In a rare, highly complex and historic procedure, teams of physicians and surgeons at Childrens Hospital Los Angeles (CHLA) last week completed the separation of identical conjoined twin girls who were born nine months ago along with their sister—a separate and normally developed fraternal triplet.
This is only the second known case of conjoined twins also being part of a set of triplets.
At press time, both girls were awake and breathing comfortably on their own. They were expected to be moved out of the intensive care unit perhaps as early as Thursday, Sept. 18.
Pediatric general surgeon James E. Stein, assistant professor of surgery at the Keck School of Medicine of USC, led the team of some 60 medical personnel, including general, orthopaedic and plastic surgeons, anesthesiologists and nurses. The separation surgery lasted 24 hours, with the exact time of separation occurring at 11:17 p.m. on Sept. 10.
“There is no reason to think they will not survive or lead healthy lives,” Stein said.
The girls, whose names were not released out of respect for their parents’ wish for privacy, are a type of conjoined twin known as ischiopagus tripus. (“Ischio” is a Greek word for hip, “pagus” for fixed or united, and “tripus” for three legs.).
They had separate heads, necks, shoulders, arms, hearts, lungs and chest walls. Before the surgery, they were lying face to face, intertwined from just below their diaphragms down to their pelvises. They each had one leg and shared a conjoined third leg in back. Their livers, colon and parts of their bladders and reproductive organs were also conjoined.
“Ischiopagus twins, while one of the rarest forms, are also in many ways the most complex,” Stein said. “Since they involve so many organ systems—liver intestine, urinary, reproductive, vascular and musculo–skeletal systems—we have utilized nearly every area of expertise offered here at CHLA.”
Of the more than 1,000 conjoined–twin cases documented, only 153 have been ischiopagus, and of those, 58 (6 percent) have been ischiopagus tripus.
“The quality of life for these children is expected to dramatically improve now that they have been separated,” said orthopaedic surgeon Richard A.K. Reynolds, associate professor at the Keck School and leader of the orthopaedic component of the team. The girls were described as cheerful and mentally alert, but had been denied the normal developmental milestones of babyhood, like rolling over, crawling or standing.
Preparing for the landmark surgery was a logistically daunting task requiring months of meticulous planning, including rehearsals and the building of models of the babies’ pelvises so surgeons could refer to them during surgery. Before surgery the twins underwent diagnostic procedures like angiography and cystoscopy, and had a reversible colostomy procedure performed, as well as the insertion of five “tissue expanders.”
“We use these to gain additional skin and soft tissue so that after the separation there is sufficient tissue and skin to close the open wounds,” explained plastic surgeon John Gross, who headed up the plastic surgery team. Gross is chief of plastic surgical services at LAC+USC Medical Center and assistant professor of surgery at the Keck School.
William McIlvaine, visiting associate professor of clinical anesthesiology at the Keck School, led the anesthesia team. “What made this surgery so unusual,” he explained, “is that we put together five very major operations sequentially. We split the liver. We split the gastrointestinal tract. We split the genitourinary tract. We split the pelvis. Then we put everybody back together.”