This is how Lew Teperman and his surgical team harvested their 21st liver.

1. Isolate the vessels. Early on the morning of Feb. 20, Teperman strode into Operating Room 16 in Tisch Hospital at N.Y.U. Medical Center. Before him, etherized, lay Risa Machuca, 24, an assistant to a music-video director in Los Angeles. Upstairs in the transplant unit, her mother, Gail Schlanger, a former waitress from Liberty, N.Y., and a recovering alcoholic with end-stage cirrhosis, waited for the right lobe of her daughter's liver.

Teperman, a good-natured, solidly built man of 44, greeted the 11 nurses, residents, surgery fellows and anesthesiologists who crowded the small, equipment-jammed room, squabbled with them over his taste in background music, then scrubbed up. At 8:53, with a courtly "May we start?" he picked up a scalpel, traced an enormous wishbone shape on Risa's torso and began cutting, to the mellow-rock strains of the Crash Test Dummies.

The first order of business in removing a lobe of the liver is to identify, expose and isolate the main vessels that connect it to the rest of the body and cut away all the minor attachments. A quick anatomy lesson: the liver consists of two conjoined lobes, a fist-size left and a much larger right that duplicate each other's functions as filters of the blood. There are two main roads into the liver and two main roads out. Leading in are the portal vein, which brings blood from the intestines laden with waste products and nutrients, and the hepatic artery, which supplies fresh, oxygenated blood from the heart. After the liver filters out the waste and stores nutrients, it sends the waste, along with digestive acids, through bile ducts back to the intestines and sends the exhausted blood back to the heart via the hepatic vein. All of these structures have separate entrance and exit ramps for the right and left lobes.

The chief danger in this operation is bleeding from the hundreds of blood vessels that must be severed. The bigger vessels -- anything more than two or three millimeters across -- are tied off or sewn shut at two points and then cut in the middle. The smaller ones are cauterized with a yellow-handled electrical tool called a Bovie, which looks like a miniature soldering iron.

Teperman, leaning over an opening into Risa's abdomen the size of a Teletubby's TV screen, threaded silk around a vessel, tied it and snipped the vessel with scissors; looped, tied and snipped again.

He and the senior surgical fellow, Fadi Dagher, took turns on the Bovie. Whenever the Bovie touched fat, a small flame flared briefly in Risa's torso. Soon the room filled with the thick, acrid scent of burning flesh.


2. Expect the unexpected. Normally, it takes about eight hours to take out a liver lobe. But about a quarter of liver donors have anatomical abnormalities that require extra work.

Risa had three of them, and they were doozies. She had an extra bile duct coming off her left liver lobe but leading into the right-duct branch. She had an extra hepatic vein, located, very unfortunately, on the back side of the liver. This meant Teperman had to do some cuts by feel, reaching in and holding the liver from behind and slipping the scissors between his hand and the back of the liver. And she had an extra hepatic artery, again crossing over from the left lobe to the right. This forced the doctors to cut into the left lobe, which they normally would not touch.

Everything was tangled, and some of the tangles were stuck to each other. The doctors knew this going into the operation, but not the extent of the problem. "The lady has very aberrant anatomy," Teperman announced three hours into the surgery.

None of Risa's extra attachments could be simply sacrificed, because they were all essential to the functioning of her liver, which had to be kept working until moments before the lobe was removed from her body, both for her sake and her mother's. This also complicated the process of hooking the liver up to her mother, who had one attachment where Risa had two.

"For every structure," Teperman said later, "you have to make the decision of what stays with her, and it has to remain viable, and what stays with the part that's going to the mother, and it has to remain viable, and often it's a decision that's a matter of millimeters."

Finally, at 12:31 p.m., Teperman determined that Risa's right lobe could be safely separated from her left. The irreversible part of the operation could begin. "Call for the recipient," he said.

3. Stay focused. At 1:30, after snipping out Risa's gallbladder and stitching a bile duct closed, Teperman took a 15-minute break, during which he went downstairs, used the bathroom and drank a Coca-Cola. A friend gave him several potato chips and a little water. This was to be his only pause and his only sustenance during 10 1/2 hours of precision hand work, the first nine of which were performed standing.

Teperman is in good physical shape; he runs and lifts weights two or three times a week. But it is the stakes of the operation that keep him focused and sharp. "You're thinking and doing at the same time, but you're not thinking about how dangerous it is when you're doing it," he said. "You're thinking about what's the right move to make."

The music helps, too, he said, especially in a stifling, windowless room that feels like a basement even though it's on the sixth floor. "Good tunes, something familiar," he said. "You're going through something that may be unfamiliar, and hearing a familiar sound makes it work."

4. Cut through the lobe. "Jump in, let's go," Sheryl Crow sang at 2:07 p.m. as Teperman revved up an electric tool that vibrates at high speed to cut through tissue and immediately sucks it away. "Lay back, enjoy the show."

If dissecting out the vessels around the liver was like sight-reading a Chopin étude on a piano wired to explode if you hit a wrong note, cutting through the liver lobe itself was more tedious but no less dangerous, like walking a tightrope for five miles. Risa's liver had another anomaly. "She's a wonderful lady, but her liver was huge," Teperman said -- about 20 percent larger than average. This, too, meant more work.

Teperman and another surgeon, Glyn Morgan, began making their way a millimeter at a time through the lobe, a chunk of meat about five inches wide, three inches high and crisscrossed with veins of all sizes. Every time they reached a small vein, they stapled or singed it shut. When they reached a big vein, they had to decide where precisely along its length to cut it.

In his concentration, Teperman grew more terse. "Clip . . . clip . . . more music . . . scissors . . . suck here." Someone put on the Counting Crows CD for the third time. No one objected.

At 3:24 p.m., Teperman called in the head anesthesiologist, Marc Kanchuger. "I can't see the monitor," Teperman said, referring to the screen on which Risa's vital signs were displayed. "Can you move it toward me, please?"

"The more questions he asks of me, the more nervous he is," Kanchuger said. "Whenever they say, 'Get Kanchuger,' you know they're nervous, otherwise they'd have the resident take care of it. But everything is fine. Her numbers are perfect."

Just after 5, Teperman, without pausing in his work, began catechizing a medical student who had been observing the operation.

"How many hepatic veins are there?" he asked her. "What's the portal triad? How many segments is the liver divided into? Who is Couinaud?"

"Eight segments," replied the student, Shoshana Hort. "And Couinaud was the guy who identified the sections of the liver."

"Very good," Teperman said.

Across the hall, Gail Schlanger's surgeon, Devon John, had taken his half of the operation as far as he could. He and his crew were listening to Miles Davis and waiting for Risa's liver.

At 5:38, behind his bluish surgical mask, Teperman let out a big yawn.

5. Don't drop the liver. As the operation entered the homestretch, Teperman and Morgan picked up the pace, and their moves grew quicker and more graceful, four hands working as two. Lift and tie, clamp and cut, tease and clip.

"It's like a well-rehearsed orchestra," Teperman said later. "Sometimes you come out of the operating room and just say wow, every maneuver clicked. Each person thought about what the other one was going to do for the next move and was ready for it."

Teperman had on his closing music now, a quiet but rousing acoustic set by the 70's journeyman Nils Lofgren. He used to use "Dixie Chicken," by Little Feat, but another surgeon borrowed the CD and never brought it back. "No mercy, no quarter," Lofgren sang as an unattended pager beeped mournfully. "No place to hide for me or the man."

At 6:07 p.m., with all the clamps in place, Teperman made a couple of quick cuts and lifted the large portion of Risa's liver out of her body. Cradling it in his arms, he crossed the room quickly with a furtive expression on his face, looking for all the world like a man stealing a piglet. He set the liver down in a stainless steel bowl filled with chunks of frozen saline solution.

Teperman and a resident sat on opposite sides of the bowl and flushed out the liver, first with saline to get all the blood out, lest it clot before Gail could be hooked up to it, then with a preservative solution. Teperman yanked and tugged some of the vessels to expose them more, then sewed felt patches onto the cut side of the liver, which looked raw with cooked spots on it.

Teperman placed the liver on a scale for weighing babies. "O.K., Dr. Morgan," he called across the room. "You lost. It's 875 grams."

At 7:21, Teperman entered Operating Room 15 carrying the plat du jour, liver on salted ice, covered tastefully with a blue towel. He set it down on a table and announced, "The long awaited."

6. Make a final call. Eight o'clock and all was well. Risa's liver was snug in Gail's abdomen, and Devon John was in the process of hooking it up, which takes about five hours.

After waiting to make sure Risa's bile ducts weren't leaking, Morgan, a resident and an intern were closing her up. She will carry a reminder of this day in the form of a Mercedes logo of scar tissue running from her sternum down to her thighs. ("Depending on how it turns out," she had said two days before the operation, "I'm thinking of getting a tattoo of a vine or some bougainvilleas. You gotta work with what you have.")

Teperman went downstairs to the messy canteen for a plate of chicken wings and another Coke.

He swore he wasn't exhausted. "I was tired when I came out," he said, his feet up on a chair. "Now I ate something, and I'm fine."

After dinner, Teperman went up to the transplant unit on the 14th floor to tell the family the good news, but they were long gone. He popped an Altoid and called Gail's husband and her sister, Linda.

"Linda, this is Dr. Teperman. Where are you guys? We came up here looking for you." Pause, smile. "You were hungry. Admit it." Pause. "Risa's up here; she's fine. Gail's still on the operating table, but everything's fine. Her new liver is in. It looks beautiful."

Andy Newman is a reporter for the Metro section of The New York Times.
The New York Times April 8, 2001

From nytimes.com Copyright 2001 Andy Newman. Reprinted by Permission. This material may not be used in any manner except for personal reference without the written permission of the author or The New York Times Company.