Cutting for Stone

by Abraham Verghese

  With so many people from two hospitals involved, it would have been difficult to keep the operation a secret. There were two television crews parked outside Our Lady. Newspaper editors were past the deadline for the morning paper, but they were preparing to weigh in on the ethics of this historic transplant, and now they could wait to see how it went before committing themselves.

  Making history or keeping it a secret was the last thing on the surgeons’ minds. Deepak, sitting on a bench separated by a row of lockers from where Stone suffered, tried to block out the sickening sound of his colleague's retching by reviewing a liver atlas.

  At 4:22 a.m. Shiva was given diazepam and then pentothal, and a tube was passed into his trachea. The donor operation had begun. Thomas Stone and Deepak expected it to take anywhere from four to six hours.

  IF THE BEATING HEART is pure theater, a playful, moody, extroverted organ cavorting in the chest, then the liver, sitting under the diaphragm, is a figurative painting, stolid and silent. The liver produces bile, without which fats are not digested, and the liver stores excess glucose in the form of glycogen. In silence and without outward signs, it detoxifies drugs and chemicals, it manufactures proteins for clotting and for transport, and it clears the body of ammonia, a waste product of metabolism.

  The liver's smooth and shiny outer surface is monotonous and unexciting, and apart from a median furrow dividing it into a large right lobe and a smaller left, it has no visible cleavage planes. It is a surprise to find surgeons speak about its eight anatomical “segments”—as if they are discrete, as if they are like sections of an orange. Try pulling these segments apart and you'll have raw surfaces oozing blood and bile and a very dead patient. Still, the idea of segments allows the surgeon to define areas of liver that have a full complement of blood and bile conduits and that are therefore semiautonomous units, subfactories within the factory.

  Four families of vessels enter or leave the liver. First, the portal vein, which carries all the venous blood leaving the gut and hauls it to the liver, blood that after a meal is rich in fats and other nutrients for the factory to process. The hepatic artery brings oxygen-rich blood to the liver from the heart via the aorta. The hepatic veins have the task of taking all the spent blood that has filtered through the liver and returning it to the heart via the vena cava. The bile formed by each liver cell gathers in tiny bile tributaries that merge and grow and eventually form the common bile duct that then empties into the duodenum. Excess bile is stored in the gallbladder, which is nothing more than a balloonlike offshoot of the bile duct. In keeping with the liver's chaste and understated demeanor, the gallbladder is tucked out of sight, just under the overhang of the liver.

  DEEPAK, STANDING ON THE RIGHT, made the incision. The first step was to remove Shiva's gallbladder. Then, turning his attention to the stalk of vessels entering the liver (the porta hepatis), he dissected out the right hepatic artery, then the right branch of the portal vein and the right biliary duct. To get the right lobe free, he also had to cut through liver tissue and disconnect the hepatic veins at the back where they joined the vena cava—the dark side of the liver, the place where the surgeon might “see God” if there was bleeding. In removing a lobe of the liver for cancer, it is possible to control bleeding by pinching off the stalk of blood vessels in the porta hepatis—the Pringle maneuver. But this wasn't an option for Deepak, because it would compromise the function of the lobe they were removing, choke it half to death before giving it to me. There are now ultrasonic and even radio-frequency “dissectors” that make cutting through the liver easier, less bloody. But Deepak, with Thomas Stone as his assistant, had to resort to clamp crushing and “finger fracturing” to break through the liver tissue while avoiding the major blood vessels or bile ducts. Deepak worried about his senior partner: Thomas Stone's mind seemed to wander, something Deepak had never encountered before. Little did Deepak know that Stone was struggling to keep away the image and the memory of his futile efforts to save Sister Mary Joseph Praise, and his dangerous attempts at crushing a baby's skull.

  The donor operation went without a hitch. At 9:00 a.m., I was wheeled into the operating room, and at 9:30 a.m., just as Shiva's right lobe was coming free, the Boston General team, without Thomas Stone, made a long incision across my middle, below my rib cage but above my belly button. They began mobilizing my liver, cutting away its ligaments and trusses.

  Thomas Stone took Shiva's freed right lobe to a side table, where, with hands that were steadier than his insides, he flushed the portal vein with University of Wisconsin solution. Deepak, meanwhile, ensured that there were no bile leaks in the raw edge of what remained of Shiva's liver, which was largely his left lobe. He looked all around for any overlooked bleeders, repeated the sponge and instrument count twice, and then he closed Shiva's belly. In a month, Shiva's liver would regenerate to its previous size.

  Now, Thomas Stone and Deepak donned fresh gowns and gloves and came to me to complete the removal of my liver. Because my clotting functions were poor, there were lots of tiny bleeders, particularly behind my liver as they freed it from the diaphragm. I required many units of blood as well as platelets. They carefully identified and preserved my bile duct, the hepatic artery, and the portal vein. It was one in the afternoon when my four-and-a-half-pound companion, which I had sheltered under my rib cage all these years, left me. A gaping cavity under the dome of my right diaphragm, an unnatural void, remained.

  Connecting Shiva's liver, or rather his right lobe, was a laborious process. Bleeding had to be meticulously controlled in order to see clearly and for Thomas Stone, with Deepak's assistance, to suture artery to artery, bile duct to bile duct, and vein to vein. The scissors and needle holders were specially designed for microsurgery. Both surgeons wore headlights and magnifying loupes as they manipulated sutures that were finer than a human hair. One advantage of Deepak's decision to give me Shiva's right lobe was that it fit more naturally under the dome of my diaphragm, and its hilum—the place where the vessels entered—was oriented more naturally toward the vena cava. It made the surgeons’ jobs a little easier.

  The remnants of the D team took Shiva to the recovery room and then waited in the locker room. Their mood unexpectedly became somber. It was now out of their hands, and that made the tension almost unbearable.

  An anxious Hema, with Vinu at her side, watched the clock in the waiting room. At first, she was thankful for her chatty companion, but then even he could not distract her. She kept thinking of Ghosh and wondering if he would have chastised her for letting Shiva take such a risk. A stone in hand … or was it “bird”? Grass is greener … he would have a maxim for the situation.

  Word came from the operating room via the Ringmaster—he called at each stage of the operation—and Hema now wished he wouldn't, because the shrill ring never failed to startle her and made her imagine the worst, only to be told “They have begun” or “The portal vessels have been isolated” when what she wanted to hear is that they were done with Shiva. At last, she did hear those words, and soon she saw Shiva, awake but groggy in the recovery room and wincing in pain. She was giddy with joy, stroking Shiva's hair, and she knew that wherever he was, whatever form his reincarnation had taken, Ghosh, too, was relieved.

  Shiva's eyes, coming into focus, asked the question. “Yes,” Hema said. “They're putting your liver lobe into Marion right now. Deepak said the part you donated looked magnificent.”

  She wasn't allowed to stay long. Instead of returning to the waiting room, she decided to slip away to the chapel. A solitary stained-glass window allowed in very little light. When the heavy door closed behind her, she had to seek the pew with her hand and ease into the velvet-covered bench. She covered her head respectfully with the tail of her sari. As her eyes adjusted, she got the fright of her life, seeing a figure on its knees near the altar. An apparition! she thought. Then she remembered the prayer chain for Marion, the round-the-clock vigil in this chapel. As her pulse recovered, Hema settled back and obse
rved the veiled head, the scapular falling back, stiff and separate from the pleated tunic. Hema realized that in importuning every deity she could think of, she had somehow neglected to appeal to Sister Mary Joseph Praise. The oversight caused a fierce and silly panic, blood surging up her neck. Oh, please don't let that be a reason to punish my son. She wrung her hands, squirmed and chastised herself for forgetting. Forgive me, Sister, but if you only know how stressful this has been, and if it is not too late, please watch over Marion, please see him through.

  She felt the response arrive as distinctly as if it were a voice or a touch: first, a lightness in her forehead, then a calmness in her chest that said she had been heard. Thank you, thank you, Hema said. I promise to keep you updated.

  She returned to the waiting room. She was so exhausted that she could only wonder how Stone and Deepak managed to stay upright. From the waiting room window the earth looked as if it were mostly sky and concrete—no real earth to speak of, no manifestation of nature on the ground other than the sun setting in that direction. It was so odd, and yet this was the view her son had known for the last six years.

  At 7:00 p.m., Thomas Stone was at her side. He nodded, then smiled, an expression so rare that she knew it had gone well. He said nothing, and she, too, was speechless, tears running down her cheeks. In studying Stone's face, grooved where his magnifying spectacles and lamp had sat, and grooved also from worry and work, she realized with a start how old he had become, how old they had both become, and how if they had nothing else in common, they had this: that they were both still standing after all these years, and that her sons (his, too, at some level, she had to admit) were both alive.

  Thomas Stone sat down, or rather fell into the sofa, and he didn't protest when she forced juice and a sandwich on him from Vinu's ice chest of goodies. Stone washed the juice down with a bottle of water and started on a second before life seemed to stir within him. His gaunt face filled out. “Technically, everything has gone well,” he said. “Marion's new liver, Shiva's old lobe, was already making bile before we had even finished the anastomosis.” He smiled again, a shy twist of the corners of his mouth, pride in his voice. The bile, he said, was an excellent sign.

  “We had a scare,” he added. “There was a moment when Marion's blood pressure dropped precipitously. No explanation for it. We were ahead on fluid and blood, but still his heart raced to one hundred and eighty beats a minute. We poured fluid in, tried this and that … and just as suddenly, the pressure came back up.” She was about to ask him precisely what time that was, but then she didn't bother, because she knew. She closed her eyes and thanked Sister for her intercession. When she opened them, Thomas Stone was staring at her as if he understood. She felt so close to him, so grateful. She couldn't go so far as to hug him, but she did reach for his hand.

  “So, I must leave now,” he said to Hema after a minute. “It will be touch-and-go for a while for Marion, given how sick he was when we started. But at least he has a working liver. His kidneys are still not functioning, and he needs dialysis, but I trust it is just hepatorenal syndrome and the new liver will fix that.” He was holding things back from her. He didn't tell her how, when things had looked so dire in the operating room, hed looked up at the ceiling and prayed not to a God or to spiders, but to Sister Mary Joseph Praise, asking to be redeemed for a lifetime of mistakes.

  THERE WAS REJOICING in the hospital, first that one of its own who had been near death was still alive, and second that Our Lady had made history. The Mass of Gratitude in the chapel was packed, Hema and Vinu in the front pew and the crowd spilling out to the cloisters.

  Outside Our Lady of Perpetual Succour, the news vans were lined up—international as well as national. Every previous liver transplant in the world had its origins in a corpse-to-be, in someone who was brain-dead. A living donor—and an identical twin who had given half his liver to his brother—that was big news. The media didn't quite get that this technical breakthrough would be most meaningful to babies born with congenital biliary atresia—lack of bile ducts. Adult organs from people dying of trauma were scarce enough; a child donor was exceedingly rare. Stone and Deepak opened the way for a parent to donate part of his or her liver to save their infant.

  By the second day, the ferreting journalists had connected Shiva to his fame as the fistula surgeon—”fixing holes is what I do”—and by the third day, they'd labeled Thomas Stone the “estranged father.” It was perhaps only a matter of time before they discovered the story of Sister Mary Joseph Praise, though it would probably necessitate a reporter traveling to Addis to unearth that tidbit.

  I CAME AWAKE on the fifth day. My first memory is that of floating up from the ocean bottom, my eyes still waterlogged and with what felt like scuba gear stuffed in my mouth and throat—I couldn't speak. As I broke to the surface, I understood that I was still in the ICU at Our Lady, but I heard nothing of what anybody said. I saw Hema and Stone and I looked for Shiva. He's decided not to come from Addis, I remember thinking, and I was disappointed.

  Twelve hours later, in the late evening of the fifth day (though it was perpetual twilight in the ICU), I surfaced for good, relieved to see that Hema was there, and that I hadn't imagined her presence.

  She stayed by my side, holding my hand. I craved her touch, fearful I might sink back into the abyss where it was all dark and from which there was no promise of return. But I would drift off into light sleep for short periods. Night turned to day, bringing with it a new bustle and energy and more traffic through our room.

  On the seventh day, I was awake long enough for Hema to make the fantastic statement that half of Shiva's liver was in me. Sick patients need to have everything explained at least twice, because you can presume they will not have heard half of what you said. Hema repeated herself at least ten times, and it was only when she showed me the Times, and the picture of me and of Shiva, that I believed.

  “Shiva is recovering,” Hema said. “He's fine. But you've developed pneumonia and there is fluid collecting around your right lung. That's why you are still on the ventilator. But it's getting better, so Deepak says you will be off the ventilator tomorrow. Your new liver is functioning well, and your kidneys have bounced back.” This was not the reunion I had imagined with Hema, but the expression on her face, her joy, her relief, were priceless. She rarely left my side.

  I saw Deepak and Stone for the first time later that same day. I struggled with my emotions. I know I was supposed to feel gratitude. Sometimes I think we surgeons wear masks to conceal our desires, to hide our willingness to violate the body of another. Only the guarantee of amnesia, the fact that the patient will remember nothing but the anesthetist's saying “Sweet dreams,” allows us to be surgeons. They stood before me, these perpetrators of organized violence on my body. The fact that both men were shy and unassuming seemed almost deceitful given the ambition, the hubris, that had allowed them to risk Shiva's life for mine. It was the only time I was thankful for that evil tube going down my throat and between my vocal cords, because what I would have said to them would have sounded ungrateful: It's a good thing Shiva made it, otherwise I'd be after your hides.

  When I awoke sometime later, I forgot about the tube and tried to speak, which made me feel I was choking, which made me panic. My struggles triggered the ventilator alarm, and now I was terrified that the nurse would decide I was “fighting the ventilator,” which could bring an order for intravenous curare. That drug, derived from the poison darts of Amazon tribes, paralyzes all the muscles, leaving you still as death, so that the ventilator can do its work unimpeded. But God help you if you aren't given a strong sedative along with it, because then you are awake, alert, but unable to twitch or even blink. The thought of being in that paralyzed, locked-in state had always horrified me, even as I blithely ordered curare (andsedation) for hundreds of patients. Now that I was a patient, my curse was that I knew too much.

  With Hema's help, her soothing voice, I did my best to calm down, to let the machine
push air into me, and the nurse retreated. When I felt better I wrote, How is Shiva?

  She didn't have to reply, because just then my other half came in, led by Thomas Stone.

  My brother, whom I had not seen for seven years, looked haggard, not at all like the picture in the Times. I felt vertigo in seeing my reflection moving independently of me. Shiva wore a hospital gown, one palm resting carefully on his belly, the other hand pushing his intravenous pole ahead of him, and using it as a walking stick. My brother wasn't given to laughing and most jokes were wasted on him, but when he saw me, he grinned like the chimp who'd locked up the zookeeper.

  You monkey, you, I wanted to say, and I reached hungrily for his hand, our fingers interlocking. You should laugh more, it suits you: see how the furrows around your brow vanish and your ears ease back? I felt fluid running down my temples, and his eyes were full, too. I squeezed his fingers, a Morse code to convey what was in my heart. He nodded—You don't have to tell me anything is what he was saying. He bent forward gingerly, and I wondered what he was up to, surely not a kiss … He clinked his skull against mine. It was such an unexpected, jarring, and surprising act, a throwback to being little boys, the softest of testas, that it made me laugh, which made that horrible tube scratch the inside of my throat, and so I had to stop.

  I pointed to Shiva's belly. He pulled aside his gown and I could see some of the incision, though a gauze pad with a drain passing through it hid the remainder. I raised my eyebrows at him, asking if it hurt. And he said, Only when I breathe, and we both laughed and both had to cut that off because of the pain. Stone stood looking on at this silent dialogue, amazed, a strange expression on his face.