How to Do a Liver Transplant (4 page)

‘Keep your hands up and elbows down,' she barked. ‘Let the soap drip off and don't touch anything!' My nervous energy was causing my knees to knock together and I thought I had wet my pants but it was just the water dribbling off my elbows and down my leg. When she had had enough of watching me spray water everywhere, the nurse grasped the back of my shirt and frog marched me
through the heavy double doors into the operating theatre. I held my dripping wet hands aloft, just as I had seen on TV medical dramas. The nurse then grumbled her way through the instructions for the ‘more complicated than it appears', gown and gloving process.

‘Dry your hands with the little towel. Don't touch anything. Now, pick the gown up in the tips of your fingers, let it fall open, one arm in and then the other,' the nurse demanded. She roughly spun me around by the shoulders and tied the back of the gown tightly, like she was lacing me into a corset. ‘Now, pick up your gloves and put them on without touching them on the outside.' Of course, in my haste to please her, I hadn't dried my hands properly (or they were damp with sweat) and my fingers went in all the wrong holes. I could tell the frustrated nurse wanted to grab me and shove the gloves on the right way or put them where the sun doesn't shine. Luckily for me, she could no longer touch me because I was now officially ‘sterile'. Finally, after a full ten minutes, I had everything on and I was ready to ‘operate'. I approached the operating table and then, without thinking, I rubbed my nose with my now sterile hand. The nurse swore and grabbed me by the shoulders once again, spinning me around and ripping my gown off in one movement, like a stripper at a bachelor party. I had completely contaminated myself and had to go and start the whole process again. The nurse turned on her heel and walked off in disgust, leaving me to it.

When I finally got to the operating table, the surgery was well underway. Dr Smith was standing on the patient's right and told me to take my place in an impossibly small area wedged between his back and a tall metal table suspended over the foot end of the bed and laden with rows of shiny surgical instruments. I was so close to Dr Smith that every time he moved I had to take a tiny step backward otherwise his hip would touch my belly. I was not quite ready for this invasion of my personal space but I soon learned that this closeness is not given a second thought and that surgeons leave their inhibitions at the door. This proximity to each other soon makes you understand why it is not a good idea to have garlic for lunch.

‘Here Kel, hold this,' Dr Smith muttered. His eyes did not leave the TV screen as he grabbed my hand and placed it onto the scissor-like handle of a long instrument protruding from the patient's abdomen. I had no idea what I was holding but hold it I did, with a white-knuckle grip, determined not to move a muscle. I was going to be the best instrument holder they had ever seen. There was one slight problem, though. I didn't appreciate that not moving my hand did not necessarily mean that I should not move anything else. My extreme stillness quickly resulted in the pooling of blood in my legs and within a few minutes I saw a dark veil come down in front of my eyes. I tried to stifle an incredible urge to vomit. I managed to utter the words, ‘I feel sick …' before I felt myself falling and the lights went
out. Fortunately for the patient on the operating table, I fell backwards onto the floor and not face first into the wound. I woke up a few minutes later on a trolley in the recovery room alongside all the patients who had just come out of surgery. Dr Smith was grinning down at me.

‘Gee Kel, are you all right? That was a pretty interesting way to start your first day. See, I knew girls shouldn't do surgery,' he joked again and walked away, chuckling and shaking his head. At least I hoped he was still joking. It was not the most illustrious start for a budding surgeon, but even after this small taste of the operating theatre, I could not be deterred. This was what I wanted to do. I got right back on the horse and returned to Dr Smith's theatre for the rest of the cases that day and never went down again.

I heart gallbladders

F
or most surgeons, it is pretty easy to recall the first operation you ever saw and the feeling that it gave you. Getting to help Dr Smith remove the gallbladder that day (at least the small part I saw before I hit the deck) was the beginning of my love affair with that little sac of bile. Never let it be said that there was a gallbladder I didn't like. Even after claiming the scalps of more than 2000 of them, I never get tired of taking them out. It is really relaxing and it sends me to my happy place. There is a reason I have been unofficially crowned the Gallbladder Queen.

Myths surrounding the gallbladder and its removal are plentiful – probably more than any other body part. Old wives' tales about gallbladder surgery, previously passed over the back fence, have been amplified by the internet. Just ask Dr Google and be entertained by the fanciful stories about home remedies for gallstone removal. Whenever I think I've heard them all, along comes someone with an even crazier idea that makes me smile. People do love to hold on to their gallbladders and often have to be really talked into parting with them. The most common concern is that because it's there, it must be required for something. Sure it is – when it works. But when it is diseased, the gallbladder doesn't do a darn thing, other than threaten people's lives. I remind patients all the time that the body is built to do without many of its parts if need be. Kidneys, sections of the liver, the pancreas, most of the bowel and the appendix are all up for grabs. Life finds a way.

My favourite question about the gallbladder is, ‘Will you be using a laser to get rid of my stones?' I am not a Jedi Knight and I do not have a light sabre – well, not a real one, anyway. It is something I'd like to try but there are no lasers involved. I suspect if I used one, I might cut a hole in something I shouldn't. Other people wonder why you can't just pass a gallstone. ‘People manage to pee out the kidney stones don't they?' they ask. Unfortunately you cannot pass a gallstone unless it is very tiny. To get into the bowel, the stone must pass into the bile duct and then through a
tiny valve curiously named the Sphincter of Oddi. This process can cause blood poisoning or swelling of the pancreas and is downright dangerous. This brings me to the olive oil and lemon juice drinkers. There are many recipes available claiming that if a gallstone sufferer drinks these things in sufficient quantities, the gallstones will be magically flushed out of the gallbladder. The reality is that you can drink olive oil and lemon juice by the gallon and you might as well chase it with a head of lettuce because all you are doing is making salad dressing. A vinaigrette will not shift a stone, but it will help the person spend the night on the toilet shifting a bucket-load of stool. Finally there are the true devotees of this technique who tell me that they know it worked because they have found gallstones in their poo. I find this very interesting because it means that they have actually been sorting through their own faeces in order to look for them. We even have a name for it – ‘poo sifting'. If a patient insists that they have truly produced gallstones, I will ask them to bring them along in a bottle so I can send it to the lab to prove that they are little pieces of carrot. It is always carrot.

A gallbladder attack can be so bad that some patients become the complete opposite of the ‘poo sifters' and will actually beg to have their gallbladders removed. ‘Just do it,' they groan, out of their minds with pain. Therein lies the genius: this simple operation can magically transform a desperate person into a serene being within hours of
leaving the operating theatre. This turnaround from sick to well is a powerful thing for me and this is the appeal of removing a gallbladder. Thankfully, so many diseases that we used to see in their most advanced stages have virtually disappeared because of modern medicine. We understand a lot more about why things happen and can even prevent diseases before they occur. Gallstone trouble, however, can still be just as terrible as it was in 1420 when the problem was first described. It is incredible that a stone the size of a ballbearing can end the life of a fully grown man. Gallbladder disease is now perhaps worse than ever before, as western society gets fatter and older. So, when they eventually figure out a cure for cancer and I happily won't have to operate for that any more, I figure I will still have gallstones and all the intriguing problems they cause to keep me busy.

Bile is the thin, golden liquid that the liver churns out 24 hours a day. It leaks out of the cells where it is made and collects in the bile ducts that form an amazing arboreal network of pipes, draining every section of the liver. Thousands of branches coalesce into larger right and left ducts that unite just outside the liver, forming the main bile duct. The bile then takes a 15-centimetre journey down this conduit before emptying into the bowel. Once there, it mixes with the food we have just eaten and becomes the detergent that breaks down the fat. If you shake a container of bile, it even froths up like soap. If bile is a type
of soap, then the gallbladder is the reservoir of the soap dispenser. It stores and concentrates a little extra bile that the body keeps up its sleeve for when a fatty load of fish and chips comes along. A normal gallbladder is a delicate, almost translucent sac about the size of a Roma tomato. It is loosely attached to the undersurface of the liver by a thin layer of connective tissue. It is joined to the main bile duct by a short spiralling tube called the cystic duct. When there are stones present and a fatty meal comes along, the gallbladder tries to do its usual thing and eject its load of bile. This catapults the stones straight into the spirals of the cystic duct where they become wedged. If you can imagine what happens during childbirth, when a baby's head tries to emerge from a vagina, it is not a big leap to figure out what will happen when a gallstone attempts to do the same thing and exit the gallbladder. The experience is one of indescribable pain. It is so bad that patients will often believe they are having a heart attack.

Why humans get gallstones is still a little bit of a mystery, but it definitely seems to have something to do with oestrogen, fat and cholesterol, and what too much of any of them will do to bile. An excess of body fat generates extra amounts of the hormone oestrogen – in both men and women. This seems to increase the amount of cholesterol in bile, making it thick and slimy like green treacle. Thick bile is a fertile environment for crystals to form in and, over time, stones seem to grow from these tiny nidi.
Anything that changes the oestrogen balance in the body increases the chances of stones forming. Rapid weight loss can do it too, and a cruel side effect of doing a good thing can be a gall attack. Pregnancy is also a time where women develop stones, so as well as their bundle of joy, many women experience a bundle of pain, with their gallstones attacking them shortly after delivery.

There is another, rarer, cause of gallstones and it is just a little bit revolting. In many parts of the developing world there are parasitic worms that, similar to the movie
Alien
, enjoy making themselves at home inside their human hosts. They live in the bile ducts and feast on the bile and the cells shed by their benefactor. Of course, what goes in must come out and these critters evacuate their bowels and fill the bile ducts with their little droppings. These deposits harden and eventually become stones. In addition, when these creatures die their carcasses contribute to the detritus. All of this is extremely irritating to the bile ducts and results in severe scarring, continual bouts of infection, cancer, and liver failure.

Another strange thing about stones is that no one knows why some people's gallbladders will go on the attack and why others will carry a gallbladder full of rocks around their whole lives with nary a care. Gallstones come in a spectacular array of shapes and sizes. There might be thousands of tiny little ones like grains of sand or a single stone the size of a chicken egg. Many of them are a beautiful
pearlescent yellow and sharply faceted like a gemstone. Some patients even comment that they might be worthy of being fashioned into a necklace. Whatever the size, shape or number, these stones can all cause trouble – pain, jaundice, blood poisoning, inflammation of the pancreas, infection, cancer and death.

Surgically removing a gallbladder – ‘cholecystectomy' is the technical term – is a really great operation. No two gallbladders are the same and this adds to the enjoyment. Sometimes the surgery is really easy and it is all over in under an hour, and other times it is a three-hour extravaganza and I just
wish
it was over. And then, just when I think I've done the worst one I've ever seen, along comes another one that is even more terrible. Since the early 1980s, the operation has been done laparoscopically, that is, via keyhole surgery through four tiny cuts in the abdominal wall. The first time it was done this way, it took more than six painful hours, but thankfully we've got a lot better at it and I can now get an easy one done in under 30 minutes. Separating the patient from their gallbladder with laparoscopic surgery involves inserting a series of hollow tubes or ‘ports' through the abdominal wall. To get the first port in, we make good use of nature's doorknob – the belly button, a very convenient place to gain access to the abdominal cavity. Before the port is inserted, it is most important that the belly button is inspected to ensure it is sparkling clean. As it turns out, some people give very
little thought to umbilical hygiene and it is not uncommon to find some significant concretions nestled deep in this little orifice. Using a pair of tweezers to relieve it of its lint, cleaning the belly button can be a surgical procedure in itself.

Once a satisfactory state of cleanliness is reached, the belly button is grasped with a metal clamp and hauled upward. This lifts the abdominal wall off the bowels to avoid injuring them as a narrow tube is punctured through the skin and muscle. A gas hose is attached to this portal and carbon dioxide is pumped in, instantly inflating the tummy to around the size of a nine-month pregnancy. In their natural state, all the organs inside the abdomen are pressing against each other. Without the gas, there would be no separation and no space to operate in. The skin becomes translucent and tight as a drum, and once all the ports are in, the patient looks a little like a bloated porcupine. In keyhole surgery, all the action takes place on a TV screen. The picture is obtained by a long telescope attached to a camera that is passed through one of the portholes. Immediately, a magnified view of a rich red liver appears on several monitors scattered around the room. The gallbladder clings to the undersurface of the liver, just peeping out. It doesn't fully reveal itself until a long slender poker is inserted into another port and the liver is gently lifted to expose the full nature of the problem. Will it be simple or difficult? You just don't know until that very moment and
the anticipation can be really exciting. If the gallbladder is translucent and soft, the nursing staff will smile because they all know that this will be a quick and easy operation. But if the gallbladder is thickened and swollen with infection, everyone will groan, knowing we will be there for the next two hours while I painstakingly scrape and scratch the gallbladder away from its attachments. I grimace because I know my arms will ache for the whole of the next day from being held aloft for so long.