No sure course for doctors during surgery on joined twins

Halted operation expected to continue at Hopkins

September 14, 2004|By Erika Niedowski | Erika Niedowski,SUN STAFF

It is one of the rare operations where two lives are in the balance.

Surgery to separate conjoined twins - which occur once in every 200,000 live births - brings with it countless complexities and potential complications. And at every turn, surgeons say, they must evaluate and then re-evaluate whether it's medically practical to continue.

"You don't make a commitment to do one thing and then finish," said Dr. James T. Goodrich, director of pediatric neurosurgery at the Children's Hospital at Montefiore Medical Center in New York, who co-led a team that successfully separated twin Filipino boys last month. "You're going in with the philosophical idea that you can stop at any point."

Led by Dr. Benjamin S. Carson, a team of surgeons at the Johns Hopkins Children's Center decided Saturday night to halt the separation of 13- month-old German twins joined at the head after one developed a heart problem.

The doctors closed the incisions in the girls' scalps, then moved them, still connected, to the intensive care unit, where they remain under general anesthesia. The affected twin's vital signs have stabilized, said Hopkins spokeswoman Staci Vernick Goldberg, and doctors are likely to resume the surgery this week.

No matter how much doctors prepare for separation surgeries - performing multiple imaging studies, studying anatomical models of shared structures, even doing surgical "dry runs" - it is not uncommon that they are forced to shift gears unexpectedly in the operating room.

Imaging studies had convinced Goodrich, for instance, that 2-year-old twins Carl and Clarence Aguirre, also born connected at the head, did not share brain tissue. But during the final part of the surgery to disconnect them, the team discovered that the boys' brains were indeed fused at a 2-inch section.

After a two-hour pause spent re-evaluating what they had found, the doctors decided to continue the separation.

Goodrich said that when he spoke to Carson about the plan to separate Lea and Tabea Block in Baltimore, the Hopkins neurosurgeon indicated he would attempt to do the surgery all at once but be prepared to stop if necessary. The operation had been expected to take 48 hours.

"To their credit, they considered that," said Goodrich of the doctors' decision to stop. "Historically, that has not been the case."

Goodrich's co-team leader, Dr. David A. Staffenberg, chief of pediatric plastic surgery at Children's Hospital, said the Hopkins team likely will be better prepared when it resumes its work.

"We'd be hopeful that they've learned something that will help them when they do go back into the operating room," he said.

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