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Sunday, September 19, 2021

UC Davis Children’s Hospital successfully separates conjoined twins in rare case

Team of over 100 health experts collaborate on first surgery of this kind at UC Davis

After a 24-hour surgery on Oct. 24 and 25 at UC Davis Children’s Hospital, nine-month-olds Abigail Bachinskiy and Micaela Bachinskiy went from being attached at the head to beginning their lives as two individual babies. When Granger Wong, the chief of plastic surgery at UC Davis Health, first heard there were craniopagus twins—conjoined twins fused at the head—born at UC Davis Medical Center, his mind was flooded with tempered excitement and concern for the twins.

“You have to balance the human side of it, because these are little babies and you don’t want little babies to have birth defects,” Wong said. “But then on the other hand, that’s what we’re trained to do and to treat, and this is a very rare and highly complex case, so from that aspect it’s fascinating.”

Although the twins were born on Dec. 30, 2019, Wong, who served as the lead plastic surgeon of this case, and the rest of the operating team needed to wait until the babies were strong enough to tolerate the operation to separate them. Wong explained that their extensive planning and use of up-to-date technology over the course of 10 months allowed the team to familiarize themselves with the anatomy of the twins and practice the surgical plan before the operation day.

“The surgical plan was practiced and choreographed to the point where […] you train for it so much that although you have a lot of concerns, it was a familiar execution,” Wong said. “It wasn’t quite as nerve wracking as one might think.”

Wong described the process as similar to how film directors created storyboards for each scene. UC Davis Health experts drew out their surgery plan on a whiteboard, planning every step down to the minute. The entire team—anesthesiologists, operating room nurses and scrub technicians included—rehearsed the operation three times, helping to mitigate any nervousness for the day of surgery. 

Rajvinder Dhamrait, the medical director of the children’s surgery center and the lead anesthesiologist of the operation, added that the procedures they had to conduct prior to the surgery also helped them become more familiar with the twins’ anatomy. Leading up to the day of surgery, the twins had to be anesthetized several times, an unusual case considering other types of conjoined twins usually only have to be anesthetized once. 

For Abigail and Micaela, multiple MRI scans had to be taken as they grew in order to model the growth of bones and vascular structures. In addition to learning valuable information—such as how each baby responded to drugs—with each scan, the anesthesiology team was able to practice moving the babies while they were situated in certain positions to mitigate any potential dangers during the operation. As the same anesthesiology team treated the twins over the course of 10 months, Dhamrait expressed they feel as though they have grown up with them.

“It’s very personal because we have bonded with the family and we’ve bonded with the girls, so it is pretty special to look after them,” Dhamrait said.  

Dhamrait still remembers his first conjoined twin case 16 years ago as a fellow at Great Ormond Street Hospital in London. He explained that he had specifically chosen this hospital because he had wanted to work somewhere that was capable of hosting such a surgery, but never imagined he would have the opportunity to be involved. In his entire 12 years of training, Dhamrait explained that the surgery was the best opportunity he had come across. Once he came to UC Davis and took over as the medical director of the unit, he specifically asked for an operating room large enough to conduct a conjoined twin separation.

“I never, honestly, never thought it would ever happen,” Dhamrait said. “For it to happen within two years of opening, it was just mind blowing.”

As stated in a paper published in 2019 detailing another craniopagus separation, “the craniopagus variant of conjoined twins is a rare congenital defect that occurs in 0.6 of every 1 million births.” 

Dhamrait explained that what made this case special was the fact that the rarest form of conjoined twins was UC Davis’ first ever separation. In addition, for most craniopagus twins, since their brains are merged together, it is impossible to separate them. These particular twins were joined in a way where their anatomy was conducive to separation. Dhamrait described the successful operation as one of the proudest moments in his 10 years of being the medical director, and attributed their success to the combined effort of surgeons, anesthesiologists and nurses.

“Now I can say, ‘I work in a hospital; I work in a health system that can cover this kind of case,’ which is something that we all have to be proud of,” Dhamrait said.

In a general sense, this success demonstrates the skill of clinicians at UC Davis Children’s Hospital in being able to take on highly complex cases, Dhamrait explained. He described that it is not often they can serve as a model for other centers from which to learn. More than that, this case also shows that those in the local community do not have to travel to other hospitals to receive this treatment, but can rely on UC Davis Health to treat them.

Five or ten years ago, Dhamrait could never have imagined conducting such a surgery at the Children’s Hospital. Yet, the consistent implementation of new facilities and faculty have allowed UC Davis Health to develop into a more accomplished institution. Wong argued the technology available to them today allowed them to understand more about the normalities and abnormalities of nature. 

“Nature is wondrous in all the things that it does right.” Wong said. “But sometimes there’s a glitch in formation and it results in something like these conjoined twins. It’s fortunate that in these times that we have the technology and the expertise to correct some of the glitches in nature to then result in two healthy divided separate baby girls.”
Written by: Michelle Wong —science@theaggie.org

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