How to Do a Liver Transplant (16 page)

After all this preparation, it is my turn to get to work. I yell out, ‘All right to start?' If there are no objections, I make a sizeable incision in the patient, about four centimetres beneath the ribs extending from one side of the abdomen to the other. Professor Lynch always says, ‘Unless the anaesthetist at the top of the operating table can see every stitch going in, then the cut is too small.' The incision is often called a Mercedes Benz because it is shaped like the luxury car's trademark symbol and is very fitting – expensive car, expensive operation. As soon as the skin and underlying muscle layers are breached, litres of clear amber fluid called ascites will gush out of the patient's abdomen, spilling onto the floor. I do my best to try and capture it with two powerful suckers and the two-litre
capacity plastic bags attached to the sides of the table, but nonetheless a great deal of it inevitably ends up on and in my shoes.

With the fluid evacuated, the soon-to-be-defunct liver comes into view. A healthy liver is smooth and shiny. A liver with cirrhosis, however, is a shrivelled, lumpy little thing with much the same profile as a giant walnut. To give me enough room to perform the transplant, I set up an elaborate metal frame which is clamped to either side of the operating table and supports a semi-circular arch. This arch rises about a foot above the patient's chest. Clawlike metal blades are positioned under the patient's ribs on both sides and with a grunt and a groan I haul the chest upwards, hooking the blades onto the frame. The liver is tucked high up under the ribs, almost in the chest, so without this medieval-looking device I would not be able to see a thing. Exposure is everything in surgery and if you can't see, you can't stitch. Surprisingly, this retractor doesn't hurt the patient at all and it also just so happens that the frame is a very convenient place for everyone in the surgical team to rest their elbows. The only drawback of this retractor is that it has a big metal knob, anchoring it to the side of the table. This bolt presses uncomfortably into my groin for the entire case, reminding me that surgery is painful for everyone.

When the view is optimal, the next task is to cut out the failing liver. This is done quickly and in such a way
that everything is set up to put the new one in. As soon as the liver came out of the donor, the clock began to tick. A short ‘bucket time' is crucial to a transplant's success and blood must be flowing through the new liver inside 12 hours of its removal from the donor for the best result. Getting the old liver out is not as easy as it might sound. The massive varicose veins that surround the liver and coat every surface of the abdomen explode with even the slightest touch, and because these patients have blood that does not clot, the haemorrhage can be so ferocious that much of the ‘taking out' part of the transplant is frequently done underwater in a sea of blood. The more I stitch, the more the patient will bleed. Even the normally innocuous holes that I make with my tiny needles will ooze uncontrollably. Just making the skin incision in people with cirrhosis can result in losing half a litre of blood. All of this lost blood is salvaged by a special machine that recirculates it back into the patient, cutting down on the need to impose on the blood bank – a type of recycling, if you will.

To remove a liver, it must be freed from all its attachments. Just as I would do to the ‘new' liver on the back table, I need to strip all the superfluous tissue off the blood vessels going to the old liver in order to gain as much length as possible. I need to fashion something to stitch the new one on to. To understand this better, a quick lesson in liver anatomy is required. For such a big organ (approximately one and a half kilos depending on the size of the person),
the liver has very little in the way of attachments to the body. Aside from a few flimsy ligaments, the only things that really hold it in place are its blood vessels.

The liver is unique because it has two separate blood supplies. The first is the hepatic artery that brings blood brimming with oxygen straight from the lungs via the heart. The bile ducts are the main beneficiary of this blood and it is for this reason that the hepatic artery is the Achilles heel of liver transplantation. If the blood stops flowing in the hepatic artery at any point after the surgery, the liver may not survive. The fragile bile ducts will die and liquefy, forming infected lakes of bile within the liver. These pools will quickly fill with pus and the patient will begin to rot from the inside out. Unless they are re-transplanted with a fresh liver, it is possible the patient will die.

The second blood supply to the liver is the impressive but delicate portal vein. The size of a garden hose, the portal vein drains blood from the bowels, stomach and spleen. It gives the liver cells the first pickings of the nutrients, fats and toxins produced by the gut. Then there are the imposing hepatic veins. Like everything in surgery, what goes in must come out and the main hepatic veins are how the blood comes out of the liver. These are the three stout tributaries that return the blood from the liver almost directly into the heart. Make a hole in one of these babies and you will really know you are alive because shortly after, the patient may not be. These hepatic veins are the most
significant support structures for the liver and, incredibly, only a single row of tiny stitches between these veins is all that is required to keep the new liver in place. More than a few times I have had patients refusing to get out of bed the day after a transplant for fear that their new liver will fall out of position. I am happy to reassure them that this doesn't ever happen and we have never had to retrieve a fallen liver out of anyone's pelvis.

Once all the blood vessels are stripped clean of their fat and sinew, a very cool thing happens. I can actually put my hand under the right side of the liver and the whole thing can be rotated from side to side on its central axis to get a good look underneath. This manoeuvre will reveal the final impediment to freeing the liver – the short hepatic veins.

Not to be confused with the three main hepatic veins, these are the smallest but most perilous vessels of them all. There are around ten to twenty of these short, fat little buggers emerging straight out of the back of the liver and going directly into the body's grandest vein, the inferior vena cava. Only a few millimetres long, they can prove to be very treacherous. Detaching them involves an hour of stooping down low in order to get a view deep under the liver where they live. There is only a sliver of space to operate in. Fine silk threads must be passed around every last one of these veins to securely tie them off forever, as the new liver does not need them to get by.

Because the liver is being lifted up and tilted to one side, these veins are placed under tremendous tension and they tear with alarming regularity. They are completely unforgiving, and within seconds a tiny tear can expand into a gaping hole in the inferior vena cava. In a large vein, a negative pressure is created when the patient breathes in. When there is a hole in said vein, this negative pressure causes the blood to suck back for a brief moment, similar to the way an ocean pulls back just before a tsunami hits. There is a horrible moment when I will be treated to a rare glimpse of the glistening insides of a great vein moments before the ensuing tidal wave of blood floods the operating field and obliterates the view completely. Moments in surgery like this definitely justify the use of some emergency language. ‘Christ alive,' is one I have heard as the blood begins to pour out. ‘Holy fuck' or some equally profane reference to the sexual act is another one that easily rolls off the tongue. No one ever seems to mind, because there are times in surgery when only the word ‘fuck' will do.

When there is bleeding like this flowing from the vena cava, deep under the liver, it is time to cut your losses and abandon any further careful dissection by placing large metal clamps across the mighty vessel to stem the tide.

‘Liver's coming out!' I cry. ‘Mark the time,' as I cut away the last few strands of tissue holding the diseased organ in place. Using two hands, the old liver is scooped out of the abdomen and plopped unceremoniously into a
waiting dish. It makes an extraordinary sucking sound as it releases itself from its bed, as if making one final protest. Turning back to the patient, I am faced with the surreal sight of a vast hole where the liver used to be.

As the old liver is coming out, the new liver, ensconced in its protective plastic bags, is taken out of the cooler and brought onto the operating table. It is carried with reverence across the room because this is the moment when there is a real chance it might end up on the floor. It has never happened to me, but I imagine if it does, I would just have to wash it off and use it regardless. What other choice would there be? I hope I never have to find out. Ice-cold salty water is hooked up to a tube inserted into the portal vein of the new liver and poured though at full speed to keep the liver cool and to flush out all the preservation solution. If this is not done, when the blood is allowed to flow through the liver again, the preservation solution goes directly into the recipient's bloodstream. This liquid contains a huge load of potassium and when that hits the heart, it can cause it to stop. Heart stoppage is definitely not desirable in the middle of a transplant, so it is best avoided by taking the time to flush the liver.

When everyone is ready, the new liver is lifted out of its bag and shoehorned into its new home. It is then a race to sew the blood vessels back together again. This typically takes anywhere between 13 and 22 minutes and yes, we do compete with each other for the best times. The first to be
joined up are the main hepatic veins, sewn almost directly onto the heart down a deep and narrow hole with thread not much thicker than a human hair. The new liver is still cold and pale and this seems vastly out of place next to the warm, pulsating tissues that surround it. There is no talking during this part of the operation, just tremendous focus. I am in the zone. I am lent a hand by my assistants who, for the time it takes, must contort themselves into unnatural positions holding metal retractors at just the right angles so I can get the optimal view. Knots are tied down with gloved fingers, pushed into the depths with just the right amount of tension so as not to break the thread. As I do this I pretend that I am Luke Skywalker using ‘The Force' and close my eyes as I feel the tension in the thread of the stitch rather than see it. With the hepatic veins complete, the next step is to join up the portal vein. This will bring most of the blood into the liver. It is easy to twist this vein or to make it too long, so a great deal of judgment must be used to cut it to just the right length. Too long and the vein will kink and clot, too short and it will snap like an overstretched rubberband.

When these two join-ups are complete, it is time to release the clamps and witness a miraculous sight. The cold, pale liver instantly fills with blood and life begins again. Like slapping a newborn baby on the bottom to stimulate its breathing, I give the new liver a loving rub to massage the blood right out to its edges. The liver once again
becomes warm, as the blood rushes in and returns it to its familiar rich red colour. I often wonder if the new liver was able to speak at this point, whether it would let out a big sigh and say, ‘Damn you all, I thought I was dead and I could finally have a rest. Now you want me to go to work for someone else?' The reperfusion causes the liver to swell and become about 30 per cent bigger, easily expanding to fill the space where the old one used to be. This is the point where you hope the size match between the donor and recipient has been estimated correctly. If the liver is too big, it will proudly bulge out of the abdomen like an unfurling spinnaker on a sailing ship. When this occurs, the liver becomes virtually impossible to move around and makes stopping the bleeding behind it very difficult.

The moments after blood rushes through the new liver are very dangerous for the patient and they can become massively unstable as there is usually another wave of rapid blood loss. The anaesthetists hover expectantly at the top of the table, poised to correct any drop in blood pressure or slowing of the pulse. This is the time during the transplant that the patient is most likely to die. The new liver takes some time to start working and the blood, still affected by the ravages of cirrhosis, will take a while to clot. Little holes in all the blood vessels begin to open up one after another with the changes in pressure, and each one needs to be attended to with fast precise stitches. I roll the liver back and forth to locate these holes, yelling out, ‘Stitch,
stitch, stitch,' as I hold out my hand waiting for the nurse to slap the next instrument loaded with needle and thread into the palm of my hand. I don't take my eyes off the action for a second. As each stitch is put in and tied, the scrub nurse sprays my hands with water so the knots tie down smoothly and won't snag on my blood-caked gloves. The tails of my stitches are trimmed off and as I finish with each one, I flick them backward onto the floor, not because I am messy, but so the ends do not get wrapped around my fingers, wasting a vital second as I tie the next knot. At the end of the operation, there is a mountain of fine blue nylon thread on the floor, mixed with congealed blood. It sticks to the bottom of my shoes and the nurses get grumpy when I forget and trek the gooey mess all over the floor.

Once the bleeding has settled down, my attention turns to the hepatic artery. Now the pace of the operation slows considerably. Joining this artery together is a painstaking job that must be performed with technical perfection. I keep saying that life hinges on small things and this is the case when it comes to this blood vessel. The serpentine hepatic artery is a three-layered structure and sloppy technique can cause these layers to split apart, rendering it useless. Peering down my microscope glasses, I place each stitch, not touching the delicate vessel with anything other than the tip of my needle. I pierce the wall of the artery at a perfect right angle and it takes about 20 stitches, placed at an exactly equal distance apart, to put it together. When
the clamps holding back the blood are released, the artery wriggles to life and hopefully will stand erect with the pressure of the pulse. Then, there will be yet another wave of bleeding as tiny holes upstream of the artery start to bleed. More ‘Stitch, stitch, stitch!' About this time the liver will be starting to work a little. Clots are produced and slowly the bleeding will ease. The transplant liver usually has its gallbladder still attached, but not for long as I whip it off. The last thing a transplant patient needs is an attack of gallstones. The final step is to connect up the bile duct that will deliver bile from the new liver into the bowel, and we all relax a little.