Earlier this fall, a surgical team at HUP successfully completed the region’s first bilateral hand transplant, a complex procedure that required 30 specialists in organ transplantation, orthopaedic surgery, reconstructive micro-surgery, plastic surgery, and anesthesia. Even with two teams working simultaneously, the operation lasted more than 11 hours.
While the procedure itself was clearly an achievement, the planning for it was no less impressive. Read below to see how it all unfolded.
First Step: Ethical Considerations
Organ transplants are performed to save lives. That fact balances out the risks of both the surgery and the lifelong dependence on powerful drugs to prevent rejection. A bilateral hand transplant was not life-saving; was it worth these risks?
That was the initial thought of Abraham Shaked, MD, head of the Penn Transplant Institute, when L. Scott Levin, MD, chair of Orthopaedic Surgery, professor of Surgery, and director of Penn Hand Transplant, first approached him in 2009 with the possibility of doing the procedure at HUP. But that was before Shaked met the patient, a young woman who had lost all of her limbs due to a severe post-surgical infection.
“The first time we met, she gave me a hug, with no hands or arms. The minute you have it [the hug], you think about life in a different way,” he said. “For us to give a productive life to these types of individuals … that’s the meaning of life for them.”
Art Caplan, PhD, director of the Center for Bioethics and professor of Medical Ethics, initially shared Shaked’s concerns, but “I came to understand that this transplant is not cosmetic; it is truly functional, allowing a patient to carry out activities of daily living. Prosthetics don’t give the kind of function you need for a good quality of life if you are a double amputee.”
And they don’t allow a person to literally touch a loved one.
Practice, Practice, Practice
The surgical techniques used to perform the hand transplant were not new, said Benjamin Chang, MD, associate chief of Plastic Surgery, associate professor of Clinical Surgery, and co-director of Penn Hand Transplant. “We’ve all fixed bones, re-attached muscles, repaired nerves, and sewn skin.” The major difference was that this was vascularized composite allotransplantation (VCA). Unlike with solid organs, a hand transplant involves multiple tissues, including blood vessels, bone, nerves, muscles, tendons, and skin.
Preparations started 18 months prior to the actual surgery. Using the patient’s measurements and x-rays, the team created a step-by-step transplant procedure specifically tailored to her needs. Chang said they divided the surgery into multiple parts. One team procured the donor limbs, while two other teams opened and prepared the patient’s stumps to receive them. Two teams then prepared the donor arms and, finally, two teams attached the donor limbs to the patient’s stumps. Chang led one team while Levin, who is board certified in both orthopaedic and plastic surgery, led the other team as well as the procurement team. “He was the driving force that made all this possible,” Chang said
As part of the planning process, the team created a spreadsheet assigning each surgeon to specific steps “to best utilize their expertise and to make sure the surgeons had breaks to keep them fresh.” They also had sterile engraved tags made so they could identify and then clearly mark each of the many muscles, tendons, nerves and blood vessels that needed reattachment-- in both the patient’s limbs and those of the donor.
Pilots review checklists before flights and the surgical team decided to follow their example. “We created and printed out a checklist of each step and taped it on the OR wall,” he said. “As each team completed a step, Stacey (Doll, director of Quality and Regulatory Compliance - Solid Organ Transplant) checked it off. This ensured that we didn’t miss anything and also guided us in the right order.” Doll worked with the hand transplant team from the start to help organize the process and assemble all the available resources in Penn’s solid organ transplant program.
The team had several rehearsals and, after each one, they’d debrief and further tweak the procedure to improve it. “We prepared as a team for patient safety and for a predictable outcome,” Levin said. “We paid attention to paying attention … and there were no surprises to speak of.”
Added Chang, “Our extensive planning --- and practice, practice, practice --- paid off.”
Gift of Life: A Key Partner
Penn’s most important partner in this process was Gift of Life, the nonprofit organ and tissue donor program serving the region. It was a unique transplant, said Richard Hasz, VP of Clinical services for Gift of Life, “presenting challenges on many levels.”
The first challenge centered on the donor family. Unlike most transplanted organs, a person’s hands are recognizable. “We needed to understand both the critical medical and emotional aspects of this particular donation process,” Hasz said. Finding a good match was another challenge. As a visible transplant, it had to be the right size, gender, skin type, and age, with no obvious trauma, tattoos, or other visible marks.
“We had to re-educate and train our transplant coordinators on how to make these requests and how to counsel the donor family on why we’re doing it – as well as what to look for in a good match.”
Gift of Life also created a new protocol for the procurement process, “to establish the timing and sequence of the organ and hand removal,” Hasz said. In addition to the donation of limbs, “five individuals received organs from that donor and at least 50 received tissue.” The protocol also gave family members explicit rights to consent to the donation even if a donor card was located.
The protocol placed hands first, but “the surgeons knew up front that the solid organs were a priority,” Hasz said. “We would stop the hand procurement if we were in danger of losing any of the organs.”
In spite of the challenges, it took Gift of Life only a couple weeks to identify the donor. “Families in this area are very giving, especially if you explain the compelling need,” he said. “This family had amazing strength. They were able to look past their own pain and give that gift to someone else.”
Relearning How to Move
Preparation for the hand transplant went beyond the surgery; it also presented new challenges to the rehabilitation team. Levin chose Laura Walsh, MS, OTR/L, CHT, Hand Therapy team leader, and Gayle Severance, MS, OTR/L, both occupational therapists and certified hand therapists, to do post-surgical therapy.
Walsh and Severance created customized protective splints to protect the transplanted limbs – especially the point at which they are attached to the patient’s own arms – and also to allow her to use her arms for basic tasks, such as eating and using a computer. While the patient was still in the hospital, they began a rigorous workout schedule of 4 to 6 hours a day, working on “strengthening her shoulder and arm muscles to move the new limbs,” Walsh said.
Once the patient can again feel hot and cold (protective sensation) on her new limbs, sensory re-education will begin to help her recover the brain-hand sensory connection. As Walsh explained, when sensation initially returns, the brain is only getting “very global signals. For example, the brain can process that the hand is holiding a round object but cannot distinguish a baseball from an orange.”
In sensory re-education, the patient touches an object first with eyes closed – to allow the brain to process what is felt – and then with eyes open to “fully educate the brain on what the body is really feeling,” she continued.
As we went to press, Levin said the patient was doing “superbly,” but she has many months of rehabilitation ahead of her. It will be at least a year before the nerves grow far enough into her arms to have independent motion of her fingers and possibly longer to regain feeling in her fingers. “It could be up to 18 months before we know what her potential function may be.”
The multidisciplinary team expects to continue performing bilateral transplants, following the same basic principles but customizing their preparation -- as they did with their first transplant -- to assure optimal outcomes.
“We prepared, we studied, we listened to each other, and then we came together to make it happen. We’re poised to take this program to the next level,” Levin said. “It’s our goal to work seamlessly together in the field of VCA so we can successfully treat these patients and give them their lives back.”
