Current approaches to minimally invasive lung transplantation—a technical guide

Patient positioning, incisions and instrumentation.

Central Message.

On the basis of several recent surgical advances, minimally invasive approaches have become feasible for a selected group of lung transplant candidates.

A shift toward less-invasive procedures has been observed in thoracic surgery over the past 20 years. Initially, these approaches were considered feasible only for standard resections with low intraoperative risks. However, with advancements in surgical skills and increased experience, surgeons have continuously pushed the envelope. As a result, minimal invasive surgery is now offered for more extensive procedures, such as bronchovascular sleeve resections¹ and intrapericardial pneumectomies.² In parallel with these advancements, surgical tools and instruments have significantly improved, particularly with the development of robotic platforms. This progress has led to a widespread application of robotic-assisted minimal invasive surgery in cardiothoracic operations.^3,4

For a long time, less-invasive approaches were deemed unfeasible for clinical lung transplantation because of the complexity of the procedure. However, some centers have developed expertise of performing lung transplantation through sternal-sparing bilateral thoracotomies with standard (open) instruments, allowing surgeons to reach into the chest.^5,6 Notably, despite the adoption of bilateral thoracotomies by some programs, the clamshell incision remained the most common approach for lung transplantation.

Recently, there has been a renewed interest in minimally invasive techniques for lung transplantation, with several centers around the world reporting successful cases of minimally invasive lung transplantation (MILTx), both with and without the use of a robotic assistance (eg, Barcelona, Cedars-Sinai, NYU, Vanderbilt).7, 8, 9, 10, 11 Although there is no universally accepted definition of MILTx, it is generally characterized by a skin incision of 6 to 8 cm, minimal use of a rib spreader, and reliance on specialized minimal-access instruments and knot-pushing devices.

This work aims to provide an overview of minimally invasive approaches to lung transplantation, focusing on the technical aspects and equipment currently used by three centers that routinely perform MILTx. Because of the nature of this manuscript, written informed consent from patients and institutional review board approval was not required.

Patient Selection

There is a consensus that, at the current stage, not every lung transplant candidate is also a suitable candidate for minimally invasive approaches. However, patient selection heavily depends on the surgical team's experience in MILTx. As with any evolving technique, patient selection remains a moving target. Therefore, we have categorized patient characteristics into 3 groups: good candidates, challenging but possible candidates, and currently not recommended candidates. Notably, certain patients—such those with a deep chest, or central branching of pulmonary artery and veins—may be better candidates for a robotic approach (Table 1). In contrast, a nonrobotic, minimally invasive approach is generally easier in patients with a small, flat chest.

Table 1.

Candidates for minimally invasive lung transplantation

Good	Challenging but possible	Not recommended
COPD, ILD	PAH, CF/bronchiectasis	ReTx, coal worker's pneumoconiosis, sarcoidosis
BMI <28	ECLS bridged patients	BMI >32
		Previous lung or heart surgery (excluding diagnostic wedge resections)
	Hilum rotated posterior
	Central branching of PA and pulmonary veins
Male	Female with large breasts
	Extensive mediastinal fat
	Extensive bronchial collaterals, lymphatic tissue

COPD, Chronic obstructive pulmonary disease; ILD, interstitial lung disease; PAH, pulmonary arterial hypertension; CF, cystic fibrosis; ReTx, retransplantation; BMI, body mass index; ECLS, extracorporeal life support; PA, pulmonary artery.

The Vanderbilt Technique

Proper patient positioning is crucial. We found that access to the hilar structures became easier when the utility incision was moved laterally while gradually reducing its length. This adjustment requires positioning both arms on padded arm boards and elevating the chest—either with an inflatable balloon or a stack of sheets. To facilitate bed rotation, the patient's hips are stabilized using adjustable rectangular braces (Figure 1, A).

Figure 1.

A, Positioning of the patient and incisions for a nonrobotic minimally invasive approach. B, Central aortic cannulation under direct vision is feasible through a 6- to 8-cm utility incision in the fourth intercostal space.

A 6- to 8-cm skin incision is made in the breast fold, and the thoracic cavity is accessed through the fourth intercostal space. A small Finochietto rib spreader or a Mini-access retractor (Koros) is used to create a small window; however, extensive spreading is unnecessary and should be avoided. An additional soft tissue retractor can improve exposure, particularly in patients with significant subcutaneous fat. In addition, a 10-mm accessory incision is made in the sixth and seventh intercostal space along the anterior axillary line. A diaphragmatic retraction stich is placed through this port in cases where the diaphragm is elevated. On the left, a pericardial stich is placed above the phrenic nerve and tied to the medial part of the utility incision in order to retract the left ventricle.

Intraoperative venoarterial extracorporeal membrane oxygenation (ECMO) is important for MILTx. As previously shown, it helps protect the graft postimplantation by enabling controlled reperfusion and lung-protective ventilation strategies. In addition, it unloads the heart, facilitating access to the hilar structures—a crucial advantage when working with small incisions and limited exposure to the chest. We use an 18-Fr Fem-Flex arterial cannula (Edwards Lifesciences) inserted using the Seldinger technique via the right utility incision. Maintaining full control over the cannulation site at all times is imperative, since manual compression is not possible. We therefore recommend using pledged-armed purse string sutures (Figure 1, B). Because of space limitations of the right utility incision, a femoral drainage cannula is preferred.

Dissection and anastomosis are performed using instruments primarily developed for minimally invasive heart valve surgery. Pneumonectomies are conducted under direct vision through the utility incision. The assistant's main role is to retract the mediastinum, often in a blind manner. We found a Sweetheart retractor, wrapped with a cohesive bandage (Coban; 3T Medical Complete Systems) to be particularly helpful, as it provides broad contact to the mediastinum and is less prone to sliding due to the wrapping. In addition, the bandage helps prevent damage to the phrenic nerve. Dissection instruments with various curves are required given limited maneuverability. The most useful clamps and instruments for MILTx are depicted in Figure 2, A.

Figure 2.

A, Collection of instruments needed for minimally invasive lung transplantation. B, These instruments facilitate dissection and anastomosis through small incisions. C, Most of the stapling is performed through the distal 12-mm port.

Implantation follows a technique similar to that of open approaches using a single-running double-armed 4-0 polydioxanone suture (PDS) suture (SH needle) for the bronchial anastomosis.¹² Using a minimally invasive needle driver and forceps enables precise control of the different stitching angles needed for a running suture anastomosis (Figure 2, B). The venous anastomosis is performed using a single-running double-armed 4-0 PROLENE suture (SH needle) and the pulmonary arterial anastomosis using a single-running double-armed 5-0 PROLENE suture (RB-1 needle). In case of a proximal branching of the right truncus anterior (A1, 3), the anastomosis can be performed with the recipient's ongoing pulmonary artery. Several options are available for endoscopic vascular clamps including the Chitwood DeBakey clamp, the robotic Satinsky clamp (both from Scanlan International) and the endoscopic Satinsky clamp (Wexler Surgical). Given anatomical variations among patients, we recommend having all these options available so the most appropriate one can be selected. We prefer placing both the venous and the arterial clamps through the distal 10-mm port. A Chitwood Knot Pusher (Scanlan) is used to tie the sutures. After reperfusion, drains are placed using the distal utility port, the patient is weaned from ECMO and the incisions closed.

The Cedars-Sinai Technique

The patient is positioned supine with an axillary roll placed longitudinally along the spine, and their arms tucked at the sides. A 6-cm thoracotomy is made in the second, third, or fourth intercostal space chosen for the best access to the pulmonary artery—the third space is the most commonly used for restrictive lung disease, our most common underlying indication. The incision is medial on the right (adjacent to the sternum) and more lateral on the left (extending to the axilla). In female patients, the breasts are pulled downward for the third intercostal or upward for fourth intercostal to avoid cutting through breast tissue. The intercostal muscle is incised without undermining the skin incision, and a small Alexis soft-tissue retractor placed. An Estech window access retractor with suitable depth blades is placed and the ribs gently spread, certainly not to the maximum extent possible. A counterincision is made in the midaxillary line in the sixth to eighth intercostal space to allow for a 12-mm Thoracoport.

Pleural adhesions are divided first. If these are extensive, then it may be better to increase the size of the incision rather than to perseverate. An Allison lung retractor wrapped in a Raytec gauze is used to retract the hilum medially and slightly anteriorly (friction from the Raytec gauze greatly assists in the latter effect). The hilum is dissected using electrocautery primarily. The same sequence is used in virtually every case dividing in turn, using a 35-mm Ethicon endoscopic stapler placed via the Thoracoport (Figure 2, C): superior pulmonary vein, upper lobe pulmonary artery, interlobar artery, inferior pulmonary ligament (electrocautery only) and inferior pulmonary vein. The remaining hilar tissue and the bronchus is divided with electrocautery skirting around any hilar lymph nodes, and the lung is removed. Incision of the specimen side pulmonary veins and artery decompresses the lung to facilitate removal. The chest cavity is washed out and hilar preparation carried out: the pericardium is opened circumferentially around the pulmonary veins. On the right side, Sondergaard's groove is dissected along its extent for a depth of 10 mm to facilitate left atrial (LA) clamp placement. The pulmonary artery (PA) is prepared by freeing enough tissue circumferentially to place a clamp comfortably on the main branch artery. The bronchus is prepared by sharp transection, ensuring a short tongue of membranous bronchus extends beyond the cartilaginous end. The prepared donor lung is then “squeezed” into the pleural cavity with the aid of a Keller funnel. It is invariably easier to insert the donor lung than it is to remove the diseased native lung, so little force is actually needed for this step (Video 1). The lung is reorientated into the anatomical position once it is in the pleural space. Long-shafted instruments designed for minimally invasive surgery are used, along with a knot-pusher for tying sutures. The bronchus is sewn with a running 4/0 PDS and the peribronchial tissues approximated anteriorly to cover this anastomosis, also with 4/0 PDS. The LA clamp (VATS-style Lambert-Kay Aorta Clamp; Wexler Surgical) is then placed via the counterincision made for the Thoracoport. The left atrial cuff is sewn with a running 4/0 PROLENE with an imbricating technique along the posterior wall. Finally, the PA clamp is placed via the main thoracotomy incision and the PA anastomosis performed with a running 5/0 PROLENE. The LA clamp is removed first, to allow retrograde deairing through the PA anastomosis. The PA clamp is removed in stages, allowing for controlled progressive reperfusion over around 10 minutes.

In off-pump cases, the team usually takes a break of 30 minutes to allow the newly implanted lung this time to acclimatize before it experiences the full cardiac output. In patients with ECMO, there is no need for this break. In both off-pump and ECMO cases, 5000 units heparin are given for each side.

For robotic cases, we may use the direct technique for explant and hilar preparation, or we may use the robot for these steps, depending on surgeon preference. The Da Vinci Xi platform is used. The center of the boom marked by the laser target is aimed at the main bronchus. The incision is the same, but only a soft tissue retractor is needed—no rib spreader. The second arm is used or a 30° camera and the third arm for a dual blade retractor, both placed through the main working incision. The first arm is used for the left-hand instruments (mostly Resano forceps) and the fourth arm for the right hand instruments (mostly needle driver, scissors or Maryland dissector). These arms are placed one rib space cephalad and one rib space caudad to the incision respectively, and line up with the lateral margin. Although Da Vinci provide a robotically operated endoscopic stapler, we still prefer to apply the Ethicon stapler through the 6-8th space counter-incision as for the direct minimally invasive approach—this gives the most space for articulating the stapler. The steps of the robotic procedure are identical to the direct minimally invasive approach, only exchanging the 4/0 PROLENE suture for the LA with a CV-4 Gore-Tex, and using a longer (36”) 5/0 PROLENE for the PA anastomosis. The anastomoses are all performed running with the bedside assistant following using a Yan suture catching-forceps (Delacroix-Chevalier) via the working incision. Knot pushers are used for tying immediately for the bronchus, or after deairing for the vascular structures, as for the direct technique.

The NYU Technique

Recipients are supine with the arms tucked and the chest bumped longitudinally to allow for lateral access. An 8-mm robotic port is placed in the fourth interspace using a blunt trocar. Carbon dioxide (CO₂) insufflation is initiated at 5 to 8 mm Hg. Three more robotic ports and an assist port are placed (Figure 3) and the robot is docked. A 30° camera is used in the “up” position for the procedure.

Figure 3.

Port placement for a fully robotic lung transplantation. Port 1 (the camera port) is placed in the fourth interspace bluntly. Next, the 12-mm robotic port for superior stapling/working arm is placed in the second or third interspace, depending on patient chest cavity size. The third port placed is an 8-mm robotic port in the fifth interspace, lateral to the internal mammary artery. The fourth port is a 12-mm robotic port for inferior stapling/working arm is placed in the sixth or seventh interspace, depending on patient chest cavity size. The final port is an 8-mm AirSeal device (Conmed) placed laterally in the fourth interspace, 5 cm away from port 1.

For the pneumonectomy, the instruments are a fenestrated-bipolar forceps, a long-bipolar grasper, and a dual-blade retractor. The dual-blade retractor is used with a sponge to retract the mediastinum. We divide all vascular structures with 12-mm SureForm Curved-Tip white load staples. Dissection starts with the superior pulmonary vein (PV), which can be divided from the superior or inferior arm. The A1/A3 PA and remaining PA are stapled separately using the inferior arm. The inferior PV is divided from the superior port. For larger vessels, a Tip-Up-fenestrated grasper can help encircle the vessel (Figure 4, A). Monopolar scissors are used to cut the lobar bronchi (Figure 4, B). The native lung is left in the chest during hilar dissection, to allow CO₂ insufflation to aid in hilar retraction. After hilar preparation, the camera and assist port sites are connected to create the 5-cm access site. A wound retractor is placed. The native lung is removed under direct visualization, and the new allograft is placed using a Keller funnel. The camera port is placed back in the medial aspect of the access site.

Figure 4.

Dissection of the vessels (A), division of the bronchus (B), bronchial anastomosis after shortening of the recipient main bronchus (C), pulmonary artery (D) and venous anastomosis (E) in a robotic lung transplantation.

A DeBakey forceps and large needle driver can be used for the entire implantation. A curved hook is used by the assistant to follow the sutures. The bronchial anastomosis is completed with running 4-0 barbed PDS (Figure 4, C), with the sutures tied robotically on the anterior wall. The minimally invasive PA clamp is placed through the lateral aspect of the assist port. The PA anastomosis is performed with a running Gore-Tex CV-5 suture for the backwall and a separate running suture for the front wall (Figure 4, D). The sutures can be tied robotically or with a knot pusher by the bedside surgeon. A separate incision inferolateral to the inferior robotic port is used for the minimally invasive Satinsky clamp for the left atrium. The backwall is imbricated with a Gore-Tex CV-4 (Figure 4, E), and a second suture is used for a simple running front wall. The clamps are removed for deairing, and the PV suture can be tied robotically or by the assistant. Drains are placed via the inferior robot port site and the Satinsky clamp site prior to reinflation of the lung.

For patients who require intraoperative ECMO support, our preferred method is a right femoral cutdown, with placement of a 17-/19-Fr arterial cannula and a 23-/25-Fr venous cannula, depending on the patient size. If needed, a diaphragm retraction stitch can be placed in the central tendon and retracted through the Satinsky clamp site.

Discussion

Reducing surgical trauma, even in extended thoracic surgery, has been a significant driving force behind the growth of minimal invasive approaches. For a long time, MILTx was considered unsafe because of the considerable intraoperative risks associated with the procedure. These risks are real, and even when performing in a maximally invasive approach (ie, clamshell) with optimal access to the pleural space, the critical hilar structures and the heart remain at risk for injury and mortality in lung transplantation.

There are several potential advantages of MILTx; however, the true benefits remain to be fully established (Table E1). Theoretically, smaller incisions may reduce postoperative pain and promoted faster recovery. The largest reported series of MILTx, published by the Cedars-Sinai program, demonstrated that recipients had shorter intensive care unit and hospital stays, required less opioid medication and showed greater forced expiratory volume in 1 second and forced vital capacity values at 3 months’ posttransplant.¹³ Although this analysis included propensity score matching to adjust for factors such as age, sex, body mass index, diagnosis, lung allocation score, double versus single lung, hypertension, diabetes, and hospitalization status, an imminent selection bias remained, because not all recipients qualify for a minima invasive approach. Nevertheless, this study provides valuable insights into benefits of MILTx. Interestingly, these findings align with those from the field of minimal invasive oncologic thoracic surgery where similar conclusions have been drawn.¹⁴

With growing experience and ongoing technical advancements, we anticipate that the selection criteria for MILTx will continue to expand. The ideal recipient to start a nonrobotic MILTx program is a thin, male patient with interstitial lung disease with a flat chest, because the hilar structures are more challenging to access in patients with deeper chests. However, we believe that MILTx can also be applied in patients with greater body mass index or less favorable diagnosis including pulmonary arterial hypertension or cystic fibrosis (Figure E1, A-D). However, extensive adhesions, particularly around the hilar structures, remain a contraindication for minimal invasive approaches. Lung transplantation can be complex, and even minor surgical errors can significantly impact patient recovery. Currently, the proportion of patients eligible for a minimal invasive approach lies between 20% and 40%, but we are confident that this number will increase as expertise continues to grow.

Figure E1.

Computed tomography scout views of transplant candidates are shown in the upper row. Big chest cavities (A) are favored for robotic MILTx (orange). Chest size is less relevant for nonrobotic MILTx techniques, however, body composition and accessibility to the chest are important (B and C; pink). The patient displayed in (D) is not a candidate for MILTx. For central extracorporeal membrane oxygenation cannulation (ascending aorta), the distance of the chest wall determines feasibility (E and F). Deep chests (G), or hearts rotated to the left with the superior vena cava (V) lying in front of the ascending aorta (Ao) (H) are challenging.

As a general rule, the choice of incision or access must not compromise surgical quality or patient safety. This means that the dissection and anastomosis must be performed in the same meticulous and thorough manner. An essential aspect in this regard is the management of intraoperative ECMO support. Recent literature suggests that intraoperative venoarterial ECMO should be liberally applied in all lung transplantations, as it facilitates controlled reperfusion, lung protective ventilation and cardiac unloading, thereby simplifying hilar dissection.¹⁵ A central aortic cannula is preferred over femoral arterial cannulation when, the ascending aorta can be safely accessed, as this helps prevent differential hypoxemia (Figure E1, E-H). To visualize the ascending aorta, the right utility incision should be made anteriorly in the fourth intercostal space. However, this approach may limit the exposure of the right lower lobe vein and make posterior pericardial dissection more challenging. If the heart is rotated to the left and the ascending aorta is obscured by the superior vena cava, a peripheral ECMO approach may be more practical. A well-positioned femoral drainage cannula is preferred to increase available space in the utility incision.

An important point to discuss is the impact of MILTx techniques on surgical training. MILTx represents a natural progression toward smaller incisions, evolving from the clamshell incision to sternal-sparing anterolateral thoracotomies, minithoracotomies, minimally invasive assisted procedures, and robotic procedures. Currently, surgeons who perform MILTx uniformly have extensive experience in open lung transplantation and are confident with traditional approaches before they transitioned to MILTx. Training fellows and residents, however, can be challenging in MILTx. New camera systems such as mini-needle cameras or the use of operating room robots with 2 consoles can be used to improve training in MILTx.

As with all new technical advancements, also MILTx continues to evolve. There is a need for new minimally invasive vascular clamps (eg, Satinsky), with varying angulations and different sizes. In addition, innovations such special mediastinal retractors—which can be connected to chest retractors similar to atrial retractor used in minimal invasive mitral valve repair—are being explored. The development of uniportal robotic platforms is another promising area of improvement.

The authors of this manuscript believe that a well-established infrastructure, along with advanced surgical and anesthesiologic expertise is essential before initiating a MILTx program. During the early learning phase, operating room and anastomosis times are generally longer than in standard approaches. For robotic MILTx, reliable access to a surgical robot and the support of experienced robotic surgery assistants are crucial. Recent advancements in prolonged graft preservation using 10 °C cooling have helped to overcome many of the infrastructural and organizational challenges of MILTx.

In conclusion, MILTx approaches have been pioneered by several lung transplant programs in the United States and Europe. With increasing experience, we are confident that MILTx will play an expanding role in lung transplantation. However, future studies are necessary to determine which patients are candidates for MILTx, and to fully assess benefits and risks of these approaches.

Conflict of Interest Statement

The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Supplementary Data

Video 1

A Keller funnel can be used to squeeze the graft through the small utility incision into the recipient chest. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00432-8/fulltext.

Appendix E1

Table E1.

Patient characteristics and outcomes

	Cedars-Sinai experience∗		NYU experience†	Vanderbilt experience‡
	Robotic MILTx	Nonrobotic MILTx	Robotic MILTx	Nonrobotic MILTx
Age, y	66 (64-72)	67 (61-70)	65 (58 and 73)	67 (62-70)
Male sex	62%	65%	50%	59%
Height	170 (165-180)	166 (160-175)	160 (155 and 165)	173 (160-183)
BMI	ND	ND	23.5 (18 and 29)	25.3 (22.9-29.6)
Diagnosis
COPD/emphysema	6/21 (29%)	4/90 (4%)	2/2 (100%)	5/17 (29%)
ILD	12/21 (57%)	66/90 (73%)	0/2 0%	8/17 (47%)
Other	3/21 (14%)	20/90 (23%)	0/2 0%	4 (24%)
Type of Tx
Single	8/21 (38%)	45/90 (50%)	0/2 0%	0/17 (0%)
Bilateral	13/21 (62%)	45/90 (50%)	2/2 (100%)	17/17 (100%)
Intraoperative mechanical support
VA ECMO	9/21 (43%)	25/90 (28%)	0/2 0%	17/17 (100%)
Cardiopulmonary bypass	0/21 (0%)	5/90 (5%)	0/2 0%	0/17 (0%)
No support	12/21 (57%)	60/90 (67%)	2/2 (100%)	0/17 (0%)
Total surgery time, min	ND	ND	489 (458 and 519)	370 (345-410)
Median length of stay, d	14 (12-21)	14 (12-17)	18 (29 and 6)	18 (15-31)

MILTx, Minimally invasive lung transplantation; BMI, body mass index; ND, not determined; COPD, chronic obstructive pulmonary disease; ILD, interstitial lung disease; Tx, transplantation; VA ECMO, venoarterial extracorporeal membrane oxygenation.

^∗Adapted from Ann Thorac Surg. 2025 119(5):1107-1116.

^†Adapted from J Thorac Cardiovasc Surg. 2025 Apr 17:S0022-5223(25)00300-9.

^‡Unpublished data.