**3.2 Recipient operation**

#### **3.2.1 Single lung transplant**

Once a donor is verified and deemed suitable for transplant, the recipient is brought into the operating room for transplantation (12). Generally the contra-lateral lung is used to support the recipient during the transplantation procedure. Some patient will require

Lung Transplantation 299

and debris are vented through the pulmonary artery anastomosis first. Then pulmonary plegia solution is allowed to vent from the left atrial cuff anastomosis by releasing the arterial clamp to allow a slow flush. While the left atrium is observed by TEE for air bubbles the left atrial clamp is removed and the anastomosis is secured. The reperfusion is controlled by slow release of the arterial clamp and any hypotension is treated promptly by alpha-agonists. The lung is inflated while monitoring the left atrium on TEE. A leak test may be performed at this time by carefully ventilating the new lung with the bronchus submerged in warm normal saline and inspecting for air bubbles. After placement of chest tube, with satisfactory hemostasis, hemodynamics and oxygenation the chest is closed in layers with absorbable sutures. With the patient in the supine position the double-lumen endotracheal tube is changed to a single lumen tube and a fiber-optic bronchoscopy is performed to inspect the bronchial anastomosis and remove any clots or secretions present

A bilateral anterolateral thoracotomy is a preferable incision for bilateral sequential lung transplant as it preserves the structural integrity of the sternum and prevents significant incision-related morbidity (13). In a patient with small chest cavity or when there is potential need for cardiopulmonary bypass, a clamp-shell incision is made dividing the sternum across for the transplantation. The dissection of the lung and the donor lung preparation is performed as described above. The lung with the lesser physiologic

The single lung transplants are performed sequentially while the patient is supported by the contra-lateral lung. If the operation is being performed without cardiopulmonary bypass (CPB), it is important to stabilize the patient after the first lung implantation before proceeding with the next. Following implantation of the second lung and patient stable, chest tubes are placed and sternum approximate using metal plates or sternal wires. Then

Patient undergoing lung transplantation requires a team of caregivers who are committed, familiar with the protocols and able to ensure ongoing communication between members of the team. The team members include, transplant coordinators, transplant pulmonologist, transplant surgeon, anesthesiologist, pain management team, critical care specialist, ICU nurses, Infectious disease specialist, pharmacologist, physical and occupational therapist, nutritionist and social worker. Clinical pathways are developed addressing complete patient care with incorporation of immunosuppressive and infection prophylaxis protocols (14). Despite clinical pathways, regular team meeting discussing daily care of patient facilitate

Despite advances in the donor management and preservation of lung, primary graft dysfunction is not uncommon following lung transplantation (15). In the majority however the degree of dysfunction is minor to moderate and reversible, therefore does not progress to graft failure. The incidence of primary graft dysfunction has been reported between 11-57

contribution is transplanted first as the other lung support single-lung ventilation.

in the bronchial tree.

**3.2.2 Bilateral sequential lung transplant** 

the wound is closed in layers with absorbable sutures.

efficient and timely interventions and improve post-operative care.

**4. Post-operative management** 

**5. Respiratory management** 

cardiopulmonary bypass to perform the lung transplantation safely. General anesthesia is provided via a double lumen endo-tracheal tube, a left sided tube is preferred thus avoiding the potential complication of obstructing the right upper lobe orifice. Following placement of arterial and venous access lines as well as a Trans-esophageal Echo (TEE) probe, the patient is placed in a lateral decubitus position, with groin exposed on the same side to allow canulation of femoral vessels, if needed. A variety of incisions may be used to enter the thorax including a posterolateral incision, anterior submammary incision, or a lateral incision that either spares or partially divides the muscle.

Hilar dissection is performed exposing the pulmonary vessels while preserving the phrenic nerve. Vagus neurovascular bundles are carefully preserved particularly on the left side where the recurrent laryngeal nerve emerges and encircles the ligamentum arteriosus. The recurrent laryngeal nerve may be injured during the dissection of the left main pulmonary artery and a heightened awareness of this will help to avoid injury. Dissection around main bronchus is kept to minimum to preserve its blood supply. The pericardium is opened around the pulmonary veins to release the left atrium for placement of vascular clamp. When the donor lung is in the room the recipient is given heparin intravenously and the pulmonary veins and artery are divided as distal as possible. We use a linear cutting vascular stapler. The main bronchus is divided at the lobar branch level initially and then divided with a sharp knife about 2-3 cartilage rings from the carina.

At the back table, final dissections are made to the donor lung. This includes removal of excess mediastinal tissue, mobilization of the main pulmonary artery and the left atrial and venous structures from pericardial attachments. We perform a repeat cold retrograde flushing of the pulmonary vascular bed with the preservation solution prior to implantation to evacuate any residual debris from the pulmonary vascular bed and improve preservation (9). The main bronchus of the donor is opened and microbiological specimens are collected. The bronchus is then divided with a knife leaving two rings of cartilage from the origin of the upper lobe bronchus. The donor lung is then brought to the operative field. We perform the bronchial anastomosis as to "frame" the lung in position first. The membranous portion of the bronchus is anastamosed using a running 4-0 absorbable monofilament suture while the cartilaginous portion is secured with interrupted figure-of-eight suture of the same type. Single-running suture techniques have also been described in the literature and appear to be equally effective. Next, attention is turned to the venous anastomosis. A vascular clamp is placed along a portion of the left atrium and the recipient left pulmonary vein orifices are connected by dividing the bridge of atrial tissue in-between to create a single oval "atrial cuff". The donor atrial cuff is then anastamosed to the recipient atrial cuff in an end-to-end fashion using a single, double-armed running 4-0 polypropylene suture. Finally the pulmonary artery is prepared for the final anastomosis. Excess length of pulmonary artery is removed after appropriately sizing the vessel. This is particularly important on the right side, as there is a long length available on the donor. The donor pulmonary artery is anastomosed to the recipient in an end-to-end fashion with a single, double-armed running 5-0 polypropylene suture. Occasionally, a size mismatch exists where the recipient pulmonary artery is larger than the donor pulmonary artery. In this case, the larger inferior pulmonary trunk arising from the main pulmonary artery is anastomosed end-to-end with the donor main pulmonary artery. In this situation the upper branch is divided flush with the main artery to prevent any clots forming in the 'blind-end'. Attention is paid to keep the donor lung cold during the entire period using ice slush and cold sponges, until reperfusion. Bolus of solumedrol is given intravenously (we give 500 mg) prior to reperfusion of the graft. In preparation for reperfusion, the patient is placed in the Trendelenberg position, air

cardiopulmonary bypass to perform the lung transplantation safely. General anesthesia is provided via a double lumen endo-tracheal tube, a left sided tube is preferred thus avoiding the potential complication of obstructing the right upper lobe orifice. Following placement of arterial and venous access lines as well as a Trans-esophageal Echo (TEE) probe, the patient is placed in a lateral decubitus position, with groin exposed on the same side to allow canulation of femoral vessels, if needed. A variety of incisions may be used to enter the thorax including a posterolateral incision, anterior submammary incision, or a lateral

Hilar dissection is performed exposing the pulmonary vessels while preserving the phrenic nerve. Vagus neurovascular bundles are carefully preserved particularly on the left side where the recurrent laryngeal nerve emerges and encircles the ligamentum arteriosus. The recurrent laryngeal nerve may be injured during the dissection of the left main pulmonary artery and a heightened awareness of this will help to avoid injury. Dissection around main bronchus is kept to minimum to preserve its blood supply. The pericardium is opened around the pulmonary veins to release the left atrium for placement of vascular clamp. When the donor lung is in the room the recipient is given heparin intravenously and the pulmonary veins and artery are divided as distal as possible. We use a linear cutting vascular stapler. The main bronchus is divided at the lobar branch level initially and then

At the back table, final dissections are made to the donor lung. This includes removal of excess mediastinal tissue, mobilization of the main pulmonary artery and the left atrial and venous structures from pericardial attachments. We perform a repeat cold retrograde flushing of the pulmonary vascular bed with the preservation solution prior to implantation to evacuate any residual debris from the pulmonary vascular bed and improve preservation (9). The main bronchus of the donor is opened and microbiological specimens are collected. The bronchus is then divided with a knife leaving two rings of cartilage from the origin of the upper lobe bronchus. The donor lung is then brought to the operative field. We perform the bronchial anastomosis as to "frame" the lung in position first. The membranous portion of the bronchus is anastamosed using a running 4-0 absorbable monofilament suture while the cartilaginous portion is secured with interrupted figure-of-eight suture of the same type. Single-running suture techniques have also been described in the literature and appear to be equally effective. Next, attention is turned to the venous anastomosis. A vascular clamp is placed along a portion of the left atrium and the recipient left pulmonary vein orifices are connected by dividing the bridge of atrial tissue in-between to create a single oval "atrial cuff". The donor atrial cuff is then anastamosed to the recipient atrial cuff in an end-to-end fashion using a single, double-armed running 4-0 polypropylene suture. Finally the pulmonary artery is prepared for the final anastomosis. Excess length of pulmonary artery is removed after appropriately sizing the vessel. This is particularly important on the right side, as there is a long length available on the donor. The donor pulmonary artery is anastomosed to the recipient in an end-to-end fashion with a single, double-armed running 5-0 polypropylene suture. Occasionally, a size mismatch exists where the recipient pulmonary artery is larger than the donor pulmonary artery. In this case, the larger inferior pulmonary trunk arising from the main pulmonary artery is anastomosed end-to-end with the donor main pulmonary artery. In this situation the upper branch is divided flush with the main artery to prevent any clots forming in the 'blind-end'. Attention is paid to keep the donor lung cold during the entire period using ice slush and cold sponges, until reperfusion. Bolus of solumedrol is given intravenously (we give 500 mg) prior to reperfusion of the graft. In preparation for reperfusion, the patient is placed in the Trendelenberg position, air

incision that either spares or partially divides the muscle.

divided with a sharp knife about 2-3 cartilage rings from the carina.

and debris are vented through the pulmonary artery anastomosis first. Then pulmonary plegia solution is allowed to vent from the left atrial cuff anastomosis by releasing the arterial clamp to allow a slow flush. While the left atrium is observed by TEE for air bubbles the left atrial clamp is removed and the anastomosis is secured. The reperfusion is controlled by slow release of the arterial clamp and any hypotension is treated promptly by alpha-agonists. The lung is inflated while monitoring the left atrium on TEE. A leak test may be performed at this time by carefully ventilating the new lung with the bronchus submerged in warm normal saline and inspecting for air bubbles. After placement of chest tube, with satisfactory hemostasis, hemodynamics and oxygenation the chest is closed in layers with absorbable sutures. With the patient in the supine position the double-lumen endotracheal tube is changed to a single lumen tube and a fiber-optic bronchoscopy is performed to inspect the bronchial anastomosis and remove any clots or secretions present in the bronchial tree.

#### **3.2.2 Bilateral sequential lung transplant**

A bilateral anterolateral thoracotomy is a preferable incision for bilateral sequential lung transplant as it preserves the structural integrity of the sternum and prevents significant incision-related morbidity (13). In a patient with small chest cavity or when there is potential need for cardiopulmonary bypass, a clamp-shell incision is made dividing the sternum across for the transplantation. The dissection of the lung and the donor lung preparation is performed as described above. The lung with the lesser physiologic contribution is transplanted first as the other lung support single-lung ventilation.

The single lung transplants are performed sequentially while the patient is supported by the contra-lateral lung. If the operation is being performed without cardiopulmonary bypass (CPB), it is important to stabilize the patient after the first lung implantation before proceeding with the next. Following implantation of the second lung and patient stable, chest tubes are placed and sternum approximate using metal plates or sternal wires. Then the wound is closed in layers with absorbable sutures.
