20 Surgeons, 10 Anaesthetists, 5 Rehearsals, 18-Hr Surgery: India’s First Shoulder-level Full-arm Transplant

New Delhi: 20 surgeons, 10 anaesthetists, 5 practice sessions, and 18 hours of surgery – this is how doctors at Kerala-based Amrita Hospitals performed India’s first shoulder-level full-arm transplant.

The third of its type in the world, such a transplant has previously been performed only in Mexico and France once each.

After going through multiple requests for limb transplants from across the globe – including several middle east countries and south-east Asian countries – Amrita Hospital in Kochi recently accepted a request to perform a shoulder-level full-arm transplant.

It was Amaresh’s request. An unmarried man, he suffered a severe injury in September 2017 due to electric shock while repairing a charged electric cable. His hands had sustained multiple fractures and electric burns. Unfortunately, doctors had to amputate both his hands to save his life. While the right hand was amputated at the elbow, the left hand had to be severed right at the shoulder level.

After struggling for many years with a life without hands, Amaresh’s long wait for a suitable donor was heard when the family of Vinod agreed to donate his hands.

Vinod, a 54-year-old man working in West Asia, was on a visit to his native place in Kollam district, Kerala, when he met with an accident as his motorcycle collided with a bus. Vinod suffered a serious head injury and lost his life in Thiruvananthapuram.

As Vinod’s family readily agreed to donate his various organs, including his hands, following his death, the doctors at Amrita readied a plan to fly to Thiruvananthapuram to harvest the organ.

Dr Subramania Iyer, head, centre for plastic & reconstructive surgery, and Dr Mohit Sharma, professor, centre for plastic & reconstructive surgery, led a team of 20 surgeons and 10 anaesthetists to transplant both limbs in what they call a “marathon” surgery.

“It was a very complicated operation. Shoulder-level full-arm transplants are quite rare. In fact, this is only the third such surgery in the world. The higher the level of amputation, the more challenging the hand transplant becomes. There are profound technical issues in a shoulder-level transplant, especially fixing the donated upper limb to the shoulder of the recipient,” Iyer said.

In 2015, Amrita Hospital conducted the country’s first-hand transplant on a 30-year-old man with a team led by Dr Iyer.

Harvesting and transplant of the arm

As it was the country’s first transplant from shoulder level, the team of doctors had to ‘self-train’ themselves after going through the available literature on the previous two transplants in Mexico and France.

As they waited to fly to Thiruvananthapuram, the four teams started learning the methods of retrieving the full-length arm from the deceased body – something which was supposed to be done for the first time by doctors in India.

“It was impossible to get the training on how to harvest the limb of the deceased’s body. We read the available literature on the subject,” Dr Mohit Sharma told News18.com.

“We conducted practice sessions five times on dead bodies before removing the actual arms from Vinod’s body,” Sharma said while adding that “the team continued to refine its technique”.

The team carried special boxes to bring back the arms, intact. One of the special preservatives carried by the team was brought from the French doctors which help to keep the harvested organ oxygenated and completely functional.

Based on the properties of Lugworm (Arenicola marina) haemoglobin, preservation is known as one of the breakthrough innovations which has 400 times more oxygen carrying capacity than normal haemoglobin.

It took the team an hour and a half to retrieve the shoulder-level arm of Vinod whereas the left elbow-level arm took the usual 20 minutes.

“Shoulder level arm has altogether a different retrieval procedure which is quite complex. Firstly, muscles have to be carefully selected and retrieved which are coming from chest, neck and upper limb followed by major arteries, veins and nerves,” Sharma explained.

After a pair of hands were harvested for transplantation, Amaresh was rushed to Amrita Hospital on 5 January 2022.

In the right, shoulder-level arm transplant, the surgery to transplant both arms continued for 18 hours where the team of doctors worked on joining one major artery, 4-5 different veins, multiple muscles and nerves.

The procedure requires strong collaboration between orthopaedic surgeons and plastic and reconstructive surgeons. “We need to connect very very fine vessels and nerves under the microscope with the help of sutures. It’s like a thread to stitch body tissues together which is one-third the diameter of human hair.”

Dr Iyer said that while Amaresh’s surgery was successful, there was a problem with the blood supply to the upper limb, which they could solve only with two subsequent procedures. “Finally, the patient was discharged three weeks after the surgery.”

So far, across the globe, only 210 hand transplants have taken place, out of which 11 transplants – fixing 22 hands – have taken place at Amrita Hospitals in Kochi. “It is the highest number across the globe for any single centre to conduct these many transplants,” Sharma said.

A long journey to full recovery

While the patient has finally received the transplant and is likely to be able to perform basic life functions such as maintenance of personal hygiene or the ability to eat food, the road to recovery is long.

Amaresh earlier suffered an electrical injury which made the transplant even more challenging as the high tension current passed through the nerves damaging them to the core.

“It becomes very difficult to attain full function of the limb in electric injuries. In case of hand-chop injuries, the damage is only done at the site where the chances of functional recovery are higher,” Sharma said.

Meanwhile, Amaresh has been asked to restrain from lifting heavy or hot things. “He cannot pick up a hot cup as there is no sensation in the hand or arm,” he said.

The patient has to continue medication lifelong. These medicines are immuno-suppressants which prevent the body from rejecting the transplanted organ. He has been asked to report any abnormality such as spotting of rashes, immediately to the hospital as it may signal organ rejection and needs medical attention. In this case, higher doses of medicines would be prescribed.

Moreover, five hours of physiotherapy will be continued for one year to 18 months to achieve sensation in the arms.

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