Safety and feasibility of bilateral lung transplantation with video-assisted thoracic surgery

Abstract Background The clamshell incision remains the most common approach for bilateral lung transplantation because it provides excellent exposure of bilateral pleural cavities and the mediastinum. However, it is associated with significant morbidity, including sternal dehiscence and instability. Video-assisted thoracic surgery (VATS) offers a less invasive alternative. This study aimed to evaluate the feasibility, safety, and early postoperative outcomes of the VATS approach. Methods We retrospectively analyzed 136 patients who underwent bilateral lung transplantation with extracorporeal membrane oxygenation support between August 2017 and March 2025. Patients were categorized according to surgical approach: clamshell ( n = 105) or VATS ( n = 31). Perioperative outcomes, complications, and pulmonary function were compared between the two modalities. Results The VATS group had a significantly shorter operative time (319 vs. 417 min., P < 0.001), less blood loss (832 vs. 2,789 mL, P < 0.001), and required fewer transfusions. Sternal wound complications and airway interventions occurred exclusively in the clamshell group. Patients in the VATS group exhibited significantly higher pulmonary function at 1 month postoperatively than did the clamshell group (forced expiratory volume in 1 s (FEV 1 ): 85.79 ± 18.00 vs. 67.25 ± 22.55, P < 0.001; forced vital capacity (FVC): 73.42 ± 14.14 vs. 60.00 ± 17.81, P < 0.001). These differences gradually attenuated but remained statistically significant at 12 months postoperatively (FEV 1 : P = 0.05; FVC: P = 0.04). Conclusions VATS approach for bilateral lung transplantation is feasible and safe, offering lower surgical morbidity and better pulmonary function than the conventional clamshell incision. This technique may provide distinct advantages in centers with established thoracoscopic expertise. Graphical abstract