Right and left lower lobes from two healthy donors are implanted in the recipient in place of whole right and left lungs, respectively.

A posterolateral thoracotomy is performed through the 5th intercostal space. Fissures are developed using linear stapling devices. Dissection in the fissure is carried out to isolate the pulmonary artery to the lower lobe, and to define the anatomy of the pulmonary arteries to the middle lobe. The pericardium surrounding the inferior pulmonary vein is opened circumferentially.

After placing vascular clamps in appropriate positions, the division of the pulmonary artery, the pulmonary vein and the bronchus is carried out in this order. The right lower lobe is extracted. If the branches of the middle lobe artery are small, they are ligated and divided.

Pulmonary artery to the lingular segment is carefully identified. The pulmonary artery is divided in an oblique fashion. If the branches of the lingular artery are small, they are ligated and divided.

The extracted lobes are flushed with 1 l of Euro-Collins solution both antegradely and retrogradely from a bag approximately 50 cm above the table. Lobes are gently ventilated with room air during the flush.

With the spine position, the "clamshell" incision is used and the sternum is transsected. The sternum is notched at the level of transsection by aiming the sternal saw at a 45 degrees angle and cutting toward the midpoint to facilitate postoperative sternal adaptation.

Before heparinization, bilateral hilar dissection is carried out. Branches of the pulmonary artery and the veins are taped outside of the pericardium.

The pericardium is opened. The ascending aorta and the right atrium are cannulated after heparinization and the patient is placed on standard cardiopulmonary bypass.

Pulmonary vein branches are divided between the silk ties. The right main pulmonary artery is stapled distal to the first branch, and then divided.

The bronchial stapler is fired as distal as possible. Then, the main stem bronchus is divided and the right lung is excised.

A stay stitch is placed on the bronchial stump. Meticulous hemostasis in the posterior mediastinum is achieved at this point because it is extremely difficult to reach this portion after implantation of the donor lobe.

The upper pulmonary vein stump is grasped and retracted laterally. The pericardium is opened circumferentially around the upper pulmonary vein. Interatrial groove is developed to permit proximal placement of a vascular clamp. The right pulmonary artery is separated from the surrounding tissue behind the superior vena cava.

Left pneumonectomy is performed. The chest is irrigated with warm saline containing antibiotics. The upper airway is also irrigated by an anesthesiologist.

A stay stitch is placed on the right main stem bronchus near the carina. The right main bronchus is transected just proximal to the upper bronchial take-off.

A moist cold sponge is placed in the right chest cavity and the right lower lobe of the donor rests on this during implantation. Additional ice slush is placed over the graft to slow the warming process.

The bronchial anastomosis begins with a running 4-0 polydioxanone suture for membranous portion.

The cartilaginous rings of the donor and recipient are jointed with simple interrupted 4-0 polydioxanone sutures. No attempt is made to intentionally intussuscept of the donor lower bronchus to the recipient main bronchus. The bronchial wrapping is not employed except for the patients who are on a high dose of steroid therapy.

The right pulmonary venous anastomosis is performed by connecting the donor lower pulmonary vein to the recipient upper pulmonary vein. A vascular clamp is placed on the recipient's left atrium intrapericardially. The back wall of the venous anastomosis is performed with a running 6-0 Prolene suture. It is important to assure intima-to-intima approximation. The anterior wall of the venous anastomosis is performed in the same fashion and the sutures are kept untied.

In patients with primary pulmonary hypertension, the pulmonary artery is markedly dilated. A vascular clamp is placed behind the superior vena cava. The right pulmonary artery is transected proximal to the first branch. Leaving a long pulmonary artery might increase the risk of arterial kinking after reperfusion. Note the huge size discrepancy between the recipient main pulmonary artery and the donor lobar pulmonary artery.

To compensate for the huge size discrepancy, tack stitches are placed on the recipient's pulmonary artery. In this case, four tack stitches were placed.

The back wall of the pulmonary artery anastomosis is performed with a running 6-0 Prolene suture.

The anterior wall of the pulmonary arterial anastomosis is performed in the same fashion. At completion of the anterior wall anastomosis, saline solution is injected into the pulmonary artery to remove residual air.

The first implanted right graft is packed in iced saline and slush while the left graft is implanted. The donor left lower lobe is placed into the left chest cavity and kept cold with iced saline and slush.

The sequence of the left graft anastomosis is the bronchus, vein and artery.

Both implanted lungs are re-ventilated gradually. The right graft is first reperfused by loosening the pulmonary artery clamp momentarily. The anterior wall of the venous anastomosis is kept open to allow de-airing of the right graft with the atrial clamp still in place. The venous sutures are then secured and the clamps are removed.

Left graft is reperfused in the same fashion. We ventilate both lungs manually and confirm full re-expansion of the grafts. Cardiopulmonary bypass is gradually weaned and then removed. Fibrin glue is applied to both hilum to obtain complete hemostasis.

Two chest tubes are placed in each chest cavity and a pericardial drainage tube is placed in the pericardium. The resultant cut ends of the sternum fit nicely together at the time of closure with three sternal wires.

(A) Before operation. Marked cardiomegaly was present. (B) Three months after receiving LDLLT. Well-expanded lobes filled the chest cavity, leaving no detectable dead space without cardiomegaly.

After receiving a living-donor lobar lung transplantation, 31 of 33 recipients (94%) are currently alive for as long as 77 months at Okayama University.