Nepalese babies survive 103-hour operation

A team of bleary-eyed surgeons in Singapore yesterday completed a marathon 103-hour operation to separate a pair of conjoined twin sisters who were born sharing a brain cavity.

Doctors said they were "cautiously optimistic" that Ganga and Jamuna Shrestha, from Nepal, would recover but admitted it was too early to say how much permanent brain damage they might have suffered.

The girls were last night recovering - in separate rooms for the first time in their 11-month-long lives - in Singapore General Hospital's intensive care unit after more than four days on the surgeons' table.

Keith Goh, the neurosurgeon who was instrumental in bringing the twins to Singapore and who led the surgical team, said: "Happily we had no adverse events during the entire five days, so we are cautiously optimistic."

However, he tempered the euphoria yesterday afternoon by adding: "How they will survive only time will tell."

Lee Seng Teik, the leading plastic surgeon in the team of 16 doctors who worked round the clock after the girls were placed under anaesthetic at 9am on Friday, doubted that everything would go smoothly in the future.

"We expect there to be problems that we will encounter as we go along, in the medium and long term," he said.

There was some astonishment in medical circles at the length of the operation, which the Singapore surgeons said was due to the need for painstaking care in separating hundreds of tiny blood vessels which the babies' brains shared.

Neurologists had to try to identify where each tangled vessel belonged before it was irrevocably cut.

Other operations for craniopagus - as a join at the skull and brain is called - have lasted no more than 30 hours. The longest operation undertaken by the team of surgeons at Great Ormond Street hospital in London - one of the most experienced in the world at separating conjoined twins, although they have not separated fused brains - lasted just 18 hours.

The risks are increased the longer the operation lasts.

The girls, who come from Khalanga, a mountain village in Nepal, and are named after sacred rivers in India, are expected to stay in intensive care for at least two weeks, and in hospital for three months. They are still under sedation and will undergo a controlled wake-up process during the next few days.

Separation occurred at about 9am (3am in Britain) yesterday, 88 hours after the actual surgery began. It took 52 hours longer than the doctors had predicted last week.

Dr Goh said the mother, Sandhya Shrestha, her husband KC Bushan, and her father, Arjun Dev Shrestha, burst into tears when told the news.

Dr Teik's team then began covering Jamuna's gaping brain. They first covered her head with the synthetic material Goretex to replace part of the dura, a fibrous tissue layer covering the brain.

They then mixed bone material with polymer sheets to act as a base for new cells to grow. These cells are expected to become solid bone within a year.

The mixture was then covered with skin taken primarily from Jamuna's back. She was wheeled out of the operating theatre at 11.10am.

Ganga, whose head was "not [looking] as nice", according to Dr Teik, spent another five hours in surgery as the plastic surgeons completed a similar process, taking the grafted skin from her thighs.

The girls were moved from a supine to a prone position and back several times during the prolonged operation.

Claire Ang, one of the anaesthetists, said the team went through a whole gamut of emotions.

"It varied from hysterical to euphoric and involved light-headedness, frustration and mood swings - from being very emotional to not caring at all and just wanting to sleep," she said.

Most of the doctors cat-napped for a couple of hours each day but said they could not sleep properly because they were constantly thinking about the unfolding drama on the operating table.

Dr Goh said their after care would continue for years.

"Their brains are shaped like a tower," he said, using plastic models to demonstrate how the two brains were separated. "They can't go through society with a head shaped like this."

Even though he expects the girls to be transferred to a specialist in Nepal within months, Dr Goh promised the Singapore team would continue to monitor their progress. "We hope to see them on a regular basis," he said. "It's a lifelong commitment to look after these children."

He expressed confidence that, as the girls' heads grew during the next 10 years, the disfiguration would diminish.

"The human body has an amazing capacity for correcting these sorts of things," he said.

Explaining why the operation took so long, Dr Goh said the separation process was not as simple as making a straight-line cut.

"It was more like a tortuous route up the mountains," he said.

With each of the hundreds of interwoven blood vessels the surgeons had to decide which girl it belonged to and what damage might be done by cutting it.

He admitted there was bound to have been some brain damage, but that it was far too early to gauge the extent of it, or how much the girls' long-term ability to function would be impaired.

Before the operation doctors said they had very distinct personalities.

Ganga, who has a cleft palate, was much feistier and always hungry, while Jamuna was more shy.

The girls' parents and grandfather, who had broken their vigil at the hospital only to pray at a local Hindu temple and to take an occasional shower, declined to speak publicly yesterday.

But one of their uncles, Abhaya Shrestha, said from Khalanga that the whole family was delighted.

"We had only 50% hope that they would survive," Mr Shresta said. "Now this is a miracle and we just can't describe how happy we all are to hear the news."

Computer imaging made it all possible

The operation to disentangle two babies' brains was only made possible by advanced computer technology devised in Singapore, writes Sarah Boseley, health editor, but it had never been used in the country before.

Ben Carson, the American paediatric neurosurgeon who in 1987 was the first to separate a pair of craniopagus twins without causing brain damage, was the pioneer.

Two years ago he used the imaging program to rehearse the operation on the Banda twins from Zambia, which he and his team carried out in South Africa.

Dr Carson was an adviser to the Singapore surgeons in the lengthy preparation before the separation of Ganga and Jamuna.

The imaging software combines a series of scans of the babies' brains to build a 3-D virtual model. The Singapore surgeons spent six months studying the brains and rehearsing. Wearing 3-D glasses, they manipulated the image by moving their hands, without buttons, keyboard or mouse.

"We made three scans of those poor babies, and then we let the surgeons see it and plan," researcher Luis Serra said."Ben Carson looked at the data, familiarised himself, then he and [neurosurgeon] Keith Goh talked about it."

But computers could not have fully prepared the surgeons for the complexity of their task.

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