Conjoined Twins Surgery In India - Dr. Prashant Jain

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Conjoined Twins Surgery In India
Conjoined Twins Surgery In India - Dr. Prashant
Jain
On 21st April, 2013, a super speciality team led
by Dr Prashant Jain at BLK Super Specialty
Hospital made a decision to save two
precariously hanging newborn lives. By the night
of 12th August, 2013 they had made history. The
story behind the rarest of rare separation of
conjoined twins at BLK Super Specialty
Hospital. Twin girls Hussaina and Hassana were
born conjoined in Nigeria on 28 August, 2012.
Celebrations in the family soon turned to shock
and sorrow, however. The twins were joined back
to back (pygopagus in medical terms). To an
extent that they had common urinary and vaginal
opening and a common anus. A clan travels across
continents in search of hope Perplexed by this
rare condition, the doctors in Nigeria told the
parents that surgical separation of the twins
was possible but they would have to lose one of
the two girls. Then fate intervened and they were
referred to Dr Prashant Jain, Head Pediatric
Surgery Department BLK Super Specialty Hospital.
A multi disciplinary team of super specialists
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A multi disciplinary team of specialists and
super specialists was formed, led by a Pediatric
surgeon Dr. Prashant Jain. The team consisted of
super specialists from pediatric critical care,
anesthesiology, neurology, neurosurgery, plastic
surgery, spine surgery, neuro-anesthesia,
vascular surgery, hematology, radiology and
transfusion medicine. State-of-the-art
technology at BLK CT angiography, MRI and MCU
studies were conducted to investigate and define
the complex structural anatomy of the twins
through high definition images. MRI and CTScan
revealed that girls had a common sacral bone,
they shared their lower spinal cords, lower
gastrointestinal tract and genitourinary tracts.
They also had a common opening for passing stool
and urine, and also common genitalia.
Fortunately, brain, heart, lungs and kidneys of
each twin were normal. The twins tested positive
for a sickle cell trait, and hereditary blood
disorder that increases the risks and complexity
of anesthesia of anesthesia and surgery
further. Logistics and planning After much
brainstorming, the team decided to plan for
separation in three stages. In the first stage,
tissue expanders will be placed to get adequate
skin for covering the raw areas after
separation. In the second stage, actual
separation of the spinal cords, intestine and
genito-urinary tract would be carried out along
with reconstruction. In same stage, a temporary
opening (colostomy) for passage of stool would
be made on the abdominal wall. In the third
stage, colostomy would be closed after 6 weeks.
The team met regularly during the next two
months to put the surgical plan in
place. Flowcharts detailing the moves of each and
every person involved in the surgery were
meticulously prepared and refined. Every surgical
step was defined and rehearsed over and over
again till it reached precision. The girls were
color coded (one pink and the other blue) so that
there would be no error at all. This color code
was extended to all catheters, wires, tubes
and leads that would be connected to the girls
during surgery. The team decided to use an
advanced technique of neuro-monitoring to avoid
any damage to the nerve roots of both spinal
cords. The anesthesiologists job was made all
the more challenging by the fact that whatever
drug was given to one twin, the other would
receive it inadvertently through a large sharing
vein, and dosages were calculated and monitored
accordingly. Surgical steps were
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practiced using dummies procured for the purpose.
Reconstruction of high definition images showed
that the twins had a shared blood circulation,
thereby extending a clue to the anesthesiologists
to plan for managing the risk of passing of
drugs from one child to another during surgery.
Each twin was assigned a separate team of
doctors representing each specialty, some of
whom were not participate in the surgery but
would be on standby if anything went wrong. May
25, step 1 Tissue expanders were placed on 25th
May. These are essentially silicon bags, which
were placed under the skin on the buttocks. These
were gradually inflated once a week by pumping
in saline over a period of 2 month. This helped
in expansion of the skin and generation of good
tissue cover required during the
surgery. August 12, step 2 (After separation in
ICU) The surgery began at 6 AM on August 12th,
2013. Relay teams of surgeons who were tasked
with separating the three involved systems
without any compromise, moved in and out of the
OT in accordance with the flowcharts prepared
earlier. Neurosurgeons used microscopes, while
separating the spinal cords. Intensive
neuro-monitoring was conducted during the entire
surgery. The girls were re-positioned twice
during the surgery to enable surgeons to gain
access to areas that were to be separated. After
13 nerve-wracking hours later, the girls were
moved to separate operation theatres for further
reconstruction of genitalia, urethra and anus by
Pediatric surgeon. The recovery After the
surgery, the girls were shifted to the Pediatric
ICU where they were electively kept on
ventilator support for 24 hrs with close
monitoring of blood pressure, blood oxygen and
carbon dioxide levels, body temperature and
urine output. They were gradually taken off
artificial ventilation the next day. Presently,
both twins are stable and have shown no signs of
any neurological deficit.