Info

Fig. 12.1. A) The skin incision runs along the infra-mammary crease and crosses the sternum at the level of the fourth interspace. The intercostal incision in made along the upper surface of the fifth rib. The costal cartilage of the fourth rib (shaded in diagram) is resected to allow upward mobility of the fourth rib with retraction. The transverse sternotomy is omitted. B) A Finochietto chest retractor is used to spread the ribs vertically, while a Balfour retractor is placed with one jaw on the sternum and one jaw on the muscle and skin of the lateral chest. The intercostal muscle division is carried far more lateral and posterior than the skin incision to maximize rib spreading. The combined efforts of these two retractors typically result in excellent exposure without sternal division.

Fig. 12.1. A) The skin incision runs along the infra-mammary crease and crosses the sternum at the level of the fourth interspace. The intercostal incision in made along the upper surface of the fifth rib. The costal cartilage of the fourth rib (shaded in diagram) is resected to allow upward mobility of the fourth rib with retraction. The transverse sternotomy is omitted. B) A Finochietto chest retractor is used to spread the ribs vertically, while a Balfour retractor is placed with one jaw on the sternum and one jaw on the muscle and skin of the lateral chest. The intercostal muscle division is carried far more lateral and posterior than the skin incision to maximize rib spreading. The combined efforts of these two retractors typically result in excellent exposure without sternal division.

through the fifth intercostal space. It is now appreciated that separate bilateral anterior thoracotomies, without sternal division, provide superb exposure for BLT, and minimize the morbidity associated with transverse sternotomy.26 With experience, intrathoracic cannulation for cardiopulmonary bypass can be accomplished avoiding a groin incision and vascular repair following decannulation.

Recipient Pneumonectomy and Use of Cardiopulmonary Bypass

Except for lung transplants performed for pulmonary vascular disease, cardiopulmonary bypass (CPB) is used in a selective fashion.27 Cardiopulmonary bypass is warranted for refractory pulmonary hypertension, poor right ventricular function as measured by transesophageal echocardiography, hemodynamic instability, hypoxemia, or worsening hypercarbia during temporary pulmonary artery occlusion. In about 10-20% of bilateral sequential lung transplants, CPB is required to facilitate implantation of the second lung, due to dysfunction of the first allograft implanted. CPB is used routinely for all patients with pulmonary vascular disease. In SLT, CPB is performed through the chest or alternatively through femoral cannulation. In BLT, standard cannulation techniques are employed utilizing the right atrial appendage and ascending aorta.

Once the pleural space has been widely exposed, the inferior pulmonary ligament is divided. The pulmonary veins and the pulmonary artery are encircled outside the pericardium. At this time the need for CPB is determined.28 The ventilation to the contralateral lung and occlusion of the ipsilateral pulmonary artery determine whether the contralateral lung provides adequate gas exchange and hemodynamics to tolerate pneumonectomy and allograft implantation without CPB. Assessment of right ventricular function with the transesophageal echocardiography probe is especially useful at this time.

The upper lobe pulmonary artery branches are ligated and divided. This maneuver increases the length of pulmonary artery available for the subsequent anastomosis. The pulmonary artery is then stapled, a clamp is placed distally and the artery divided in between. The pulmonary veins are divided between the stapled lines or between silk ligatures placed around each branch at the hilum. This increases the size of the atrial-pulmonary vein cuff for the subsequent anastomosis.

The bronchus is identified and the bronchial arteries are secured with ligatures. The bronchus is transected just proximal to the upper lobe origin and the lung is excised. The recipient bronchus is trimmed back into the mediastinum taking care to avoid devascularization. The pericardium around the pulmonary veins is opened widely and hemostasis is achieved.

Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

Get My Free Ebook


Post a comment