So I left off my story about the kidney hospital when we were making rounds. One interesting thing that I left out is that many foreign patients, from various African nations especially, come for renal problems to Ahmedabad. We met a lot of people with admitted family members from Nigeria and Uganda.
When that was over Dr. Trived invited us to meet Dr. Modi to see when they might be operating again, doing more transplants… So of course we tracked Dr. Modi down. =) He was very nice and explained to us very well what and how they do the procedures. Most transplants at this hospital are from familial donors: mothers and wives mostly. This is partly what helps their success rate stay higher than average. As a result of this donor situation, each transplant requires 2 operations simultaneously: 1. Donor Nephrectomy (kidney removal) and 2. Recipient Transplant.
Dr. Modi primarily does the donor nephrectomies, and I watched him the next day in the operating room. He explained that the method they use at this hospital is laparoscopic and the approach is from the back through the flank (retroperitoneal approach). Most other places, including the USA, people do the procedure open (through a larger incision) and through the belly (transperitoneal). The benefit of doing any operation laparoscopically is that it is cleaner and makes recovery for the patient faster and less painful.
The donor nephrectomy lasted only about an hour and a half. At the end they just make an incision in the flank about 5″ to remove the kidney. Then they put it in ice and give it next door to the surgeon doing the transplant.
Both operations started at the same time, but the transplant lasted much much longer, about 4 hours. This surgery was done entirely “open” (not laparoscopic) and through the belly (transperitoneal). First they washed and “fed” the kidney with an IV solution that would provide it enough nutrients while it was outside the body. Then they kept it buried in ice until the transplant surgeon was done preparing the recipient. They apparently leave the old kidneys as they are and put the new kidney in the iliac fossa (a broad flat part of the pelvic bone). It doesn’t take long for some scar tissue to grow and hold it in place, so they actually don’t anchor the new kidney in with stitches or anything.
First the surgeon had to prepare the kidney for implantation. It had turned from pink to smooth, pale grey-purple. It looked like a sea-worn stone you might find on the beach, just big enough to fill your hand. The kidney has three main tubes coming out of it: the renal artery, renal vein, and ureter. The ureter is the tube that takes the newly formed urine and lets it flow into the bladder. The surgeon had to clear the space around the vessels of fat and other debris. He trimmed them and cut them properly to be able to attach it to the existing vessels in the recipient.
Now how do they attach the vessels? They sew them by hand with very thin suture material (vascular surgery). That itself is pretty incredible; the vessels were about 3-4 mm wide in diameter. First they connected the artery and vein. Instantly the color changed from grey to a warm, glowing pink color. They then waited to see if the kidney would produce urine in decent amounts before finsihing. So they put a catheter int he ureter and waited a while to see if any fluid would accumulate. Meanwhile they thinned the bladder wall in one spot where they would later attach the ureter.
Once they were satisfied with the urine production I noticed that the operative staff was starting to jostle around as if they were preparing for something big. “Suction! Be ready! Come now, stand here!” So I knew something was up. Then before I know it the surgeon knicked the prepped part of the bladder and a huge fountain of urine came splashing out. The operative nurse was suctioning it as it came. It might seem strange that they let urine wash all over the other organs, but actually urine is sterile until it leaves your body so it doesn’t harm anything.
Once the bladder was empty they sewed the ureter directly to it and once satisfied, closed everything up. All that flowing water coming out of the patient, from the ureter into the bladder, is like treasure for the patient. It was quite a privilage and rare opportunity that I got to watch these operations.
The patient pair whom I observed was a 68 year old mother and a 42 year old daughter. Usually they don’t accept such elderly donors, but the recipient needed a kidney for some time and couldn’t find any better match so mom gave her daughter life one more time.