group A (p=0.04 vs. 7 patients in group B). Seventy two percent of patients in group A (p=0.02 vs. 50% in group B) were extubated within 48 hours postoperatively. There was no significant difference (p=0.2) in early survival between group A vs. B (30-day: 98% vs. 94%, 180-day: 92% vs. 89% and 300-day: 92% vs. 84%).
CONCLUSIONS: The axillary rather than anterior extension in this approach is the key for better exposure including the posterior aspect of the hilum and for minimally invasiveness due to less manipulation to the heart and the phrenic nerve during the anastomosis. This approach should be the standard approach for single and double lung transplantation. 
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