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Lung Implantation

Topical cooling of the graft during implantation is critical, and is accomplished by wrapping the allograft in a gauze sponge soaked in ice slush. The lung is kept cold with additional application of crushed ice. This provides an extended period of cold preservation and gives additional time for meticulous anastomoses.

The bronchial anastomosis is performed first. The membranous posterior wall is first closed using a continuous suture of 4-0 absorbable monofilament suture (Fig. 12.2A and B). The anterior cartilaginous airway is then closed by using an

Fig. 12.2. A) The bronchial anastomosis of the right lung is depicted, showing the running closure of membranous bronchus. Self-retaining retractors, fashioned with Duval lung retractors suspended by heavy silk ties, are shown suspending the recipient pulmonary artery and pulmonary vein medially and anteriorly to expose the bronchus. B) The bronchial anastomosis of the left lung is depicted, showing the running closure of membranous bronchus. Self-retaining retractors, fashioned with Duval lung retractors suspended by heavy silk ties, are shown suspending the recipient pulmonary artery and pulmonary vein anteriorly and medially to expose the bronchus.

Fig. 12.2. A) The bronchial anastomosis of the right lung is depicted, showing the running closure of membranous bronchus. Self-retaining retractors, fashioned with Duval lung retractors suspended by heavy silk ties, are shown suspending the recipient pulmonary artery and pulmonary vein medially and anteriorly to expose the bronchus. B) The bronchial anastomosis of the left lung is depicted, showing the running closure of membranous bronchus. Self-retaining retractors, fashioned with Duval lung retractors suspended by heavy silk ties, are shown suspending the recipient pulmonary artery and pulmonary vein anteriorly and medially to expose the bronchus.

Fig. 12.3. Interrupted figure of-eight sutures. A) are used for bronchial closure in normal or larger sized airways. No attempt is made to intentionally intussuscept the smaller of the bronchial ends into the larger. In smaller airways, particularly left bronchial anastomoses in small recipients, a simple interrupted anastomosis. B) is performed to enhance accuracy and minimize stenosis.

Fig. 12.3. Interrupted figure of-eight sutures. A) are used for bronchial closure in normal or larger sized airways. No attempt is made to intentionally intussuscept the smaller of the bronchial ends into the larger. In smaller airways, particularly left bronchial anastomoses in small recipients, a simple interrupted anastomosis. B) is performed to enhance accuracy and minimize stenosis.

interrupted suture technique. The donor and recipient cartilaginous arches are approximated using interrupted figure-of-eight or horizontal mattress sutures of a similar suture material with no attempt to intussuscept the smaller bronchus (Fig 12.3). The use of simple interrupted suture to perform an end-to-end anastomosis, as originally described is utilized for small caliber bronchi, since a figure-eight technique can result in bronchial narrowing. Loose peribronchial nodal tissue around the donor and recipient bronchi is used to cover the bronchial anastomosis. Rarely a pedicle flap of pericardium or thymic fat may be necessary. Bronchial omentopexy is virtually never used today.29

The pulmonary artery anastomosis is performed next. A vascular clamp is applied proximally on the ipsilateral main pulmonary artery. The donor and recipient arteries are trimmed to appropriate size and an end-to-end anastomosis is created using 5-0 polypropylene suture interrupted at two sites (Fig. 12.4). Care must be taken to avoid excessive lengths that may result in kinking of the pulmonary artery.

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