A dry run at midnight with dummy patients in both operating rooms had uncovered a few critical glitches: anesthesia from Boston General needed a better orientation to the setup at Our Lady, and there was need to anoint a “ringmaster” whose job was to be timekeeper, to keep abreast of the activities of both teams, and who was the only person authorized to carry and, most important, record all messages from Team R to Team D and vice versa. Two new blackboards were brought in to be placed inside each theater, and tasks to be ticked off written on these. Our Lady of Perpetual Succour was put on diversion, with trauma being rerouted to other hospitals in neighboring boroughs. By 4:00 a.m. it was time for the real thing.
Thomas Stone threw up in the surgeons’ locker room. The Our Lady crew saw this as a bad omen, but the Boston General crew assured their counterparts that a pale, diaphoretic Stone augured a good outcome (though in truth, they had never seen him quite so pale and weak, lying prostrate on the bench, a puke basin at his side).
With so many people from two hospitals involved, it would have been difficult to keep the operation a secret. There were two television crews parked outside Our Lady. Newspaper editors were past the deadline for the morning paper, but they were preparing to weigh in on the ethics of this historic transplant, and now they could wait to see how it went before committing themselves.
Making history or keeping it a secret was the last thing on the surgeons’ minds. Deepak, sitting on a bench separated by a row of lockers from where Stone suffered, tried to block out the sickening sound of his colleague's retching by reviewing a liver atlas.
At 4:22 a.m. Shiva was given diazepam and then pentothal, and a tube was passed into his trachea. The donor operation had begun. Thomas Stone and Deepak expected it to take anywhere from four to six hours.
IF THE BEATING HEART is pure theater, a playful, moody, extroverted organ cavorting in the chest, then the liver, sitting under the diaphragm, is a figurative painting, stolid and silent. The liver produces bile, without which fats are not digested, and the liver stores excess glucose in the form of glycogen. In silence and without outward signs, it detoxifies drugs and chemicals, it manufactures proteins for clotting and for transport, and it clears the body of ammonia, a waste product of metabolism.
The liver's smooth and shiny outer surface is monotonous and unexciting, and apart from a median furrow dividing it into a large right lobe and a smaller left, it has no visible cleavage planes. It is a surprise to find surgeons speak about its eight anatomical “segments”—as if they are discrete, as if they are like sections of an orange. Try pulling these segments apart and you'll have raw surfaces oozing blood and bile and a very dead patient. Still, the idea of segments allows the surgeon to define areas of liver that have a full complement of blood and bile conduits and that are therefore semiautonomous units, subfactories within the factory.
Four families of vessels enter or leave the liver. First, the portal vein, which carries all the venous blood leaving the gut and hauls it to the liver, blood that after a meal is rich in fats and other nutrients for the factory to process. The hepatic artery brings oxygen-rich blood to the liver from the heart via the aorta. The hepatic veins have the task of taking all the spent blood that has filtered through the liver and returning it to the heart via the vena cava. The bile formed by each liver cell gathers in tiny bile tributaries that merge and grow and eventually form the common bile duct that then empties into the duodenum. Excess bile is stored in the gallbladder, which is nothing more than a balloonlike offshoot of the bile duct. In keeping with the liver's chaste and understated demeanor, the gallbladder is tucked out of sight, just under the overhang of the liver.
DEEPAK, STANDING ON THE RIGHT, made the incision. The first step was to remove Shiva's gallbladder. Then, turning his attention to the stalk of vessels entering the liver (the porta hepatis), he dissected out the right hepatic artery, then the right branch of the portal vein and the right biliary duct. To get the right lobe free, he also had to cut through liver tissue and disconnect the hepatic veins at the back where they joined the vena cava—the dark side of the liver, the place where the surgeon might “see God” if there was bleeding. In removing a lobe of the liver for cancer, it is possible to control bleeding by pinching off the stalk of blood vessels in the porta hepatis—the Pringle maneuver. But this wasn't an option for Deepak, because it would compromise the function of the lobe they were removing, choke it half to death before giving it to me. There are now ultrasonic and even radio-frequency “dissectors” that make cutting through the liver easier, less bloody. But Deepak, with Thomas Stone as his assistant, had to resort to clamp crushing and “finger fracturing” to break through the liver tissue while avoiding the major blood vessels or bile ducts. Deepak worried about his senior partner: Thomas Stone's mind seemed to wander, something Deepak had never encountered before. Little did Deepak know that Stone was struggling to keep away the image and the memory of his futile efforts to save Sister Mary Joseph Praise, and his dangerous attempts at crushing a baby's skull.
The donor operation went without a hitch. At 9:00 a.m., I was wheeled into the operating room, and at 9:30 a.m., just as Shiva's right lobe was coming free, the Boston General team, without Thomas Stone, made a long incision across my middle, below my rib cage but above my belly button. They began mobilizing my liver, cutting away its ligaments and trusses.
Thomas Stone took Shiva's freed right lobe to a side table, where, with hands that were steadier than his insides, he flushed the portal vein with University of Wisconsin solution. Deepak, meanwhile, ensured that there were no bile leaks in the raw edge of what remained of Shiva's liver, which was largely his left lobe. He looked all around for any overlooked bleeders, repeated the sponge and instrument count twice, and then he closed Shiva's belly. In a month, Shiva's liver would regenerate to its previous size.
Now, Thomas Stone and Deepak donned fresh gowns and gloves and came to me to complete the removal of my liver. Because my clotting functions were poor, there were lots of tiny bleeders, particularly behind my liver as they freed it from the diaphragm. I required many units of blood as well as platelets. They carefully identified and preserved my bile duct, the hepatic artery, and the portal vein. It was one in the afternoon when my four-and-a-half-pound companion, which I had sheltered under my rib cage all these years, left me. A gaping cavity under the dome of my right diaphragm, an unnatural void, remained.
Connecting Shiva's liver, or rather his right lobe, was a laborious process. Bleeding had to be meticulously controlled in order to see clearly and for Thomas Stone, with Deepak's assistance, to suture artery to artery, bile duct to bile duct, and vein to vein. The scissors and needle holders were specially designed for microsurgery. Both surgeons wore headlights and magnifying loupes as they manipulated sutures that were finer than a human hair. One advantage of Deepak's decision to give me Shiva's right lobe was that it fit more naturally under the dome of my diaphragm, and its hilum—the place where the vessels entered—was oriented more naturally toward the vena cava. It made the surgeons’ jobs a little easier.