MINISTER OF HEALTH MALAYSIA
27th July 2012, Friday
CONJOINT TWINS, MUAIMAN AZLI AND MUAIMIN AZLI
Muaiman bin Azli and Muaimin bin Azli were born as male conjoint twins on 14th April 2011 in Hospital Sultanah Aminah (HAS), Johor Bharu.
Following delivery, it was noted that the twins were joined at the pelvis with three legs between them, one of which was abnormal. They did not have any anal opening and shared a single male genitalia.
After being promptly seen by Ms. Muthu, the Paediatric Surgeon in HSA, JB, they were sent to Hospital Kuala Lumpur for further management.
The initial surgical assessment was conducted on 15th April 2011, whereby a single colostomy was performed for faecal diversion for both twins. The surgery was complicated and necessitated an ileostomy, which was later closed in May 2012.
To determine whether separation was feasible without compromising the lives of both twins, assessments and investigations were conducted determine the shared structures, in order to map out the internal anatomy. It was concluded that the twins had:
- Separate structures above the liver
- Separate kidneys (2 per twin)
- Fused pelvic bones
- Shared hindgut from the level of terminal ileum
- 2 shared bladders, with the ureters joining each bladder from each twin
- Absence of anus
- Common, single penis
- One normal lower limb each, with a third deformed limb. This limb seems to “belong” more to Muaiman.
Various discussions were held to determine the level and complexity of the separation. After months of planning, it was decided to perform the separation on 14th July 2011.
A core team of 19 Surgeons and Anaesthetists was assembled to carry out the separation, and comprised:
- 6 Paediatric Surgeons
- 4 Paediatric Orthopaedic Surgeons
- 4 Plastic and Reconstructive Surgeons
- 5 Anaesthetists
The team was further aided by about 20 Medical Officers and 20 nursing personnel. All the members were specially chosen as they had been trained in the care of children requiring complex surgery and post-operative care.
The Matrons and Sisters-in-charge were responsible for ensuring the efficient running of the Operating Theatre during the separation procedure. It would also have been impossible to perform the surgery of this magnitude without the proper support and back-up from the Department of Pathology and National Blood Bank.
Muaiman and Muaimin were brought to the Operating Theatre at 7.40am and induced at about 8.00 am.
The surgery proceeded smoothly without any adverse anaesthetic events. The twins were finally separated at 10.10 pm and Muaimin was carried out to another operation theatre as both needed further reconstructive surgery.
Muaimin’s surgery was completed at 5.15 am and he was wheeled to Paediatric ICU while Muaiman’s surgery was completed at 7.30 am. Thus the whole surgery took about 24 hours.
At the moment, the twins are stable and currently treated at KK7, of the Paediatric Institute. Both have been permitted for full feeding.
Skin grafting is planned for them and scheduled to be held on Friday 27th July 2012.
This separation was the 14th in the HKL series and third of similar conjoining. However, because of the complex urinary system and the shared, single penis, it should be considered our most complex case so far. Furthermore, the technique performed has not been reported elsewhere before and required detailed, meticulous intra-operative planning.
Long Term Outcome
- Both twins will probably have permanent colostomies, as they lack the necessary structures to allow bowel continence.
- Both will probably be continent to urine
- The sexual and reproductive function will be assessed further as they grow.
- Muaimin will require a lower limb prosthesis later. This should be fitted by the time he reaches about 2-3 years of age.
- Muaiman should be able to walk with support as he has 2 lower limbs. He will need further surgery to the abnormal lower limb.
It has been successfully demonstrated that the Paediatric Institute of Hospital Kuala Lumpur does have the capability and expertise to carry out such a complex procedure, using techniques that have not been reported from other centres around the world. The teamwork achieved and multi-disciplinary approach proved crucial in the success of this surgery.