Successful separation of pygopagus conjoined twins and primary skin closure using V-shaped flaps

A Case of Ischiopagus Dicephalus Conjoined Twins with Tetrabrachius Bipus from Dessie, Ethiopia

The development of conjoined twins always catches the eyes of researchers and clinicians. Beyond the rareness of the cases, how they develop is a debatable issue. This report presented a case of ischiopagus conjoined twins who had two heads (dicephalus), four upper extremities (tetrabrachius), and were joined below the chest with two lower extremities (bipus). The twin’s mother was referred from a primary hospital to Dessie Comprehensive Specialized Hospital for proper management of twin pregnancy, where a cesarean section was performed. The mother and her husband have no family history of birth defects or exposure to known teratogens. On imaging, the twins had separate hearts, lungs, and kidneys but a single liver, spleen, stomach, and intestine. They also shared genitourinary structures: a single penis with sub-coronal hypospadias and one imperforate anus. In addition, their placenta was single with one umbilical vein and two umbilical arteries. The conjoined twins had multiple accompanying cardiovascular anomalies but no external craniofacial, extremity, or brain anomalies. They passed away after 36 hours of follow-up in the neonatal intensive care unit at Dessie Comprehensive Specialized Hospital.

Use of local perforator flaps for closure of a thoraco-omphalopagus conjoined twin defect after separation during the COVID-19 pandemic

Introduction

Conjoined twins are a rare medical phenomenon that poses unique challenges for surgeons. Separation of conjoined twins involves multidisciplinary teamwork, complex medical management and surgical planning, and multi-stage operations and often still has a high mortality and morbidity rate. In the times of the COVID-19 pandemic, separation of conjoined twins pose even greater challenges. Aiming for the best outcome possible, while minimizing the risk of COVID transmission and ensuring the safety of the personnel, is paramount. This case report presents thoraco-omphalopagus twins who were successfully separated at 4 months of age. The preoperative planning, operative details, postoperative follow-ups, and outcomes are discussed.

Methods

The absence of a tissue expander and the inability to acquire it due to travel restrictions from COVID-19 further complicated the management on this patient. A Routine Polymerase Chain Reaction (PCR) swab test was performed on the patients and personnel. Standardized personnel protective equipment (PPE) was worn during ward and surgical care. After separation of the twins by cardiothoracic and pediatric surgeons, one twin underwent immediate skin closure using a double keystone perforator island flap and a lower abdominal perforator flap. Due to extensive defects, closure was delayed for the second twin. After a series of dressing changes, eventually local perforator flaps could be raised to close the defect using staged tension sutures and skin grafts for secondary defects.

Results

Both twins were discharged with no significant morbidity, and no personnel were exposed to COVID-19 infection during the management.

Conclusion

Preoperative coordination and planning, multidisciplinary effort, adherence to screening protocols for COVID, and strict use of standardized PPE all contributed to the successful separation of thoraco-omphalopagus conjoined twins during the COVID-19 pandemic.

Delivery of Retained Second Twin in Case of Omphalopagus Conjoined Twins: Abdominovaginal Approach

Conjoined twin is a rare complication of monozygotic twins resulting from incomplete splitting of an embryo into two separate twins or early secondary fusion of two originally separated embryos. When diagnosed at early gestation, one can get adequate time to counsel the family on whether to continue with the pregnancy and proper intervention can be planned. On the other hand, undiagnosed cases may be first recognized in labor after they have caused labor-related complications. In the present case report, an undiagnosed case of a conjoined twin has presented in labor followed by delivery of one baby with the retention of the second baby. This presented a unique challenge to the managing team and required hysterotomy to effect delivery of the unborn baby. We report this case to highlight the importance of early diagnosis of a conjoined twin. On another hand where this does not happen and a conjoined twin is suspected for the first time after it has caused labor-related complications, the management should be individualized based on the clinical circumstance.