Peri-operative intensive care
All good intensive care requires attention to detail of the routine elements of care. These include: staffing and monitoring; drug prescription and administration; feeding and fluid balance; analgesia and sedation; organ support and reducing the risk of healthcare associated infection. Doing this well requires an understanding of the relevant physiology and an awareness of the limited evidence base. Detailed protocols and implementation checklist are valuable in ensuring these minimum standards are met. (Source: Seminars in Pediatric Surgery)
Source: Seminars in Pediatric Surgery - July 29, 2015 Category: Pediatrics Authors: Sandra A Walsh, Mark J Peters Source Type: research
The management of conjoined twins: Cardiology Assessment
Structural cardiac defects occur in at least one twin in about 75% of conjoined twins with thoracic level fusion. Outcomes after surgical separation of thoracic level conjoined twins have been favorable when the hearts have been separate. However, even in this situation, the outlook is poor for an individual twin with an important cardiac defect. Arterial anastomosis between twin circulations is an important additional consideration, with poor outcomes for perfusion recipient twins. Surgical separation is contraindicated when ventricular level cardiac fusion exists. (Source: Seminars in Pediatric Surgery)
Source: Seminars in Pediatric Surgery - July 9, 2015 Category: Pediatrics Authors: Rachel E Andrews, Robert W M Yates, Ian D Sullivan Source Type: research
Conjoined twins: Radiological experience
Imaging plays a key role in the management of conjoined twins. Pre-operative multi-modality studies are vital to assess operability and to aid surgical planning. Technical advances in imaging, such as high resolution isovolumetric magnetic resonance imaging (MRI) techniques and 3 dimensional modelling now result in extremely accurate anatomical information. Varied information from a comprehensive radiological work-up enables the surgeons to plan the safest possible operative procedure, helps the anesthetic team before and during surgery, and guides the intensive care team in the post-operative phase. (Source: Seminars in Pediatric Surgery)
Source: Seminars in Pediatric Surgery - July 7, 2015 Category: Pediatrics Authors: Sarah G. Watson, K. McHugh Source Type: research
A Parents perspective
“My Little Fighters” as I affectionately call them came into the World on the 2nd December 2009 and they were joined from chest to pelvis sharing everything except the heart. It was an emotional pregnancy, a traumatic birth, followed by a 14 hour surgery at Great Ormond Street Hospital to separate my wonderful boys in April 2010. Hassan & Hussein are now 5 years old and typical little boys except they have a ‘superman leg’!! Let me share with you our amazing journey that reminds us all of the important things in life: which are family, hope and unconditional love. (Source: Seminars in Pediatric Surgery)
Source: Seminars in Pediatric Surgery - July 6, 2015 Category: Pediatrics Authors: Angie Benhaffaf Source Type: research
Urological management
The pediatric urologists role is confined to ischio-, para- and pygopagus conjoined twins. The aim is to preserve renal function, to address problems with urinary continence and to optimise genital issues with particular reference to sexual and reproductive function. Full urological imaging is essential prior to separation for planning and for the operation itself. (Source: Seminars in Pediatric Surgery)
Source: Seminars in Pediatric Surgery - July 4, 2015 Category: Pediatrics Authors: Peter Cuckow, Pankaj Mishra Source Type: research
Staged separation of craniopagus twins
Craniopagus twins are rare and account for up to 6% of all conjoined twins. No hospital will encounter many such twins and the opportunity to develop expertise is limited. We have dealt with two such sets and illustrate our approach by reference to our most recent set. We believe that detailed imaging allows precise delineation of the anatomy and facilitates detailed planning of the surgery. When venous drainage from the two brains is connected, we believe that staged separation is preferable as gradual alteration of hemodynamics may be safer than a single stage procedure. (Source: Seminars in Pediatric Surgery)
Source: Seminars in Pediatric Surgery - July 4, 2015 Category: Pediatrics Authors: David Dunaway, N u Owase Jeelani Source Type: research
Orthopedic aspects of separation
In the management of conjoined twins the orthopedic surgeon may be involved directly, as part of the surgical team at operation or indirectly, in dealing with associated anomalies or the sequelae of surgery.The overwhelming indication for orthopaedic involvement is ischiopagus, either tripus or tetrapus. The main role of the orthopedic surgeon is to facilitate midline closure through the use of pelvic osteotomies, which allow the symphyses pubes to be approximated. (Source: Seminars in Pediatric Surgery)
Source: Seminars in Pediatric Surgery - July 3, 2015 Category: Pediatrics Authors: David Jones Source Type: research
Cardiothoracic surgery
Conjoined twins often have complex cardiac anomalies associated with other congenital defects. The correct cardiac diagnosis delineates the degree of cardiac fusion and the feasibility of separation. The outcome in twins with fused hearts remains poor. (Source: Seminars in Pediatric Surgery)
Source: Seminars in Pediatric Surgery - July 3, 2015 Category: Pediatrics Authors: V.T. Tsang, P.K. Tran, M. de Leval Source Type: research
Ethics in the management of conjoined twins
In dealing with conjoined twins, we have adopted a pragmatic approach in balancing what is possible, parental wishes and the likely outcome for the children. We believe that separation where feasible should be undertaken but appreciate that a few parents may wish their children to remain joined. The advice we give balances the very real risks of surgery against the type of life the twins will experience if they remain joined. In some types of union such as end to end ischiopagus, the twins will never stand and will be bedridden. (Source: Seminars in Pediatric Surgery)
Source: Seminars in Pediatric Surgery - June 30, 2015 Category: Pediatrics Authors: Lewis Spitz Source Type: research
The separation procedure
The various stages of the separation are carefully planned but despite this, variations which will change the schedule of the procedure may exist. In general the operation commences on the opposite side from the main procedure and then the twins are turned for the remainder of the operation. Each type of conjoined twin is different but basically thoracopagus involves the hearts, omphalopagus involves the liver and small intestine and ischiopagus involves the large intestine and genito–urinary system. (Source: Seminars in Pediatric Surgery)
Source: Seminars in Pediatric Surgery - June 25, 2015 Category: Pediatrics Authors: Edward M. Kiely, Lewis Spitz Source Type: research
Surgical separation
The various stages of the separation are carefully planned but despite this, variations may exits which will change the schedule of the procedure. In general the operation commences on the opposite side from the main procedure and then the twins are turned for the remainder of the operation. Each type of conjoined twin is different but thoracopagus involves the hearts, omphalopagus the liver and small intestine and ischiopagus the large intestine and genito-urinary systems. Our results are presented together with interesting cases from which lessons have been learned. (Source: Seminars in Pediatric Surgery)
Source: Seminars in Pediatric Surgery - June 25, 2015 Category: Pediatrics Authors: Edward M. Kiely, Lewis Spitz Source Type: research
Theatre setup
The theatre staff would have been made aware of the special requirements for the operation at the planning meetings. Two sets of scrubs nurses will be required but only one set will be needed for the actual separation. The second set of scrub nurses will be needed only when both twins have survived the separation and the second twin is moved to another operating room for closure of the wound. (Source: Seminars in Pediatric Surgery)
Source: Seminars in Pediatric Surgery - June 24, 2015 Category: Pediatrics Authors: Martine Siflova, Edward M. Kiely, Lewis Spitz Source Type: research
Planning the operation
The management of conjoined twins falls into three distinct groups – non-operative, emergency separation and elective separation. Planning meetings involving all the personnel who will be required during the operation are held. The radiological findings are presented and the anaesthetic, nursing and intensive care requirements are highlighted. (Source: Seminars in Pediatric Surgery)
Source: Seminars in Pediatric Surgery - June 24, 2015 Category: Pediatrics Authors: Edward M. Kiely, Lewis Spitz Source Type: research
The Anaesthetic Management of Conjoined Twins
The management of anaesthesia for conjoined twins poses unique anatomical, physiological and logistic challenges. Although many possible configurations of union exist, and each is unique, we describe the principles of anaesthesia for conjoined twins drawing on our institutional experience of managing 26 sets for a variety of procedures including separation. (Source: Seminars in Pediatric Surgery)
Source: Seminars in Pediatric Surgery - June 24, 2015 Category: Pediatrics Authors: Grant M. Stuart, Ann E. Black, Richard F. Howard Source Type: research
Theatre set-up
The theatre staff will have been made aware of the special requirements for the operation at the planning meetings. Two sets of scrubs nurses will be required but only one set will be needed for the actual separation and the second set for the would closures. (Source: Seminars in Pediatric Surgery)
Source: Seminars in Pediatric Surgery - June 24, 2015 Category: Pediatrics Authors: Martine Siflova, Edward M. Kiely, Lewis Spitz Source Type: research
