Objective: The objective of this study was to assess the efficacy and safety of an alternative surgical incision for bilateral sequential lung transplantation. The vast majority of these operations worldwide have been performed through an anterolateral thoracosternotomy known as the 'clamshell' incision. Recently, we have undertaken most of these operations through bilateral anterolateral thoracotomies without sternal division. Methods: Our medical center performed 262 bilateral sequential single lung transplantations from 1989 to April 1998. Between July 1996 and April 1998 we performed 69 bilateral sequential single lung transplantations on 68 recipients with 52 transplantations being conducted without initial sternal division. We retrospectively reviewed the results of these operations to assess the safety of the altered exposure and the efficacy in avoiding sternal wound complications such as malunion, dehiscence, osteomyelitis, and migrating hardware. Comparison was made to a historical control group composed of the last 50 patients in whom the full clamshell incision was used. Results: Of the 68 patients who underwent transplantations, 52 patients underwent the initial exploratory procedure without sternal division. Two patients required emergency sternal division for institution of cardiopulmonary bypass to control life-threatening bleeding. Eleven of 68 patients were placed on bypass electively to permit transplantation, and the lack of a sternotomy in 8 patients did not present an obstacle to ascending aortic and right atrial cannulation. There were no wound healing complications in the 50 patients for whom the sternum was left intact. In a historical control group of 50 patients who underwent transplantation with sternal division, 34% experienced morbidity or mild disability as a direct result of poor sternal healing. Conclusions: We conclude that bilateral anterolateral thoracotomy without sternal division is a safe approach that allows adequate exposure without the risk of commonly observed problems with sternal healing.