Siamese Twins

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Surgical Plan

SURGERY DATE:

17/09/2002

SURGERY TIME:

07:30 hrs

REHEARSAL:

16/09/2002 @ 16:00 hrs

HEAD SURGEON:

Dr. Abdullah Al Rabeeah

TEAMS:

Team 1 -Anesthesia

Team 2 -Pediatric Surgery

Team 3 -Plastic Surgery

Team 4 -Pediatric Urology

Team 5 -Pediatric Orthopedics

Steps of Surgery

Team 1 - 0700 hrs
Team 2 & 3 - 0830 hrs Prepping & Incisions
At 0930 Team 3 leaves and Team 2 continues (Team 3 will be available for Vascular review).
After separation of bowel and liver, Team 4 will join Team 2 to complete urological and genital separation.
At ? 14 hours, Team 2 and 4 will leave. Then Team 3 and 5 will join to do:

Pelvis separation
Flap development 3^rd extremity

At ? 17 hours, Team 2 will join to complete posterior chest separation. Team 5 will leave.
At ? 19 hours, Twins will be separated

Two Tables

Table I

Table II

Team 2

<-- Team 4 -->

Team 2

Team 3

<-- Team 5 -->

Team 3

Expected finish time: 21 hours.

Color Codes:

Twin Mohammed - BLUE
Twin Ahmed - RED

A number of diagnostic procedures were arranged including the following tests:

1.	Basic blood work + Liver and Kidney functions
2.	Urine and stool analysis
3.	Total body x-ray
4.	Multislice C-T Scan (3-D)
5.	MRI
6.	Angiography
7.	Upper gastrointestinal studies – both twins
8.	Barium enema
9.	Voiding cystourethrogram
10.	Abdominal & pelvic ultrasound
11.	Cardiac Echo – both twins

The multidisciplinary team met several times to review the diagnostic studies and the possibility for separating both twins safely. This was found to be possible and requires the involvement of the following specialties:

1.	Pediatric Anesthesia
2.	Pediatric Surgery
3.	Plastic Surgery
4.	Pediatric Urology
5.	Pediatric Orthopedics
6.	OR Nursing

The clinical and diagnostic tests showed that Ahmed and Mohammed are joined at the chest, abdomen and pelvis. Both of them have normal head and upper extremities. However, each of them has only one lower limb and they share a third abnormal limb. They are conjoined and share their ribs, sternum and pelvis. Also, they have scoliosis in their backs. The internal organs show a combined liver, distal small intestine and colon. They also have one anus and separate external genitalia. There is an overlap over the urinary and genital systems.

Also, the twins and their parents were interviewed by the Pediatric Psychiatry team to prepare them for the separation and also to minimize the separation trauma for both twins. The Physiotherapy and Rehabilitation team also began to perform a heavy program to strengthen the lower limbs for a post-separation rehabilitation program.

Operation Details

Date:	17.09.2002
Duration:	23-1/2 hours
Starting Time:	07:15 A.M. (17.09.2002)
Finishing Time:	06:45 A.M. (18.09.2002)

The Operation included separation of the following:

1. Chest –

Ribs
Sternum
Pericardium (Common Pericardium)
Diaphragm

2. Abdomen –

Liver (Shared – Previous Surgery)
Distal Small Intestine
Common Colon
Crossed Overlapping Ureters
Testes (Two in one twin, one of which was transferred to the other)
External Genitalia (Male)

3. Pelvis – Common Pelvis -- divided between them

4. The third abnormal Lower Limb – Used to cover the abdominal defect (Mostly for Ahmed)

The Operation also included the following procedures:

1. Repair of Pigeon Chest (Pectus Carinutum) in both twins.

2. Release of dense intra-abdominal adhesions.

3. Re-implanting of two Ureters in Mohammed's Urinary Bladder and one in Ahmed's.

4. Removal of non-functioning Kidney in Ahmed's abdomen.

5. Removal of the Sacrum of the third Lower Limb to give more space for closure.

6. Removing all bones from the third abnormal Lower Limb to develop a flap (muscles and skin) to cover the wound of Ahmed.

7. Using a muscular flap from Ahmed's back to Mohammed's.

8. Using skin graft (split thickness) to cover the muscles of Mohammed.

N.B .:

No tissue expander was needed.

No artificial skin or mesh was used.

END RESULT

*AHMED*	*MOHAMMED*
Normal Head Normal Upper Limbs Normal Heart Two Lungs Split Liver Small Intestine plus Distal 2/3 Colon (No Distal Ileum) Anus One Kidney (Normal) plus Re-Implanted Ureter Normal Penis One Testes (from Mohammed) One Lower Limb (Normal) Half Pelvis	Normal Head Normal Upper Limbs Normal Heart Two Lungs Split Liver Small Intestine plus Distal Ileum plus Proximal 1/3 Colon Colostomy One Normal Kidney plus One Hydronephrotic Kidney; Two Re-implanted Ureters Normal Penis One Testes One Lower Limb (Normal) Half Pelvis