Clamshell Incision vs. Sternal-Sparing Incision in Lung Transplantation

Abstract

Purpose Transverse thoracosternotomy, or ‘clamshell’ incision, has been regarded as the incision of choice for bilateral lung transplantation (LTx) for the past decade. However, the clamshell incision can result in significant morbidity including sternal wound dehiscence, sternal instability, wound infection and pain. Bilateral anterior thoracotomy, which avoids transection of the sternum, has been proposed as an alternative. We assessed the safety and efficacy of bilateral anterior thoracotomy compared with the clamshell incision. Methods and Materials Single center retrospective review of 130 bilateral LTx patients operated January 2009-May 2012. 79/130 (61%) underwent clamshell incisions (Group A) (Median follow up time: 866 days) and 51/130 (39%) underwent sternal-sparing incisions (Group B) (Median follow up time: 699 days). Operative approach was allocated according to surgeon preference based on patient factors (diagnosis, body mass index, past surgery) and non-patient factors (donor ischaemic time, donor lung to recipient lung size match). Results 14/79 (18%) Group A patients developed sternal wound infection while 8/79 (10%) had sternal healing complications (10%). There was only one wound infection in Group B (chi-square, p=0.006). Median, (interquartile range) postoperative inpatient stay was comparable between groups (Group A vs Group B = 17 days, (13 – 30) vs. 15 days (11-25), as was ICU stay: 5.5 days (3-12) vs. 4 days (2-11 days ). No significant difference was found between groups in median (interquartile range) transplant duration:7 hours (5-8) vs. 7 hours (6–8), perfusion time: 209 hours ( 168 – 255) vs. 220 (191–247), or lung function at 1 year viz: VC% (mean±SD)= 87±19 vs. 92±23, median (interquartile range) FEV%= 81 (73–98) vs. 94 (66–105), FEV1/FVC = 0.79 (0.72–0.87) vs. 0.83 (0.71–0.91 ). Conclusions Sternal-sparing incisions performed for bilateral LTx are associated with a lower rate of wound infection and healing complications than clamshell incisions. Surgery times, ICU bed days and functional outcomes were comparable.