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
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 anesthesiologist’s 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 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.
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.
Special B’day celebrations
On 28th August 2013, the girls celebrated their first birthday along with the entire team that made it all possible.
Girls have now started walking with support and are back happily to their home town.
WE WISH THEM LONG, HEALTHY AND INDEPENDENT LIFE…………………………