Bilateral sequential lung transplantation without sternal division eliminates posttransplantation sternal complications

Objective: The objective of this study was to assess the efficacy and safet y of an alternative surgical incision for bilateral sequential lung transpl antation. The vast majority of these operations worldwide have been perform ed through an anterolateral thoracosternotomy known as the "clamshell" inci sion, Recently, we have undertaken most of these operations through bilater al anterolateral thoracotomies without sternal division, Methods: Our medic al center performed 262 bilateral sequential single lung transplantations f rom 1989 to April 1998, Between July 1996 and April 1998 we performed 69 bi lateral sequential single lung transplantations on 68 recipients with 52 tr ansplantations being conducted without initial sternal division. We retrosp ectively reviewed the results of these operations to assess the safety of t he altered exposure and the efficacy in avoiding sternal wound complication s such as malunion, dehiscence, osteomyelitis, and migrating hardware. Comp arison was made to a historical control group composed of the last 50 patie nts in whom the full clamshell incision was used. Results: Of the 68 patien ts who underwent transplantations, 52 patients underwent the initial explor atory procedure without sternal division. Two patients required emergency s ternal division for institution of cardiopulmonary bypass to control life-t hreatening bleeding. Eleven of 68 patients were placed on bypass electively to permit transplantation, and the lack of a sternotomy in 8 patients did not present an obstacle to ascending aortic and right atrial cannulation, T here were no wound healing complications in the 50 patients for whom the st ernum was left intact. In a historical control group of 50 patients who und erwent transplantation with sternal division, 34% experienced morbidity or mild disability as a direct result of poor sternal healing. Conclusions: We conclude that bilateral anterolateral thoracotomy without sternal division is a safe approach that allows adequate exposure without the risk of commo nly observed problems with sternal healing.