The Challenges of Separation Surgery

Jan. 3, 2007— -- An operation today expected to take several hours will hopefully lead to the safe separation of 5-month-old conjoined twins Abygail and Madysen Fitterer, of Bismarck, N.D.

But for the surgeons and medical teams at the Mayo Clinic, preparations for the operation have been months in the making.

In fact, a series of simulations and dry runs has likely preceded today's operation -- the equivalent of dress rehearsals for this remarkable performance.

"Right away, we know that there has been a tremendous amount of work and preparation for today's surgery," said Dr. Kurt Newman, surgeon in chief at the Children's National Medical Center in Washington, D.C.

Newman has firsthand experience surgically separating conjoined twins. Last year, he was part of a surgical team that successfully performed such an operation on a pair of twin boys from Wisconsin. In June of 2004, he was also one of the surgeons who separated conjoined Virginian girls.

"There is a lot that is known now about what has to be done, and everyone has probably been prepared," he said. "But it's a bit like in sports, where there's nothing quite like entering the stadium or arena when it's game time."

Surgical Separation a Step-by-Step Process

In addition to the complexities normally associated with surgery, procedures to separate conjoined twins come with their own set of considerations.

"The first big deal is to get the family situated and set and get the babies into the operating room," Newman said. "As you move into the operating room environment, the anesthetist will get the babies intubated and asleep."

This step, he said, presents a very complicated set of parameters. Each baby needs enough anesthesia to get through the surgery painlessly. Too much, however, could put the life of one or both infants in danger.

And since the babies are connected, administering the proper level of anesthesia to both becomes a delicate balancing act.

"The goal is to get both babies asleep, stable and anesthetized during what will likely be a long operation," Newman said.

And then there is the challenge of keeping in mind which baby is which. Color-coded hats, identification tags and any number of other methods may be used in order to differentiate each twin from the other.

"This is done so what belongs to that baby stays with that baby, and things don't get mixed up," Newman said.

The surgeon will make the first few incisions to remove the tissue expanders. The next incisions will delve deeper, cutting through muscle and bone.

Since the girls are joined at the chest, a critical issue is whether there will be enough of the breast bone to form two smaller breast bones -- one for each of the twins.

The positioning of the organs is also crucial. Their livers and intestines will have to be split, and surgeons must be particularly careful to avoid damaging any organs from one twin that crosses the boundary into the other twin's body.

"The surgery can be anything from very straightforward to very complicated," Newman said. "The team at Mayo has a lot of experience from a previous set of twins and a lot of skill with that.

"But you never know until you're there 100 percent of what you are going to be dealing with."

However, Newman said the chances are good that the surgical team will be able to separate the twins safely and successfully.

"There is a whole spectrum of different combinations or connections that you can see with this scenario," he said. "But in this situation, the outcome should be very favorable in terms of getting through the operation well."

Recovery Will Be Gradual, Painful

Though a safe separation will represent a successful conclusion for the surgical teams at Mayo, the twins will likely face a number of obstacles throughout their recovery and rehabilitation.

"The first few days will be spent making sure the twins get over the operation well," Newman said. "For the first few days, they will be really critically ill. From the first week to two weeks they will be getting their bodily functions back. And over the long-term there will be the issue of rehabilitation and any other operations that will be needed."

The separated twins will likely experience the worst stages of pain shortly after the surgery.

"I think there will be a fair amount of pain that the babies will be in, but I'm sure the teams looking after them will give them the pain medication they need," Newman said. "Over time there will be less and less of this issue."

But Newman added that the surgery, if successful, will represent the first steps for both twins toward as normal a life as possible.

"Having been in the operating room before for this type of surgery, there is nothing quite like the sensation when the babies are together one moment, and then the surgeon makes that last cut and you have two babies. It is just one of the most unbelievable moments for the surgeon, the nurses and everyone else in the operating room.

"It is a very unusual thing to experience. Gratifying, but unusual."