by Surgical Tribune

Acen (left) and Apio (right) Akello arrived at Nationwide Children's Hospital conjoined at the hip and spine and were separated during a 16-hour surgery on Sept. 3. The girls are pictured here in their hospital room with their mother, Ester Akello. (Photograph: Nationwide Children's Hospital)

Sep 14, 2015 | AMERICAS

US surgeons successfully separate 11-month-old conjoined twins

COLUMBUS, Ohio, USA: A team of surgeons at Nationwide Children's Hospital in Columbus has successfully separated conjoined twins in a complex surgery that involved more than 30 specialists from different disciplines. The 11-month-old twin girls Acen and Apio Akello from Uganda, who were born conjoined at the hip and spine, are recovering well after the separation surgery on Sept. 3.

A surgical team of more than 30 specialists from pediatric surgery, plastic surgery, colorectal surgery, neurosurgery, anesthesiology and nursing performed the operation, which took 16 hours in total.

"Because of the delicate job our neurosurgeons had of separating the spinal cord, our team was assisted by neurophysiologic intraoperative monitoring and the technicians were able to tell us which muscles and nerves belonged to Acen and which belonged to Apio," said Dr. Gail E. Besner, chief of pediatric surgery at the hospital. "This is the first time this specific type of monitoring has been done in a conjoined twins' separation surgery."

The Ugandan twins were flown to Nationwide Children's in December 2014. Earlier this year, they had surgery to have tissue expanders placed underneath their skin to prepare for their separation. "Tissue expansion was performed during the months prior to separation in order to ensure that there was sufficient skin to cover their wounds and to complete the reconstruction," said Dr. Richard E. Kirschner, chief of plastic and reconstructive surgery at the hospital.

Two neurosurgeons focused on one sister each and yet assisted each other to delicately divide their intertwined spinal cords. "Imaging helped guide our understanding of the twins' anatomy," explained Dr. Jeffrey R. Leonard, chief of neurosurgery at Nationwide Children's. "In the operating room we were able to visualize and discern which nerves belonged to which twin. Our primary concern was preservation of the twins' neurologic function so they may have adequate leg movement and bowel and bladder function once separated."

Carefully dividing the soft tissue, Besner was the surgeon who separated the twins. Although the girls were now on two separate tables, the surgery was still hours from being completed. Dr. Marc A. Levitt and his team from colorectal surgery were tasked with making sure the girls would have fecal continence post-surgery, performing two operations for imperforate anus, since neither twin was born with an anal opening. Finally, the wounds where they had previously been conjoined were covered via plastic surgery.

"We are extremely pleased with the outcome of the surgery," said Besner. "We learn from every operation that we do, and when you do an operation that is as rare as separation of conjoined twins we learn a lot with every case as to how to achieve best outcomes for our patients. The introduction of pre-operative 3D modeling, as well as intra-operative neurophysiological monitoring, was extremely innovative in this case."

Conjoined twins occur in about 1 in 200,000 pregnancies. Since 1978, surgeons at Nationwide Children's have successfully separated four sets of conjoined twins, including the Akello sisters. "Given the breadth and depth of expertise of all of our specialists, we have the potential at Nationwide Children's 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," said Besner.

It is not yet known how long Acen and Apio will remain at the U.S. hospital before going home. They will both need to have one additional surgery to remove their colostomies, which they have had since shortly after birth. "The girls will continue to receive treatment at this time, and I can't wait to watch them grow. My hope is that they will be able to sit up on their own, walk and play like any other child," said Besner.



by Surgical Tribune