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A challenging problem
Bloodless coup: The five-hour surgery didn’t need even a drop of the fluid

Three hours into the operation to replace the little boy’s diseased liver, transplant surgeon Arvinder Singh Soin sensed that his team might just pull off something extraordinary. Something to tell fellow surgeons about. Cutting through tissues and blood vessels, Soin had just detached the boy’s liver from a large vein that, surgeons know from experience, can make such operations messy.

But the boy so far hadn’t required a single drop of blood. The anaesthetist monitoring the boy’s vital signs told the surgeons that things looked good. All readings were within a range expected from a boy whose abdomen is open and whose liver is about to be pulled out. Five hours later, at the close of the operation, none of the 15 units of blood waiting for transfusion had been used.

Last week, Soin and his colleagues announced India’s first ‘bloodless’ liver transplant, an operation conducted without blood transfusion, on the four-year-old Safi from Pakistan. Doctors at the Sir Ganga Ram Hospital (SGRH) in New Delhi had transplanted a small chunk of liver taken from Safi’s uncle into the boy’s upper abdomen.

They discharged his uncle a week after surgery. With Safi’s new liver working well, doctors last week prepared to send him home too.

While several hospitals in India have performed liver transplants over the past six years, this is the first in the country where the recipient of the liver did not require a transfusion. 'It’s specially challenging because liver transplants are among the most complicated operations known,' said Soin, a transplant surgeon at the SGRH. 'Liver failure affects other systems in the body and raises the risk of severe blood loss during surgery.'

Safi had been suffering from intractable jaundice since he was eight months old. The cause of jaundice remained undiagnosed but, month after month, it got worse. It crippled the liver and led to irreversible destruction of liver tissue. As he turned four, doctors in Pakistan told his parents that without a transplant he was unlikely to survive more than a year. That’s when the parents spoke to friends and contacted paediatric hepatologist Neelam Mohan at the SGRH.

She diagnosed the cause of liver failure as a genetic disorder for which a transplant was the only solution. And she prepared the boy for surgery, giving him vitamins, vaccinations and using clay models to explain transplants to the boy. 'Talking to children makes them more receptive to surgery and leads to faster recovery,' said Mohan.

When the boy was wheeled into the operation theatre on April 9, doctors were ready with blood for transfusion. In a four-year-old child, just 200 ml blood loss would have necessitated transfusion. But surgeons at the SGRH have been trying to minimise blood loss during transplants for some time now.

'Transplants without transfusions eliminate the risk of transfusion-related infections and help in speedier recovery,' said Dr Subhash Gupta, transplant surgeon and a team member. Such operations were first done in the West on patients whose faiths forbade them to accept blood transfusions, he added.

The surgeons opened the boy’s abdomen through an incision that resembled an inverted T, the Mercedez Benz incision, as they call it. As the blood trickled out, doctors used an array of devices to stop the flow.

The decision of how to stop the flow was almost a reflex action for the surgeons, backed by experience. Soin and Gupta have both participated in hundreds of liver transplants while they were in the UK, and at least 12 transplants at the SGRH.

As the surgeons cut through skin, muscles and abdomen, they used a handheld probe that burns and seals blood vessels. When blood flowed out of the surface of the liver, they used an argon beam to seal the leak. Confronted by tiny leaking blood vessels, they used clips to clamp and shut the flow.

The critical juncture was when the liver was separated from the large vein called the inferior vena cava. It’s a point in the surgery where potentially major blood loss can occur. But the argon beam once again, defiantly, minimised blood loss.

In an adjacent theatre, a quarter of the uncle’s liver excised by Gupta earlier that morning lay waiting, bathed in an organ preservation solution. Now, it was brought in and the surgeons gave it a new home ' Safi’s upper abdomen ' using microscopes to stitch it to appropriate blood vessels and tissues.

They watched in relief as the organ gained colour. 'As the boy’s blood flowed through it, it turned from pale white to puffy pink,' said Soin. In an hour, blood tests showed that the new liver was working. The total blood loss was less than 150 ml.

The liver’s ability to regenerate allows living relatives to serve as liver donors. The liver’s capacity for regeneration will make the uncle’s liver grow to near-normal size within six weeks. While most transplants in India have involved live donors, surgeons say there is definitely a need to increase cadaver donations ' the harvesting of organs from brain-dead people.

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