Conjoined Twins - Separation

Separation

Surgery to separate conjoined twins may range from relatively simple to extremely complex, depending on the point of attachment and the internal parts that are shared. Most cases of separation are extremely risky and life-threatening. In many cases, the surgery results in the death of one or both of the twins, particularly if they are joined at the head. This makes the ethics of surgical separation, where the twins can survive if not separated, contentious. Dreger found the quality of life of twins who remain conjoined to be higher than is commonly supposed. Lori and George Schappell are a good example.

Recent successful separations of conjoined twins include that of the separation of Ganga & Jamuna Shreshta in 2001, who were born in Kathmandu, Nepal in 2000. The 97-hour surgery on the pair of craniopagus twins was a landmark one which took place in Singapore; the team was led by neurosurgeons, Dr. Chumpon Chan and Dr. Keith Goh. Ganga Shrestha died at the Model Hospital in Katmandu in July 2009, at the age of 8, three days after being admitted for treatment of a severe chest infection.

Notable also is the success of Dr. Ben Carson. In 1987, Carson made medical history by being the first surgeon in the world to successfully separate siamese twins (the Binder twins) conjoined at the back of the head (craniopagus twins). Operations to separate twins joined in this way had always failed, resulting in the death of one or both of the infants. Carson agreed to undertake the operation. The 50-member surgical team, led by Carson, worked for 22 hours. At the end, the twins were successfully separated and can now survive independently.

Carson recalls:

I looked at that situation. I said, ‘Why is it that this is such a disaster?’ and it was because they would always exsanguinate. They would bleed to death, and I said, ‘There's got to be a way around that. These are modern times.’ This was back in 1987. I was talking to a friend of mine, who was a cardiothoracic surgeon, who was the chief of the division, and I said, ‘You guys operate on the heart in babies, how do you keep them from exsanguinating’ and he says, ‘Well, we put them in hypothermic arrest.’ I said, ‘Is there any reason that— if we were doing a set of Siamese twins that were joined at the head—that we couldn't put them into hypothermic arrest, at the appropriate time, when we're likely to lose a lot of blood?’ and he said, ‘No way .’ I said, ‘Wow, this is great.’ Then I said, ‘Why am I putting my time into this? I'm not going to see any Siamese twins.’ So I kind of forgot about it, and lo and behold, two months later, along came these doctors from Germany, presenting this case of Siamese twins. And, I was asked for my opinion, and I then began to explain the techniques that should be used, and how we would incorporate hypothermic arrest, and everybody said ‘Wow! That sounds like it might work.’ And, my colleagues and I, a few of us went over to Germany. We looked at the twins. We actually put in scalp expanders, and five months later we brought them over and did the operation, and lo and behold, it worked.

In 2003 two women from Iran, Ladan and Laleh Bijani, who were joined at the head but had separate brains (craniopagus) were surgically separated in Singapore, despite surgeons' warnings that the operation could be fatal to one or both. Both women died during surgery on July 8, 2003.

A case of particular interest was that of infants Rose and Gracie ("Mary" and "Jodie") Attard, conjoined twins from Malta who were separated by court order in Great Britain over the religious objections of their parents, Michaelangelo and Rina Attard. The surgery took place in November, 2000, at St Mary's Hospital in Manchester. The operation was controversial because Rose, the weaker twin, would die as a result of the procedure as her heart and lungs were dependent upon Gracie's. (The twins were attached at the lower abdomen and spine.) However, if the operation had not taken place, it was certain that both twins would die.