The Impact of Minimal and Limited Anterior Thoracotomy Incisions in Lung Transplantation Surgery.
Heartcenter Leipzig, Leipzig, Germany.
OBJECTIVE: Predisposing factors for wound complications following lung transplantation (LTX) are sudden increases in intrathoracic pressure, rib or cartilage fractures, intercostal muscle weakness, surgical trauma, and in particular chronic immunosuppression therapy and steroid abuse. Muscle sparing limited anterior thoracotomies without transsection of the sternum may lead to decreasing the sequelae of wound complications.
METHODS:We used the single institution based transplant data bank, phone questionnaire, ambulatory care unit follow-up data in order to investigate the incidence of wound healing complications following muscle and sternum sparing and mammary artery protecting limited access small submammary anterior thoracotomy incisions (AT) for lung transplantation surgery. Intra-op cryo-ablation of the thoracotomy wound corresponding intercostal nerves and sympathetic ganglia ws performed surgically for pain control. In the need for cardiopulmonary bypass (CPB) the femoral v/a were canulated. Statistical analysis: ANOVA, t-tests, chi2 (p<0.05=*).
RESULTS:Following exclusion of 5 clamshell operations for LTX combined with cardiac surgery 71 recipients (65 % male), age 19-68, mean 54 ±8 years underwent 64 AT and 42 post.lat. thoracotomies (PT) for IPF (48%), obstructive disease (40%), CF (5%), and PAH (7%). AT ranged from 5.5 cm to 26 cm (mean 20.3 ±4.8) and PT from 12 cm to 25 cm (mean 19.8 ±2.4) and was not significant different (p=0.37). Ischemic time for single lung (322 ±59min), sequential bilat. (399 ±135 min) was significantly longer compared to ISHLT-reporting. Warm ischemic times ranged from 30 to 92 min (mean 56 ±11). Four patients required re-thoracotomy for bleeding/hematoma formation. CPB/intra-op ECMO was used in 40% (femoral a.v. cannulation). Superficial wound infection and subsequent drainage/care was needed in 2 PT incisions. Re-operation for lung herniation using patch repair technique for thoracic wall stabilization was required in 2 AT (3%) and 3 PT (7%).
CONCLUSIONS: Sternum sparing and mammary artery protecting limited access small submammary anterior thoracotomy incisions for lung transplantation surgery are feasible and do not lead to a high incidence of wound complications and lung hernias. There 0% severe wound infection. In the event of CPB supported lung transplantation femoral vessel cannulation is required, which allows undisturbed operative situs and exposure.
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