What is Minimally Invasive Lung Transplantation?
Lung Transplantation is done using the Antero Axillary incision i.e. an incision from the line passing through the mid-point of the shoulder to the mid-point of the armpit, without the use of a Heart-Lung machine or artificial Lung (Extra Corporeal Membrane Oxygenation).
What is the alternative to a Minimally Invasive Lung Transplant?
The standard incision or access to the Lung is by performing a clamshell incision, which requires an open surgery and a cut starting from the middle of the right armpit across the chest to the left armpit. This massive incision also divides the breast bone transversely or horizontally.
Advantages of Minimally Invasive Lung Transplant procedures
Minimally invasive incision in comparison to clampshel, is less painful and better tolerated by the patient. It provides good access to the Hilum (the area in the lung that is attached to the heart), and is vital for a Lung Transplantation procedure. If a Heart-Lung machine is required, it is easy to connect the patient to the Heart Lung machine through this incision. If any heart surgery is needed in addition to Lung Transplantation, it can be done through this incision with ease.
A minimally invasive procedure can be easily converted to an open surgery if the need arises, by joining the two incisions. No special instruments are required for this procedure, and the same instruments that are used for the open surgery can be used, at no additional costs that need to be incurred by either the hospital or the patients. The open surgery has one great disadvantage, which is the healing of the sternum or breast bone. These problems can be avoided in the minimally invasive approach.
It is well received by female patients, since the incisions are in the crease under the breast, therefore the scar from the surgery is not visible from either the frontal or back view of the patient, though it is visible only once their arms are raised.
Recovery from a Minimally Invasive Lung Transplant
The dosage and frequency of the pain medication needed after a minimally invasive procedure for Lung Transplantation is comparably lesser than that of an open surgery. Patients usually recover within a week, while rehabilitation also becomes easier since the breast bone is not divided. Due to the nature of the surgery, the Pulmonary Function Test (PFT) values for minimally invasive procedures are significantly better than a direct open surgery. The number of days spent on a ventilator after the Transplant in the Transplant ICU is reduced with a minimally invasive approach as compared to the open surgery approach. The difference between the two types of procedures is statistically significant.
Process of Minimally Invasive Lung Transplant
An 8 centimeter to 7 inches incision is taken between the 4th and the 5th rib on the chest wall. This helps the surgeon to gain access into the chest cavity. The hilum of the Lung is dissected to separate the blood vessels. The Pulmonary artery, Pulmonary vein and the bronchus are then surgically divided. The diseased Lung is now removed and the donor Lung is stitched in its rightful place inside the patient. This procedure is carried out in both the chest cavities.
To be eligible for a Lung Transplant, patients must meet the following requirements:
1. Patient’s physiological age is more important than their chronological age i.e their physical health must be physiologically in better condition, hence the chronological age is not a factor for this procedure.
2. Patients having a poor prognosis, with 18 to 24-month anticipated survival chances.
3. Patients having no other life-threatening systemic diseases.
4. Patients who comply with medications and medical recommendations, also who have good rehabilitation potential i.e. physiological chances.
5. Patients who demonstrate emotional stability and understand all the implications including risks and recovery of organ transplantation.
In addition the above standard selection criteria of candidates for lung transplantation, minimally invasive Lung Transplant surgery is best done for patients whose BMI (Body Mass Index) is less than 30 or equal to 30 and for those who do not have high blood pressure since it can lead to left ventricular hypertrophy i.e. the left ventricle of the heart is enlarged and this can be a surgical challenge.
When is Minimally Invasive Lung Transplant suggested?
It can be offered to all patients with end-stage Lung disease, provided they are not very obese and do not have left ventricular hypertrophy.
Due to the fragility of the Lung, the survival rates for Lung transplant patients are usually for a five-year survival rate of about 50-60 percent. Patient outcomes may differ and depend on the physiological condition of the patient as well on the proactive participation in their after-surgery care.
(Dr Jnanesh Thacker is Program & Surgical Director - Heart, Lung, Heart & Lung Transplantation & Assist Devices at Yashoda Hospitals, Hyderabad)