The operation was a very rare, complex one performed by sixteen Hopkins surgeons over a span of thirteen hours, four times longer than a typical coronary bypass surgery. On December 18, 2012 veteran Brendan Marrocco, who lost all four limbs while serving in Iraq, received a double arm transplant surgery at the Hopkins Hospital.

Preparations for the surgery began a year and a half before it even reached the operating room. To ensure its success, which involved connecting bones, muscles, nerves and blood vessels of the arms to the donated limbs, the surgical team underwent many rehearsals of the procedure on cadavers.

“We had to plan an operation tailor made for [the patient’s] anatomy,” said Jaimie Shores, clinical director of hand and upper extremity transplantation at Johns Hopkins Hospital. For instance, the surgical team had to shorten parts of the arm to ensure that both arms would be equal in length after the transpant. Body part transplants, whether it involves organs or limbs, run the risk of rejection, in which the patient’s immune system reacts adversely to the newly introduced body parts. Typically, three different medications are required to suppress any immune response that may endanger the transplant. This poses an ethical question for the surgeons in the case of a limb transplant.

“If I told you that I need to put you on three medications that have potential to be pretty toxic to your body and could potentially shorten your lifespan, but, without these three medications, you’re not going to survive because you need a heart transplant, you would say, give me the three medications,” said Shores. “But if I tell you that I’m giving you all these medications for something that is not going to be life saving for you, I’m just going to improve the quality of your life — Now we have an ethical dilemma. We don’t really know what adverse effects these medications are going to have on somebody who was completely healthy before over the course of their lifetime.”

Shores also noted that the standard trio of immunosuppression drugs, which includes a type of steroid, is associated with diabetes, opportunistic infections, tumors and cancers. The need for such drugs makes hand transplant a less desirable therapeutic option. For this reason, prosthetics, though heavy and lacking in sensation, remains the standard of care in the case of a limb amputation.

In response to this dilemma, the surgical team adopted a novel protocol to diminish the adverse immune response by injecting the donor’s bone marrow into the patient’s body. This innovative procedure reduced the number medications required from three to just one, thus hopefully reducing the damage associated with the chronic intake of these medications.

Thankfully, after months of meticulous planning and practice, the surgery was a success. With his new arms, Marracco was finally capable of performing simple physical tasks. To avoid the risk of post-surgery rejection, his immune system is currently being modulated by this newer and less toxic immunosuppression protocol. The success of the surgery opened doors for similar, future operations.

“We are truly in the infancy of [hand transplantation] right now,” Shores emphasized. “We feel like the protocol we’ve developed is a good first step, but it’s certainly not the final step...The goal of everybody in [transplant medicine] is to someday be able to do transplants without having to chronically medicate patients. This is the Holy Grail in transplant.”