Come on, let's give a hand

CHENNAI: Out of all the transplant surgeries that doctors perform in India, hand transplant is one of the toughest, as it’s a relatively new procedure whose results are difficult to predict.

A hand transplant surgery can give a fresh lease of life to an individual but there are no guarantees that he/she would regain full mobility of the limb. It also involves making a lifelong commitment to follow-up and treatment.

Lack of donors, low awareness, high risk of infection, long duration of follow-up and misinformation are some of the reasons why only 2 hand transplant surgeries have been performed in Tamil Nadu – one each in Gleneagles Global Health City, and Stanley Medical College and Hospital.

Family’s role in donation

Dr V Ramadevi, head of plastic surgery department at Stanley hospital, led the first hand transplant surgery in Tamil Nadu in 2017.

It was performed for free on Narayanasamy (29), a mason from Dindigul, who had lost his hands due to electrocution at his workplace in 2015.

The family members of Venkatesan (37) donated his arms to Narayanasamy. He had died after falling down the stairs at his home in Manali. Despite undergoing emergency surgery, he could not be revived. His family also donated all of his organs.

Dr K Boopathy, plastic surgeon at the Meenakshi Medical College and Research Centre, managed Narayanasamy’s post-operative care.

“It was a 16-hour surgery conducted by a team of 52 members. Our main goal was to prevent rejection of the limbs,” recalled Dr Boopathy.

The follow-up period was during the lockdown, and drugs were given without any interruption in schedule.

“A doctor from Chennai had to travel to Dindigul to give him the medicines during lockdown. We ensured that he continued to receive medical care without any breaks,” he added.

Narayanasamy’s recovery took years. But when did, he was given a job at a GH by the State Health Department in Tamil Nadu.

Life after transplant

Narayanasamy cannot stop gushing about the doctors and all medical personnel at Stanley for helping him through every phase of recovery.

He has about 90% operational capacity in both hands, and has recovered so well that he can do basic agriculture work and also drive a bike.

“It took me a few years but now I have a happy life. I’ve been working as a ward security in Dindigul GH for the last 5 years. I’m married and have a 2-year old child,” smiles Narayanasamy. “I wouldn’t have a life if the hospital hadn’t taken good care of me. The follow-up after surgery was crucial; the doctors were diligent about it even during the lockdown.”

Calling it a life-changing experience, he urges more people to donate organs and limbs of their deceased loved ones to help those in need.

Compatibility, complexity

At times, the family of a deceased patient agrees to donate their loved one’s hands. But, if the blood types don’t match, the surgery will be cancelled.

To ensure a successful hand transplant, it’s crucial to find a suitable donor with a compatible blood group and adaptable blood vessels.

“Compatibility tests also involve screening for communicable diseases, as the recipient must remain on life-long immunosuppressants, which carries the constant risk of infections,” adds Dr Ramadevi.

Health experts point out that hand transplants cannot be done by just one surgeon. It’s a time-consuming process that requires team work, coordination clocked to the second, and execution.

It takes around 4 teams of doctors around 16-18 hours to perform a hand transplant. As is the nature of any surgery, there are no guarantees.

“And in a hand transplant, there are many medical risks and other factors that can go wrong,” explains Dr Boopathy. “Once you connect the nerves and muscle tissue, there has to be blood flow to the donor hand on the recipient. And any form of movement comes only with rigorous rehabilitation. It’s a long period of follow-up treatment and close monitoring.”

Sentiments, superstitions

Organ donation and transplantation took a back seat during the pandemic but it’s slowly gaining momentum in the last year. Doctors urge that hand transplants need to be promoted as much as organ donation because it’s challenging to find a donor.

The rate of organ donation in India when compared to other countries, is negligible. Talking about hand transplant, the numbers are even less because it comes with amputation.

Unlike a live donation like liver or kidney, families see it as defiling the body before being cremated or buried. The decision to allow a doctor to cut a loved one’s limb, and to see the cadaver minus the limbs – that’s not easy for any family to make.

“But, we need to make them understand that a transplant is a lifesaving procedure for someone. To address this, counselling sessions are conducted for families of deceased patients by the hospital. These sessions involve showcasing examples of previous donors, providing demonstrations of successful hand transplant surgeries, and highlighting the benefits for the recipients,” explains Dr Boopathy.

Also, there are superstitions associated with hand transplant. There’s an overwhelming section of the Indian population that believes that the donor would be born without hands next birth, it would make the donor’s ancestors unhappy, the donor’s soul would not rest in peace and that the recipient would, forever, be haunted by the donor.

Families are also unable to bear the sight of their deceased loved ones without their limbs. So, hospitals attach the stump to prosthetic hands, which are covered with cloth and gloves to make it look natural when the body is handed over.

Having a completely advanced medical infrastructure and a sterilised set-up is the need of the hour for hand transplants to become successful.

“We have to conduct this complex surgery while having to serve regular duties and also following up on emergency cases. But, I am sure that there will be more donors and more such surgeries. We have to improvise technically and the functioning of the system to encourage the same,” says Dr Boopathy.

‘No dearth of skilled personnel in TN, only shortage of donors’

Dr Subramania Iyer, chairman, head and neck surgery, plastic surgery, and cranio-maxillofacial surgery, at the Kochi-based Amrita Institute of Medical Sciences, emphasises on the need to have more centres for hand transplants and makes sure to speak about it on every platform he’s invited to.

The waiting list in the transplant registry is very long. Patients wait for several years before they find a match, and even that’s rare.

“It’s not essentially a life-saving procedure but yes, it does change the life of an individual. The negative PR can be a problem and so is the wrong projection with false promises,” opines the doctor who helmed the first bilateral hand transplant in India in 2015.

“Countries like France and USA had performed hand transplants successfully by then and we wanted to do it too. We had read more than enough medical literature to support the feasibility of hand transplants and so, we organised a team of micro surgeons and doctors from many departments including immunology, rehabilitation, pathology and ICU,” said Dr Iyer.

Public talks were organised to promote hand transplants. The hospital also took permission from the government to do hand transplants. “After that, we began practicing on cadavers in the anatomy department. Patients were registered, and that’s when we understood how excruciatingly long the waiting period would be. We counselled many families but they were not ready to donate hands,” he explained.

On January 13, 2015, Amrita hospital performed India’s first successful hand transplant surgery on Manu, who lost his hands in 2013 after he was pushed out of a train for protesting against a woman passenger who was harassed by a group of goons.

“Now, 8 years after the surgery, Manu is living a full life. He has more than 90% function in both hands he received from Binoy, the donor,” smiled Dr Iyer.

Manu is a photographer and counsellor to the families for hand donation at the Amrita hospital. “When I lost both my arms, I lost all hope in life. I wanted to kill myself because I felt like I was a burden to everyone,” he recalled. “But today, I can do everyday chores, and even drive.”

It took Manu eight months of intensive rehab therapy and regular follow-up visits for his hands to start functioning. “I married my physiotherapist. I work here, as I’ve realised that we can give another chance at life to others to those who are in dire need of it,” he smiled.

Manu received his limbs from Binoy, a painter, who had met with an accident and was declared brain dead.