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Conjoined twins' separation – a complex feat

Tomorrow is the "big day" for conjoined twins Angelina and Angelica Sabuco. The San Jose, Calif. two-year-olds are being surgically separated tomorrow at Lucile Packard Children's Hospital. They were born joined at the chest and abdomen and were first evaluated at Packard Children's nearly a year ago. Their operation is the culmination of months of complex planning by teams from all over the hospital, as a Packard Children's press release describes.

When talking with the twins' physicians, I learned many details of the challenges they've surmounted to make separation possible. Here are some highlights:

  • To plan the surgery, the physicians needed to see if the girls shared any portion of their hearts. Getting good pictures of the hearts required the radiology team to inject contrast dye into the two girls' circulatory systems simultaneously, then quickly and carefully position them in the CT scanner so that both hearts could be captured in one image, said radiologist Frandics Chan, MD. The images showed that Angelina and Angelica's hearts are separate, though they may touch at the tips. This is good news, as separate hearts will make the surgery less risky.
  • The anesthesia team, led by Gail Boltz, MD, had the task of planning where each piece of equipment would stand in an operating room that will be crowded with more than 20 physicians and nurses. Fortunately, they'll have the benefit of Packard Children's large, state-of-the-art Ford Family Surgery Center, whose new operating rooms opened in December 2008. When Packard Children's separated another pair of twins in 2007, the power supply to the older operating room they used had to be upgraded to provide enough juice for all the equipment.
  • The most difficult part of the separation will be dividing the girls' livers, according to lead surgeon Gary Hartman, MD. Their livers are fused to each other along the longest dimension. At least two large blood vessels that cross from one child's liver to the other will have to be carefully tied off. "One quarter of the body's blood supply passes through the liver each minute, so the risk of hemorrhage is significant," Hartman said.
  • Each girl will be left with a large separation site, about the size of a standard envelope, which will need to be closed with new skin. To plan ahead for this challenge, plastic surgeon Peter Lorenz, MD, inserted tissue expanders under the girls' skin in July. The expanders are essentially small balloons which were gradually inflated with saline to stretch the skin, prompting the growth of about 32 square inches of extra skin on each child. Under the skin, each girl will have a custom-made resorbable plate implanted where the sternum should be. Bone pieces grafted onto the plates will gradually grow to replace them so that the girls will eventually have normal sternum bones.

In spite of the many complexities of the surgery, it will be much like any other major operation to a child's chest and abdomen. As Boltz told me, "First and foremost they're children - they're pretty much like any other kid except that they're conjoined."

Photo courtesy of Packard Children's

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