Conjoined Twins
Ethics & Standards Concerning the Surgical
Treatment of Conjoined (Twin) Children
May 8, 2014
Lucas Wheatcroft
A.P. Language & Composition
Period 3
Mr. Gene Eller
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Conjoined Twins
The miracle of pregnancy is exciting to many, and the first question asked is whether it a
boy or a girl. It’s even more thrilling to have a set of twins, but there is a phenomenon that a
finite amount of parents experience. The occurrence of having two identical twins born in the
same body is one in 50,000-200,000 births; the female-to-male ratio for this condition is 3:1, and
is more prominent in Southwest Asia and Africa. (Borges et. al. 2003)
In history, conjoined twins have been recognized for thousands of years: an Ancient
Peruvian culture of the Moche depicted Siamese twins in their ceramics that dated back to 300
C.E. (Berrin 1997) In 415 C.E., St. Augustine of Hippo’s book City of Gods referred to a man
“double in his upper, but single in his lower half—having two heads, two chests, four hands, but
one body [with] two feet like an ordinary man.” (New Advent)
There are fifteen main categories of conjoined twins, yet all share the same chorion,
placenta, and amniotic sac; some monozygotic non-conjoined twins, however, share the same
placenta. A famous set of dicephalic parapagus twins, Abigail and Brittany Hensel, came to light
on March 7, 1990 in Minnesota. These two children share the same body, yet have separate
heads; each twin has a separate heart, liver, spine, and spinal cord. With each twin controlling
half of the body, each must cooperate to simultaneously control basic functions (i.e. walking,
clapping their hands, etc.) because each brain controls one side of the body. Both were born in
Minnesota to Patty and Mike Hensel; the mother was a registered nurse and the father was a
carpenter and landscaper. The twin’s brother, Dakota, and sister, Morgan, share a dog, Sadie.
These two twins attended a Lutheran high school in Mayer, Minnesota. Despite coordinating
each other’s movements, they can swim, ride a bicycle, type, run, and drive. (Wallis 1996)
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The anatomical organ distribution of these twins consisted of two separate heads, two
spines merging at the coccyx, two spinal cords, two arms (originally three, but the rudimentary
central arm was surgically removed); two breasts, two hearts in a shared circulatory system, one
diaphragm, two stomachs, two gallbladders, one liver, one small intestine, one large intestine
(colon), three kidneys, a bladder, a set of female reproductive organs, a slightly broad pelvis, and
two legs. There are, of course, many other combinations of organ distribution amongst Siamese
twins. (Weathers 2006)
Imagine if you realized that you were pregnant after twelve weeks with a set of twins,
and one week later, doctors say that they are conjoined. A recent case of surgical separation
involved two girls, A’zhari and A’ziah Jones, having undergone a fourteen-hour operation at
Richmond’s Pediatric Hospital. These two girls shared the same abdomen and shared heart
abnormalities, but they initially had a division of their shared liver in October 2012 prior to the
major procedure. Due to critical illness by the second week of their lives, the liver had to be
urgently separated as this was their source of cross circulation. Dr. Daving Lanning, the surgeonin-chief at Richmond Children’s Hospital, said in a written statement: “However, complete
separation at that time would almost assuredly have resulted in their deaths as A’zhari was in
renal failure and A’zhiah had severe cardiac hypertrophy. A phased surgery was the optimal
plan.” In order for the abdomen to possess enough skin for separation surgery, surgeons placed
tissue expanders to enable the growth of excess skin that could be used for closure and
reconstructive surgery. (Howard 2013)
Some parents refuse to put their children through such a traumatizing surgical
intervention; the risk of death amongst one (or even both) of the twins is too dangerous to take.
Some children grow up into adulthood, desperate to experience a normal lifestyle and lead
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productive, happy lives. On July 6, 2003, Singapore was the first to separate adult twins, Laleh
and Ladan Bijani, both twenty-nine years old. These two Iranian girls had seen German doctors
in 1996, but the decision for surgery was vetoed by authorities because of risks and
complications (death or disability). In April of 2001, Singapore doctors successfully separated
Ganga and Jamuna, ten-month-old Nepalese twins. Laleh and Ladan travelled to Singapore to
determine the feasibility of separation surgery, hoping to be operated in late 2002 by Dr. Keith
Goh, who was a key member of the team that had separated the Nepalese girls. Laleh and
Ladan’s operation was scheduled to be performed at Raffles Hospital, operated by Raffles
Medical Group that opened in 2000. The decisions for undergoing surgery were obvious:
studying different careers, living in other places, and having their own families.
On July 6, 2003, thirty Singaporean, U.S., French, Japanese, and Swiss specialists, in
addition to one hundred assistants, rolled the girls early in the morning to the operating theatre to
commence the procedure that was expected to last four days nonstop. Dr. Keith Goh, Dr.
Benjamin Carson, Professor Walter Tan, Dr. Chiak Kok Hoon, and Dr. Eric Teh were the leading
experts in the surgery and took shifts with other doctors and nurses. In the late afternoon of July
8, 2003, hospital spokesmen Prem Kumar Nair broke the news that the girls had lost a lot blood
during surgery and were in need of prayer. At 2.30 p.m., he announced that Laden died due to
failed blood circulation. Within an hour, Laleh’s blood circulation also failed and she died fifteen
minutes later; for only ninety minutes after surgery, Ladan and Laleh Bijani lay on separate beds,
dying with each other. Singapore and Iran experienced shock, grief, and sadness for the two girls
and the grit and determination of the girls became an inspiration to everyone. Iranians were very
distraught over the loss over the country’s most famous twins that had lived only twenty-nine
years. On July 10, 2003, Ladan and Laleh’s bodies were flown back to Iran where they were
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awaited by thousands of mourners that lined ten-kilometer streets leading to the birthplace,
Lohrasb, were they were laid to rest peaceful on July 12. On March 6, 2004, Americans had
realized that the source of death was due to excess bleeding by undetected blood vessels in the
twin’s brains. (Ahmad 2004)
It is very important to plan carefully before major surgery for conjoined twins. In São
Paulo University Medical School, the Department of Radiology at the Children’s Institute
published an angiographic study in preoperative planning of conjoined twins. In 2006, the
Institute received female ischiopagus tripus twins of fifteen months of age. They were joined
below by the xiphoid process at an angle of ninety degrees, sharing a single pelvis. The
radiological evaluation showed that the vertebral columns and sacra were completely separated
without any visible alterations. The region anterior to the pelvic bones formed a single ring, with
a normal pubic symphysis and two acetabulas articulating the normal lower limbs. Because one
of the children were slightly larger, she presented two kidneys with one ureter, and the smaller
twin only having one kidney and two ureters; both shared a bladder and urethra. Both had
separate gastrointestinal systems, but both shared the same colon and rectum. One liver and one
spleen made this evaluation even more complex. Fortunately, the smaller twin’s hepatic
parenchyma drained into her own right atrium through small hepatic veins, so the twins would be
able to be successfully separated. (Carnevale et. al. 2006)
Southeast Asia and Africa have higher numbers of conjoined twins, and some are even
thought of as reincarnations of religious figures. That’s what residents in a small village in Aria
district, Bihar, thought when they learned about Lakshmi Tatama, an Indian girl who was born in
2005. Shambu and Poonam Tatama were day laborers who earned less than forty rupees daily.
Lakshmi was born with four arms and four legs; she was a pair of ischiopagus conjoined twins,
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in which a parasitic twin had not fully developed in the body—it was headless due to atrophy. By
the age of two (one in the United States), she was well-known allover India and was worshipped
because she was thought of as a reincarnation of Lakshmi, the Hindu goddess of wealth. At one
point, a circus even offered the parents money to buy their daughter as a sideshow; the family
had to hide. When Dr. Sharan Patil, chairman of Sparsh Hospital, learned about Lakshmi’s case,
he was stunned at his discovery of finding an infected pressure ulcer at the neck end of the
parasitic twin. Coincidentally, Poonam said in a TV program that a few weeks prior to labor, she
dreamt that she was to build a temple to the goddess Lakshmi; her daughter was even born
during the “Festival of Lakshmi”. (Burkholder 2008)
Orthopedic surgeon Dr. Patil, anesthetist Dr. Yohannan John, and thirty other doctors
scheduled the operation for November 6, 2007, at Sparsh Hospital in Bangalore. The hospital’s
charitable wing, the Sparsh Foundation, funded the $625,000 operation. With a predicted 7580% survival rate, the operation was planned to last no more than forty hours; it actually lasted
for twenty-seven hours. The steps of the surgery were to (1) spend eight hours on removing the
parasite’s abdominal organs; (2) removing the auto site’s necrotic kidney and replacing it with
the parasite’s kidney (in addition to tying off the blood vessels that supplied the parasite; (3)
reconstruct the reproductive system and urinary bladder; (4) spend six to eight hours amputating
the parasite’s legs and cutting the joined backbone; (5) divide the pelvic ring, (6) hold parts of
the reconstructed pelvis in place, and (7) suture all incisions, ending the surgery at 10 a.m. on
November 7, 2007. (Yasmeen 2007)
One week after the surgery, her father proudly held Lakshmi in his arms during a clinical
press conference, and she left the hospital a month after surgery. The family moved to Jodhur,
where Lakshmi attended a school for disabled children, and the father worked on that school’s
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farm. In February 2008, a follow-up surgery brought her legs closer together, but a future
operation may be required to rebuild pelvic floor muscles for durability, support, and improved
movement. (National Geographic)
The Hensel twins, Lakshmi Tatma, the Jones’ twins, the Bijani twins, and Sao Paulo’s
Child Institute provide a clear message that careful consideration must be carried out by the
doctors, patients and families to initiate a safe, medically-sound treatment plan that has the
lowest risk of complications. Blood loss, disability, and even death are the true realities of
surgery for separation surgeries, so some families prefer to go with surgery, and others refrain
from it to spare their children’s lives. Despite the struggles and hardships experienced by victims
and their families, one thing is for certain: their determination and courage are a true source of
inspiration for people, and medicine has evolved by studying the anatomy, physiology, and
psychosocial aspects of conjoined twins. Several surgeons, such as Ben Carson, Dr. Patil, Dr.
Lanning, Keith Goh, Walter Tan, Chiak Kok Hoon, Eric Teh, and Yohannan John, have
dedicated their lives to the doctoral dissertations of serving conjoined twins to enrich their lives
and enable them to become the best that they can be.
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