Iranian twins separated, surgery to last for another 24 hours
( 2003-07-08 15:36) (MSNBC.com)
Neurosurgeons on Tuesday finished separating two 29-year-old Iranian twins
joined at the head, who were in critical condition, a hospital spokesman said.
"We should pray very hard for them," Dr. Prem Kumar said.
The surgery will last for at least another 24 hours as a team of plastic
surgeons graft tissue taken from the twins' thighs to cover their brains to
protect them, Kumar said.
The team of doctors had to contend with unstable pressure levels inside the
twins' brains just before they worked to uncouple the sisters' brains and cut
through the last bit of skull joining them, Kumar had said.
The risky, marathon procedure began Sunday morning.
"The thing we don't know, because the twins are under anesthesia, is the
state the twins will be in when they come out of anesthesia," he said.
The brains of Ladan and Laleh Bijani were separate, but after lying alongside
each other for decades were nonetheless stuck together, a Raffles Hospital
spokesman said.
"They have to be teased apart very slowly," Dr. Kumar said earlier. "Cut.
Teased apart. Cut. Teased apart. In the process, you encounter a lot of blood
vessels and other tissues. That's taking a long time.
'MILLIMETER BY MILLIMETER'
"Parts of the blood vessel and the brain can be ripped apart if you're not
careful," Kumar said, adding surgeons were working "millimeter by
millimeter."
Dr. Marc Mayberg, chairman of neurosurgery at the Cleveland Clinic in Ohio,
said surgeons could cut viable tissue if the twins' brains were fused
together.
"But presumably, in the area where the two brains are touching, there isn't
much function emanating from there at the moment, so theoretically one would
think you could go through tissue like that," Mayberg said by telephone.
The operation was complicated further when the team discovered that the
pressure in the twins' brains and circulatory system was
fluctuating.
Kumar said the fluctuations were within "tolerable levels,"
but he was not prepared to immediately explain what would happen if that
changed.
Mayberg said the pressure fluctuations could be
fatal.
"If the pressure is due to the fact that there is insufficient
drainage from this vein, in either cranium, that could be a life-threatening
condition," he said.
On Monday, five neurosurgeons completed one of the
most dangerous steps in the surgery by rerouting the shared vein and
successfully attaching a vein graft from Ladan Bijani's thigh. The shared vein,
thick as a finger, drained blood from the twins' brains to their
hearts.
Although a large part of the twins' fused skull was severed in
two, the blood vessels will not be disconnected - and the new vein will not be
put to work in Ladan Bijani's head - until after the brains are separated, Kumar
said. Their bodies are otherwise distinct.
RISK OF
DEATH
Rerouting the shared vein was considered one of the
biggest obstacles in the surgery. German doctors told the twins in 1996 that the
surgery was too dangerous, but the Singapore team benefited from technological
advances, Kumar said.
The operation could kill one or both of the
sisters, but after a lifetime of compromising on everything from when to wake up
to what career to pursue, the sisters said they would rather face those dangers
than continue living joined.
"If God wants us to live the rest of our
lives as two separate, independent individuals, we will," Ladan Bijani said
before the operation.
An international team of 28 doctors and about 100
medical assistants were enlisted for the surgery. The Iranian government said
Monday it would pay the nearly $300,000 cost of the operation and care for the
twins.
This is the first time surgeons have tried to separate adult
craniopagus twins - siblings born joined at the head. The surgery has been
performed successfully since 1952 on infants, whose brains can more easily
recover.
Participating neurosurgeon Dr. Benjamin Carson, director of
pediatric neurosurgery at Johns Hopkins Children's Center in Baltimore, has
separated three sets of craniopagus twins.
Because this operation is a
medical first, surgeons have encountered unexpected obstacles not seen in
infants. It took longer to cut through portions of their skulls because their
older bones were denser than previously believed, Kumar said.
"Every time
something like this happens, we have to take stock of what is happening," he
said.
As the procedure dragged on, surgeons tried to get adequate rest,
slipping out of the operating room for breaks when their expertise was not
needed, Kumar said.
Classical music played softly as surgeons worked
simultaneously in tight spaces in front of and behind the twins, who are sitting
in a custom-built brace connected to an array of lines feeding them
intravenously and monitoring their vital signs, Kumar said.
"Nothing is
going on at a hurried pace," he said. "Everything is quite calm and measured.
There's lots of discussion."
The sisters were born into a poor family of
11 children in Firouzabad, southern Iran, but grew up in Tehran under doctors'
care.
As girls they used to cheat on tests by whispering answers to each
other, they told reporters last month.
The government caught on and
concluded it would be nearly impossible for them to compete individually in
university entrance exams, so it granted them a scholarship to study law at
Tehran University.
After surgery, the twins hope to move back to Iran and
live together while Laleh pursues journalism and Ladan works as a lawyer, said
Bahar Niko, 24, a teacher who befriended the sisters in Singapore.
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