Surgical Approaches: Tricks of the Trade

Abstract

Patients with non-malignant end-palliated pulmonary pathology with a prognosis of under 2 years continue to benefit significantly from lung transplantation with improvement in quality of life and in medium to long-term survival. This success is reflected in the increasing number of lung transplants performed annually and with growth of new lung transplant centres. Unfortunately, and on the background of considerable underlying burden of communicable diseases, many countries, particularly in Asia, Africa, the Middle East and South America, have none or only rudimentary lung transplant programs. This results from varying shortcomings including the lack of adequate organ donation policies; financial resources; poor societal acceptance of brain death and organ donation; and the absence of surgical, medical and multi-disciplinary training in transplantation. At the same time, those countries fortunate to have long established programs are producing excellent outcomes despite older recipients with more comorbidities and marginal donor organs including those retrieved following donation after circulatory death. The use of many functionally marginal donor lungs with resuscitative strategies such as extra-corporeal lung perfusion has added further complexity with the benefit of greater conversion of donated lungs to successful transplantation.

The basic surgical techniques of lung transplantation have changed little in the past three decades. However, in light of the exponential rise in the number of lung transplants being performed, this chapter will reappraise those surgical techniques and modifications that have stood the test of time and well as appreciating the intra-operative strategies relevant for single lung, double lung or heart-lung transplantation. Management of the multi-organ donor and the technique of donor lung retrieval are also discussed.