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Planning, Teamwork and Technology Essential to Conjoined Twins’ Separation

September 22, 2015
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In a meticulously planned 16-hour operation, a 30-person team from four specialties successfully separated 11-month-old twins conjoined at the buttocks and lower spine.

Specialists from General Pediatric Surgery, Plastic and Reconstructive Surgery, Neurosurgery and Colorectal Surgery worked together to plan and execute a successful separation of conjoined twin girls, Acen and Apio, earlier this month.

“In surgery, we like to avoid all surprises,” says Gail Besner, MD, chief of Pediatric Surgery at Nationwide Children’s Hospital. “In this case, we had extraordinarily detailed planning sessions in which we went over each step of the upcoming surgery.”

By the time the team went into the operating room, Thursday, September 3, they knew exactly what they were going to do. According to Dr. Besner, “and with no perceptible deviations, that’s precisely what we did.”

The multidisciplinary team used two new, innovative technologies for this separation.  First, with the help of William Ray, PhD, faculty in the Battelle Center for Mathematical Medicine at The Research Institute at Nationwide Children’s, the team members used 3D models of the twins in their planning.

“We were able to fully understand the anatomy and enjoy the benefit of a three-dimensional appreciation for the babies’ unique anatomy,” Dr. Besner says.

The second technology involved collaboration among neurologists, neurophysiologists and neurosurgeons. For the six-hour portion of the surgery devoted to separating the spinal cords, team members from these three groups were in constant communication.

“Because of the delicate job our neurosurgeons had of separating the spinal cord, our team was assisted by neurophysiologic intraoperative monitoring, and neurologists Monica Islam, MD, and Jennifer McKinney, MD, along with their technicians, were able to tell us which muscles and nerves belonged to each baby,” says Dr. Besner. “This is the first time this specific type of monitoring has been done in a conjoined twins’ separation surgery.”

Jeffrey Leonard, MD, chief of Neurosurgery at Nationwide Children’s, led the spinal cord separation, assisted by his colleague Lance Governale, MD. He describes the separation as being similar to the task of addressing a tethered spinal cord.

“Imaging helped guide our understanding of the twins’ anatomy,” he says. “The main task was to separate the normal from the abnormal. The abnormal portions of the spinal cords were similar to a lipomyelocele – a fatty abnormality of development.”

Using the neurophysiologic monitoring, Dr. Leonard and his team assigned the nerves to the correct twin and decided where to cut based on where the functional nerve roots ended.

In addition to helping with the spinal cord separation, the neurophysiologic monitoring was essential to the colorectal reconstruction performed by Marc Levitt, MD, surgical director of the Center for Colorectal and Pelvic Reconstruction, and his colleague Richard Wood, MD. The babies shared an imperforate anus, where their colons joined and never reached the skin level.

“We wanted to make sure each baby got a fair share of the muscle, but we needed to make sure that those muscles would work,” explains Dr. Levitt.

In addition to knowing which muscle belonged to which baby, knowing which nerve controlled which muscle was critical for the rectal reconstruction. Working sphincter muscles in the the bladder and rectum are essential for continence.

“Both babies had beautiful muscles, but once separated, those muscles ended up only on one side for each baby,” says Dr. Levitt. “Because there was no way to know how much tissue belonged to each twin before the surgery, we had to make a lot of on-the-table decisions. Because we were operating simultaneously in the same operating room, we were able to consult with each other during the reconstructions.”

Each reconstruction was unique, but essentially, a section of muscle was wrapped around the rectum to ensure continence, and the rectum was fit so that it was positioned correctly. “Because we were able to use working muscles and surround the rectums with those muscles, we expect that both babies will be continent,” Dr. Levitt says.

This is a huge gain for two patients who were never expected to have continence or experience a normal life.

Richard Kirschner, MD, chief of Plastic and Reconstructive Surgery, and his colleague Gregory Pearson, MD, performed the pre-operative tissue expansion required to have enough skin to close the wounds after separation and to reconstruct the soft tissues after the babies were separated. Additional critical members of the team included anesthesiologists Jason Bryant, MD, and Emmett Whitaker, MD, and the operating room nurses. “Every part of this superb team was essential to the success of the separation surgery,” emphasizes Dr. Besner.

“We had the opportunity to take two patients who would never have been able to have a normal life as they were before and make them into two separate individuals who, I expect, will have healthy and normal lives,” says Dr. Besner. She and the other surgeons are also faculty members at The Ohio State University College of Medicine.

Just three weeks after their separation, Acen and Apio Akello celebrated their first birthday. They continue to recover at Nationwide Children’s and will need an additional surgery to remove their colostomies, which they have had since shortly after birth.

Conjoined twins occur in approximately 1 of 200,000 live births. Since 1978, surgeons at Nationwide Children’s have successfully separated five sets of conjoined twins, including the Akello sisters.

Click here for video from the twins’ hospital stay and surgery.

 

 

Photo credit: Nationwide Children’s