By Joel Warner
By Michael Roberts
By Alan Prendergast
By Michael Roberts
By Michael Roberts
By Amber Taufen
By Patricia Calhoun
By William Breathes
Kam stood at Chris's right side wearing an odd pair of glasses called "loupes" that had what looked like microscope lenses attached. To Kam's right was a large tray bearing a wide assortment of instruments -- forceps, scalpels and curved needles already threaded. Surgical nurse Anthony Adams hovered over the tray, counting and recounting the supplies, making sure that all was in order, while other nurses bustled about assisting him. Goldberg, also wearing loupes, stood across the operating table from Kam. Ignored for the moment in a corner of the room was a small plastic basin covered with a sterile blue towel.
There was a momentary pause, like a symphony orchestra between tuneup and that first note of Beethoven's Ninth, then Kam spoke a single word: "scalpel." Adams handed over the instrument and noted the time of the first incision: 7:47 a.m.
Kam started at the middle of the abdomen and made a diagonal cut through the skin toward Chris's right hip. From his original starting point, he then cut up toward the sternum.
Instead of continuing through the next layers with the blade, he handed it over and called for a "bouvie." The penlike instrument, which cuts by using electricity to quickly burn through flesh, has the effect of also cauterizing severed blood vessels. With it, Kam proceeded through the fatty layer beneath the skin -- a very small layer on Chris -- and then through several layers of muscle to reach the abdominal cavity.
With Chris split open, Kam placed retractors along the sides of the cut to spread his abdomen, creating a gap that revealed the internal organs: pink-gray intestines and stomach and a large, dark-purple liver.
With some surprise, Kam immediately noted an abnormality in the liver. Laid on a surface, a liver resembles a partially deflated football. A closer inspection of a normal liver would reveal that it has two lobes of fairly equal size, attached in the middle. However, as Kam pointed out, the left lobe of Chris's liver had atrophied and was hardly bigger than a child's hand, while the right lobe was much larger than normal.
Kam didn't know if the defect was genetic and unrelated to the current problem, or a result of the disease. Perhaps, he speculated, the left lobe was the area most affected by the PSC, and the right lobe had increased in size to compensate. There was no other outward sign of the PSC. If the liver had been destroyed by hepatitis or cirrhosis caused by alcohol, there would have been scar tissue throughout the organ with nodules of liver tissue in between the scarring where the organ tried to rebuild itself. Such a liver would have a lumpy appearance, as opposed to the smooth look of Chris's liver, which a disease was destroying from the inside.
Kam didn't spend more than a moment considering the abnormality. It didn't matter, the liver had to come out. Reaching deep into the cavity to move the organ aside, he began what would be hours of work to free the liver by first cutting the bile duct where it exited the liver. Inside the liver, the bile ducts branch out like vines before joining the right and left hepatic ducts, which then merge into the "common" duct that carries bile from the liver into the intestines; it was this common duct that Kam severed. The duct was then tied off near the intestines.
The team began working quickly, but methodically, to cut off the liver from its complicated blood-supply system. Almost all organs have arteries that bring oxygenated blood from the heart and veins that return "used" blood to the heart to be pumped into the lungs for oxygen. But the liver also has a third "portal" system that brings nutrient-rich blood from the digestive tract -- intestines, stomach and spleen -- into the body's "chemical factory," the liver, where the nutrients are altered and packaged for use by the body.
Using forceps, Kam first clamped and then cut the hepatic artery. (About the size of a drinking straw, the artery brings oxygenated blood from the heart to the liver via the aorta, the biggest artery in the body.) He then repeated the procedure with the portal vein, a white tube about the size of a pinkie. Cut off from the hepatic artery and portal vein, Chris's liver began turning a blotchy gray-brown. Next in line was the hepatic vein, which carries blood back to the heart.
Finished with these, Kam lifted the liver to get at the connective tissue that attached the organ to the abdominal wall. Doing so revealed the purple-pink muscle of the diaphragm that separated the organs in Chris's abdominal cavity from his heart and lungs, which could still be detected by their regular movements. Goldberg followed along with a bouvie to cauterize blood leaks with a blue arc of electricity and a buzzing sound, then tiny white wisps of smoke.
The next step was the diciest part of the operation: separating the inferior vena cava from the liver. Vena cava translates rather undramatically from the Latin as "hollow vein," but it is responsible for returning the blood from the lower part of the body to the right atrium of the heart. It carries a lot of blood, and puncturing the vein could result in death within fifteen seconds.