Keywords
forearm - hand - hand transplant - vascularized composite allotransplantation - microsurgery
- amputation - surgical - standard operating protocol
Hand is an extremely important part of a human being's body. Second only to the brain,
the human hand may be responsible for a lot of the advancement that humankind has
made over the course of evolution. The importance of the human hand can be gauged
from the fact that the loss of a hand accounts for up to 60% loss of function for
the whole person.[1]
Patients may suffer the loss of upper limb due to avulsion injuries, industrial accidents,
electrical burns, traffic accidents, or congenital causes. Those with congenital absence
of whole or a part of the upper limb may develop suitable adaptations and are functionally
better adapted than those who lose the limb suddenly in an accident. This is all the
more challenging in patients who have suffered bilateral amputations. With microsurgery
techniques in their armamentarium, plastic surgeons are in a unique position to help
these patients. Replantation of amputated body parts has been performed by plastic
surgeons routinely since more than 50 years now. Vascularized Composite Tissue Allotransplantation
(VCA) allows replacement of lost limbs from brain-dead donors. These surgeries are
laborious, time-intensive, and require vast planning for ensuring the optimum use
of the available resources and a successful outcome. The authors performed India's
11th hand transplant on August 11, 2021. This paper describes the efforts taken and
the standard operating procedure (SOP) created by the department for this extensive
endeavor. It should be noted that the exact procedure may vary as per the local regulations
in each country. Hand transplant is more technically known as hand and upper limb
reconstruction using vascularized composite allotransplantation.[2] For the purpose of this paper, the term “hand transplant” will refer to upper limb
transplants at various levels—arm, forearm, wrist, or partial hand.
Philosophy of Hand Transplant
A hand transplant is not a lifesaving procedure like a renal or liver transplant but is definitely a procedure
which improves the patient's life significantly in terms of psychosocial health, daily
functionality, earning prospects, and mental well-being. Since allotransplants mandate
the use of lifelong immunosuppressants accompanied by their ill effects, any transplant
procedure needs to be titrated in its benefits with the potential risks associated
with prolonged use of immunosuppression.
The hands have such a complex structure and hold a position of importance that their
replenishment in the form of transplantation has been deemed to be worth the immunosuppression-related
risks, since the expected functional gain with a transplant is significantly more
than a prosthesis (especially below elbow). All transplant patients should be chosen
after extensive counselling sessions so that they understand the risk–benefit ratio.
When to Embark upon it: Prerequisites for Having a Transplant Unit
The journey on the path of starting a transplant program starts with the conviction
and the desire of a dedicated team coupled with a robust institutional support since
it requires inputs from both. It is a truly multidisciplinary endeavor. Each country
will have their own rules and regulations and it is important to know them before
embarking on the path to transplant. A transplant team will include a lead team of
plastic surgeons along with orthopaedic surgeons, anesthesiologists, nephrologist,
pathologist, operation theater ancillary staff, nurses, therapists, blood bank, and
social worker. It is helpful if the hospital already has a functional solid organ
transplant program.[3] Once the decision is taken to start the VCA, the first step is applying for a license
which is provided by the appropriate state health authority. The process of applying
requires extensive paperwork and is basically meant to ensure that minimum standards
are maintained in terms of personnel and infrastructure. Inspection for the transplant
license is also an important step and preparedness for the same cannot be emphasized
enough. Once the license is procured, the preparation commences.
Preparation
Though performing a transplant is technically quite similar to performing a hand replant
which most plastic and reconstructive surgeons will be well versed with, there are
a lot of different issues which require careful planning and thought. All members
of the team need to be up-to-date with the latest in the field including immunosuppression,
management of a rejection episode, etc. It includes reading up the peer-researched
literature, attending workshops and conferences, being a part of peer groups of fellow
transplant surgeons (local/national associations) and gaining information from other
centers, online sources, even seeking guidance from national and international leaders
in the field (e.g., Iyer et al and Sharma et al, have described their journey of setting
up India's first hand transplant unit in a four-part article series).[4]
[5] Attending cadaveric workshops for harvest and practice of transplant surgery will
also add to the training and create additional harvest teams which will be beneficial
to all. Presently, the authors regularly conduct these cadaveric courses.
It is important to publicize the availability of this service in your hospital. Again,
this needs to be done taking into account the prevalent rules and regulations in every
country. Public awareness campaigns, information on the institutional website and
social media handles may help in attracting potential patients to your Outpatient
Department (OPD). It will be helpful if there is a particular time or day of OPD dedicated
to these patients. Once a patient consults regarding hand transplant, he/she needs
to be explained the full-scale procedure, requirement of lifelong immunosuppression,
the costs involved, and the need to stay near the hospital from the time of registration
to almost 1 year after the transplant. In our experience, this is a lot of information
to absorb in the first consultation and up to two to three counselling sessions are
required before the patients and the family members can take an informed decision
of going ahead with this procedure.
A patient willing to go ahead will be investigated, referred to many different specialists
(most importantly nephrologists), and start arranging for funds. Crowdfunding and
help from nongovernmental organizations should be sought at this point for helping
the patient with the finances. Depending on the prevalent health care structure and
insurance system, the need for the funding should be individualized to the local context.
It is helpful to have a checklist of the various things to be completed before the
patient is registered ([Supplementary Materials S1] and [S2], available in the online version). Registration of the patient with the state appropriate
transplant authority is a watershed event. It means the patient gets into the transplant
waiting list and the patient and surgeons have to be ready to go ahead with the procedure
anytime that the donor may become available after that. Therefore, all the basic preparation
should have been completed before registering and thereafter maintenance preparations
like three monthly blood investigations of the patient, three monthly team discussion
and patient-specific planning sessions, and regular team review should be carried
out.
Preparation for Actual Transplant
The surgical team should comprise at least four experienced microsurgeons—two lead
and two assisting surgeons who also double up for donor hand dissection. This core
team should undergo repeated sessions of patient-specific planning and possibly cadaveric
dissections to plan regarding the procedure, foresee any complications, and take steps
to mitigate them. Cadaveric dissections and mock surgeries to mimic the registered
patient, clarify the steps in everybody's minds, and ensure that everyone in the team
is on the same page. It is important to take regular inventory of operating theatre
(OT) instrumentation and consumables required for the transplant. Do not not forget
the prosthesis for the donor, icebox to carry the hand in, ice packs, institutional
permission letters to harvest hands among other things. Postoperative intensive care
unit care and therapy protocol should be thought of in advance. Simultaneous public
awareness programs encourage more potential patients in the OPD. In public institutions,
arranging finances may be a huge challenge as the patients themselves may not be able
to support the expenses involved, particularly related to the immunosuppressant drugs,
outstation travel for retrieval, specific investigations like human leukocyte antigen
crossmatching, serum Tacrolimus levels, etc. In these cases, the financial support
from social institutions, governmental and nongovernmental charitable organizations,
and crowdfunding is helpful.
The use of social networking groups on various apps (like “WhatsApp” etc.) for fast
and focused coordination with the whole team is a blessing indeed. Our final aim should
be capacity building and keep an optimum level of preparedness till the actual surgery
happens. Formation of SOP is a major step toward ensuring training and preparedness
and mock drills and dry runs ought to be done repeatedly to reinforce the SOP in the
mind of every team member. Efforts should be made to complete every step that can be completed before the day of surgery.
The hand retrieval team plays a crucial role in the first step of the surgery. There
should be adequate planning and funds should be kept ready for the retrieval teams
as they may need to travel even to other cities as per the availability of the donors.
In India, transplant coordinators along with Regional Organ Transplant Organization
play an important part in organizing and coordinating between the harvest teams so
that the whole process may proceed smoothly. The state appropriate transplant authority
helps in creating a “Green Corridor” (dedicated rapid transit route cleared out for
an ambulance) for the expedited transport of the harvested limb from the donor hospital
to the recipient. It is helpful to be conversant with the procedure and having a dry
run to make things more efficient on the day of actual surgery.
Standard Operating Procedure
The authors believe that any complicated stream of operations may be broken into smaller
steps which are easy to follow by each and everyone involved. An SOP helps to standardize
the process, minimize interpersonal variations, ensures repeatability, and helps to
plan in greater detail to mitigate the reasons for failure in any operation. The senior
author (V.P.) has created an SOP for the department which is born out of multiple
sessions of brainstorming and mock drills [Pages 1–5, SOP]. The authors believe that
with minor adjustment for local conditions, the SOP can be broadly utilized by any
team starting out on this journey of transplanting hands.
Actual Transplant: What to Expect
The actual surgery is a long one. From the time the first call arrives, to the time
the surgery ends, it is a roller-coaster ride. It helps to depute manpower to manage
arrangement of things outside the OT and someone to log the entry and exit of the
personnel since the sheer number of people involved is huge [Annexure E]. Food, rehydration,
and toilet breaks can be strategically planned to prevent surgeon burnout while also
not compromising on surgical results. It is a surgical endeavor which requires full
commitment from the team who need to deliver with no holds barred. Postoperative coordination
with therapists is essential as they are the last runners carrying the baton toward
completion. It is useful to coordinate with other hand transplant units in India and
abroad, to learn from their mistakes and to discuss any problems that may emerge.
Finally, it helps to develop a personal rapport with patient. After this procedure,
the patient becomes a part of your team and your brand ambassador, instilling confidence
in other patients, showcasing what is achievable through this surgery. They become
your patients for life.
Conclusion
Starting a hand transplant program may seem to be a humongous undertaking at first
but it is surely doable by breaking the process into small manageable steps. The authors
hope that the SOPs attached will assist in standardizing the process and making this
journey less difficult for all those who venture. The preparations start early and
continue till the patient is operated.
