Extrapleural Techniques for Lung Procurement in Patients with Frozen Mediastinum

Utilizing an en bloc extrapleural technique for lung donation in a donor with systemic lupus erythematosus (SLE) complicated by polyserositis presents a challenging but highly effective strategy, particularly within the framework of Abdominal Normothermic Regional Perfusion (A-NRP). Lupus-induced polyserositis frequently leads to dense, vascular chronic inflammation and severe fibrous adhesions within the pleural spaces, rendering standard intrapleural mobilization hazardous due to the high risk of parenchymal tearing, intractable bleeding, or visceral pleural injury. By shifting the dissection plane to the extrapleural space - entering the endothoracic fascia and stripping the parietal pleura directly off the chest wall en bloc with the lungs - the surgeon circumvents these dense adhesions, effectively buffering and protecting the delicate allograft parenchyma. When executed during a Donation after Circulatory Death (DCD) recovery utilizing A-NRP, this technique requires meticulous coordination. While A-NRP maintains sub-diaphragmatic warm oxygenated perfusion to optimize abdominal organs, the thoracic cavity remains excluded from the circuit; therefore, this extrapleural dissection must be performed efficiently alongside standard topical cooling and antegrade pulmonary cold preservation flushes to minimize warm ischemic time and safeguard subsequent graft function.