Rajasthan man becomes 3rd recipient in Mumbai to undergo hand transplant | Mumbai news - Hindustan Times
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Rajasthan man becomes 3rd recipient in Mumbai to undergo hand transplant

ByJyoti Shelar, Mumbai
Oct 26, 2021 07:33 PM IST

Jagdev Singh, 22, the recipient, underwent a bilateral hand transplant procedure on October 15 and is now slowly recovering

On Monday morning, physiotherapists and nurses at Global Hospital in south Mumbai’s Parel area, helped 22-year-old Jagdev Singh stand on his prosthetic legs for nearly 12 minutes. Singh, a quadruple amputee, underwent a bilateral hand transplant procedure on October 15 and is now slowly recovering. It is a dual challenge for Singh – in addition to the recovery of his transplanted hands, he has to gradually learn to balance the weight and walk on his prosthesis.

Monika More, a train accident victim, is Mumbai’s first hand transplant recipient. The city’s second such procedure was conducted at the civic-run King Edward Memorial (KEM) Hospital. (Photo for representation)
Monika More, a train accident victim, is Mumbai’s first hand transplant recipient. The city’s second such procedure was conducted at the civic-run King Edward Memorial (KEM) Hospital. (Photo for representation)

“His main challenge will be to balance the centre of gravity of the body,” said Dr Nilesh Satbhai, the plastic surgeon who led the hand transplant team that operated on Singh.

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“There is nearly 10-15kg of weight added to his body with the transplanted hands, the plasters and the bulky dressing. We have already started his chest rehabilitation, and will slowly move to build the core strength of his body,” said the surgeon who had also carried out Mumbai’s first hand transplant on train accident victim Monika More last August. The city’s second such procedure was conducted at the civic-run King Edward Memorial (KEM) Hospital. Singh, who hails from Rajasthan, is Mumbai’s third hand transplant recipient.

Hands transplants are often termed as medical miracles, and can be transformative for double amputees. But the procedure is complex – a hand donation is hard to come by and the outcomes of the surgery are prolonged due to the extremely slow process of nerve recovery.

“Every step involved in the hand transplantation – from the time of harvesting the limb from a brain dead donor to attaching it to the recipient – the process requires absolute precision,” said Dr Satbhai.

The complexity of the surgery varies with the level of the amputation. Choosing the right candidate for a hand transplant is therefore crucial. A pre-operative assessment and work-up of an amputee involve x-ray, MRI, CT scan, angiography, cardiac and psychiatric analysis among other evaluations. The team of medical experts including the plastic surgeon, orthopaedic surgeon, vascular surgeon and others assess the amputation, the level of injury and the point at which healthy muscles are available. This assessment plan speeds up the procedure when a hand donation comes by.

When a family of a brain-dead patient gives consent for a donation, and compatibility is ascertained, a team of doctors first harvest the hands, making way for other teams to harvest the internal organs. A University of Wisconsin solution, known as the UW Solution, is infused through the arteries of the hands in order to cool and preserve the tissues. Given the limited time available, surgeons harvest the hands at a slightly higher level than required.

The hands are then wrapped using a ‘triple bag method’ – first in two bags and then in an ice-cold saline bag. At no point should the hands come in contact with water or ice as that can lead to tissue damage. Once harvested, the hands must have blood circulation restored within eight hours.

Multiple teams working at the same time ensure that all the structures, including the arteries, veins, nerves, tendons etc, are identified in the donor hands as well as the recipient who is prepared for the surgery.

“It takes a lot of coordination and large medical teams to conduct hand transplant procedures,” said Dr K Subramania Iyer, who carried out India’s first hand transplant in 2015 at Amrita Institute of Medical Sciences in Kochi. The transplantation procedure goes on for nearly 10-12 hours and sometimes more.

“It takes about a year for the hand transplant patient to become independent,” said Dr Iyer, adding that full functionality depends on the level of the amputation. “The higher the level of amputation, the more time it takes in recovery,” he said.

While there is no national registry of hand transplants, an estimated 18 such procedures have been carried out in the country. According to Dr Iyer, despite the surgical complexity, the biggest challenge in hand transplants is to get a donation.

“Unlike internal organs such as kidneys, liver or heart, hand donation is a mutilating procedure and therefore, it becomes difficult for families to agree for it. As far as the surgery is concerned, we have gathered quite a bit of experience with more centres catching up,” he said.

‘Hand transplant brought my life back’

In March 2013, Kochi resident Manu TR, then a 28-year-old event manager, was on his way to a temple in Kollur, Karnataka, when he noticed some goons harassing a woman. When Manu intervened, he was pushed out of the train. He suffered severe injuries and both his hands were crushed in the incident. “I thought my life was over,” said Manu, who became India’s first bilateral hand transplant patient in January 2015 at Amrita Institute of Medical Sciences in Kochi. “Four days after the transplant, when I noticed some movement in my fingers, it felt like I had been given my life back,” he said. A year after his surgery, he was employed at the same medical institute as a counselling assistant for organ transplants. He married a nurse from the hospital and is now a father of two – an eight-month-old girl and a four-year-old boy. “The recovery was a slow process. By the third week, I was slowly eating with my hands and some support. In four months, I was able to use a pen and pencil to scribble. After eight months, I was able to do almost everything, I even worked on my farm,” he recalled.

History of transplant

•The first ever hand transplant in the world was attempted in 1964 at Ecuador. This transplant was performed without the availability of modern immunosuppression and the hand was rejected in two weeks

•The world’s first successful hand transplant was carried out in Lyon, France in 1998. The recipient, however, faced rejection of the transplanted limb and he had to eventually undergo a graft removal procedure after two years

•The first hand transplant in the US was carried out in 1999 by a team of doctors from Kleinert Institute in Louisville, Kentucky

•India’s first hand transplant was carried out on January 13, 2015, at the Amrita Institute of Medical Sciences in Kochi

•Globally, an estimated 200 hand transplants have been carried out. India has done about 18 such procedures, three of them in Mumbai

Anatomy of human hand

•Brachial artery: Main artery of the upper limb that runs through the arm till the elbow level. The artery divides in the proximal forearm into two main branches –radial and ulnar

•3 main nerves: Median, ulnar and radial nerves control the sensory and motor functions of hands

•27 bones

•Multiple muscles and tendons

•Multiple superficial veins and nerves

Transplant procedure

•Detailed preoperative assessment and planning

•Dissection and preparation of donor and recipient hands as per the requirement and level of amputation.

Step 1: Fixing bones with help of metal plates, screws

Step 2: Arteries are hollow tube-like structures that deliver oxygenated blood from the heart to the tissues. Veins are also hollow tubes, but thinner and more fragile than the arteries. They carry the deoxygenated blood from the tissues towards the heart. Attaching the arteries and veins restores the blood circulation to the transplanted limb. The procedure is carried out under a microscope, and the suturing is done with the use of micro-sutures, which are thinner than a strand of hair.

Step 3: The muscle mass and tendons are then repaired with the help of strong sutures. Tension adjustment is crucial during this process for optimal hand function. Doctors describe this as achieving the ‘normal finger cascade’ or the natural alignment of fingers when the hand is at complete rest. Perfect nerve repair is vital to ensure the motor and sensory function as the patient recovers.

Step 4: Suturing of the skin

Post-transplantation care

•Doctors monitor any signs of rejection of the transplanted limb, for example, rashes or boil on the skin of the transplanted hand

•Biopsies are conducted at regular intervals and doctors monitor if the patient’s antibodies are activated to fight against the donor hand, which the body may identify as a foreign object

•Most rejection reactions are controlled by adjusting medications. But in case of hyperacute rejection, the graft may have to be removed as it can cause a threat to a recipient’s life

•Doctors assess the transplant in terms of immediate and delayed outcomes

•Immediate outcomes may include vascular patency or normal blood flow through the graft, hair and nail growth etc

•Delayed outcomes depend on the recovery of the nerves. Nerve recovery starts after three-four weeks of the transplant. Typically, the nerve recovery happens at the speed of one millimetre per day. This is why the functional recovery of the transplanted hands can take six months to one year.

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