“As a neurosurgeon, I guess the idea puts you in a happy mood,” said Dr. James Goodrich, who led the operation at the Children’s Hospital at Montefiore Medical Center from the Bronx, fresh York.
The surgery on the 13-month old twins, Jadon as well as Anias McDonald, captivated millions around the globe. The procedure, known as craniopagus surgery, can be so rare of which the idea has been conducted only 59 times since 1952.
Both boys have had their breathing tubes removed since the operation, which began the morning of October 13 as well as ended shortly before 1 p.m. October 14. Jadon had suffered partial paralysis of his left side after the surgery, yet he has since regained full functionality. Anias suffered seizures postoperatively, yet they have been kept in check with medication.
“I don’t think of which can be going to be a long-term issue with him,” Goodrich said.
The twins are doing so well, Goodrich says, he hopes of which in coming weeks, “we’ll have them both out of here, off to rehab.”
Added Dr. Oren Tepper, the lead plastic surgeon charged with reconstructing the boys’ skulls, “All in all, I think they’ve handled the surgery incredibly well. … They’ve been entirely stable from the ICU since the operating room, as well as I think of which, in as well as of itself, can be a real success.”
Jadon as well as Anias’ craniopagus surgery was the seventh performed by Goodrich. He as well as Tepper headed up a team of more than 30 people at Montefiore, by anesthesiologists as well as radiologists to nurse practitioners.
Here, for the 1st time, the surgical team describes in their own words the key moments inside the operating room as well as what the idea was like to be a part of such a rare surgery. The quotes have been edited for length as well as clarity.
‘We might’ve lost one or both children’
Goodrich said the “most unexpected surprise” came hours into the surgery, when the team learned of which the boys’ brains were fused more than they realized.
When the boys first arrived at the hospital months ago, the twins shared about 1.5 centimeters in diameter of brain tissue, yet as they grew during their stay, so did the fused tissue. Going into the surgery, doctors believed the twins had about 3.8 centimeters in diameter of fused brain. Once they operated, they found of which the idea was even larger.
“When we actually got in there, their brains were totally fused. the idea was a bigger fusion than we expected from the sense the idea was about 5 centimeters by 7 centimeters. For a child of which size, of which’s a Great chunk of tissue, yet we had to separate them, as well as so to do of which, the idea was a matter of just picking a plane between the two. Intraop, we’d done some beautiful imaging studies of the venous anatomy, yet as has always been the case, when you get down in there, the idea’s even more complex than you realized when you began.
“There was a very large venous complex of which had a huge potential of bleeding, as well as if we lost control of of which, we might’ve lost one or both children. I took in extra time, as well as we added another four hours onto the case to get the exposure, as well as we eventually found a nice window, which just kind of opened up, as well as we followed the idea down.
“The problem with these, these veins are abnormal. They’re very thin, as well as if they rupture, you have no way of controlling them. the idea’s a situation where you have to have total control all the way through, because once you lose the idea, you can’t back off. I was at a point of which I was wondering whether we were going to lose both kids if one of those things broke. Then again, after discussion with various members of the team, we picked an avenue of which was safe — as well as the idea worked.
“I’m just glad the idea wasn’t my first craniopagus surgery. of which might’ve been ominous. This kind of can be today our seventh set of which we’ve separated. Every one of them had their own unique idiosyncracies. These kids, from the sense of the vascularity, I actually thought they were going to be simpler. Simpler can be not the right word, yet less complex than what we’d done before. yet in actual fact, they turned out to be as equally complex as any of them. They were a challenge.”
Pediatric neurosurgery nurse practitioner Kamilah Dowling stayed in touch with the parents throughout the surgery, updating them about every two to three hours. “I might text Nicole or give her a call. First, I might check with Dr. Goodrich to see where are we today, what are we doing, as well as This kind of can be what I am going to tell Nicole. If we were having blood pressure issues, anything of which was going on at of which moment, I might share with Nicole. I feel of which we did our job as nurse practitioners. We supported the family by beginning to end. We’ll continue to support them emotionally, anything they need.”
‘The biggest hurdle’
Tepper, the lead plastic surgeon during the operation, says he feels relieved at This kind of point. He describes the pivotal moment of the surgery, when Goodrich studied the intricately fused brains as well as proceeded ahead.
“I mean, of which was actually the final decision point whether This kind of was possible or not, as well as ultimately, Dr. Goodrich actually was the one to make of which decision. What the idea required was all of us putting our heads together as well as saying, ‘Well, let’s determine if we think This kind of can be possible.’ of which’s where radiology became crucial. Dr. Joaquim Farinhas of radiology was essential looking at the anatomy. I think having the whole team there to say, ‘This kind of can be what needs to be done. This kind of can be how we can approach the idea. This kind of can be what we need to get there.’ the idea was actually important of which we were all there to make of which decision as well as say, ‘Well, This kind of can be the point of essentially no return.’
“We knew their anatomy was complex. All the imaging of which we had done beforehand tells you of which. yet until you’re actually seeing as well as feeling the tissues, you cannot predict those moments. I think getting to of which point as well as realizing of which This kind of was possible was incredible.
“For me, I think the big emotional change was when they were actually separated. I hadn’t seen twins be separated before … as well as for me, of which final moment when we were able to take those two beds as well as separate them apart was like nothing else I’ve ever seen.
“I feel relieved at This kind of point. I think there was a lot of concern, obviously, going in. We knew This kind of was going to be a big undertaking, as well as I think things went as well as we could’ve hoped for at This kind of point. I think of which the biggest hurdle — getting them through This kind of operation safely as well as getting them separated — we’ve gotten past. We’re excited about of which.”
‘Emotional toll on all of us’
Drs. Rani Nasser as well as Ajit Jada, chief residents of neurosurgery, have performed hundreds of surgeries, yet nothing quite compared to the craniopagus surgery to separate Jadon as well as Anias. They said the success came down to “pure teamwork,” with Goodrich leading the “orchestra.” One of the trickiest moments for them came when the boys were rotated, as well as doctors were trying to determine whose vascularity was whose.
Nasser: “Because the brains fuse together, as well as the idea’s actually hard to know when Jadon ends as well as Anias begins. as well as of which’s actually when we were wondering, ‘can be This kind of Jadon? can be This kind of Anias?’ Honestly, to This kind of day, I think without 3-D modeling as well as printing, we might’ve not been able to decipher This kind of as easily. the idea actually was pure teamwork as well as having many sets of eyes on This kind of.
“I’ve seen the boys grow up. I’ve literally seen them grow up. Half their lives, you know. Every time anesthesia raised a concern, we listened. as well as we listened, as well as we were frightened, yet we were focused, as well as we worked together as well as gave each various other strength to make the idea happen.”
Jada: “I think the pivotal moment for me was when we had bleeding by the sides.”
Jada: “Normally, you have time to control the blood. as well as these kids are smaller, as well as the idea was challenging, because we only had 10 seconds, basically, to control the blood before the pressure began going down.”
Nasser: “If at all, right?”
Jada: “The anesthesiologists were saying ‘pressure’s 100 over 60, pressure’s 60 over 50.’ as well as you hear of which going on.”
Nasser: “The number’s going down. …”
Jada: “as well as you’re reacting quickly to stop the bleeding at the same time. in order of which, I felt, was one of the most challenging aspects of the surgery. Or in general, any surgery I’ve ever done.”
Nasser: “Every time we were over one obstacle, there were three others. With of which perseverance, we were able to do the idea, yet the idea definitely took an emotional toll on all of us.”
‘Please, let them see’
Esther Uy, the patient care coordinator for neurosurgery, was in charge of a few nurses as well as four surgical technicians during the operation. She’s been at Montefiore for 34 years, as well as Goodrich credits her with helping his surgeries run smoothly. She describes her emotions when the surgeons reached the most critical juncture.
“All I was thinking was, ‘Please, let them see where the idea can be the right place to separate them.’ of which can be most important. If they made a wrong move on where to cut or where to clip, the idea will be a disastrous result. yet with the help of the products as well as Dr. Joaquim Farinhas showing Dr. Goodrich where to go, they were able to do the idea safely without disaster. of which’s the one of which we were so afraid of. Any time, anything can happen, yet Dr. Goodrich delivered.
“the idea can be very rewarding to see them separate. the idea’s a miracle already, to see them separated.”
‘Under the drapes’
Three anesthesiologists — Drs. Carlene Broderick, Glenn Mann as well as Madelyn Kahana — worked beneath the drapes to keep the boys alive throughout the procedure. The surgery took 27 hours, by the first cut to the last stitch. However, the anesthesiologists’ job began three hours before the first cut as they prepped the children.
Broderick: “I was ecstatic to be involved with the McDonald twins’ surgeries. I was involved with the Aguirre twins in 2004, so we knew we could do the idea. yet This kind of time, we had more confidence. In one word, the entire surgery was miraculous!”
Kahana: “When the children are joined, they share circulation in some capacity, as well as invariably they share some commonality about the drugs of which we give as well as, depending upon where they’re joined, even the way we mechanically ventilate them during anesthesia. We have to know what each various other can be doing at all times, because what I might do for one twin might effect the child of which Dr. Mann was caring for as well as vice versa. So communication was constant.”
Mann: “We were always learning how of which sort of interaction was happening by the 1st time we took care of them, straight through to the last time. the idea was always a little different. …
“Going under the drapes can be sort of what we do. The surgeons are above the drapes, as well as we’re below the drapes, doing sure the patient can be safe. The most important thing can be the maintenance of the airway, as well as we’re constantly checking the airway, the breathing tube of which both the boys have. Throughout the surgery, they were repositioned multiple times, as well as our job was to make sure of which the tube didn’t come out at any point, because of which might just be a devastating thing to happen during the operation. of which’s one thing we’re doing. At the same time, all our IV access as well as drugs of which we’re giving are under the drapes.”
What was the most intense moment during the surgery?
Kahana: “the idea was all Anias. the idea seemed like every time Dr. Goodrich got anywhere near the dura (the outermost membrane of which envelopes the brain), Anias’ blood pressure plummeted. of which happened over a fairly long period of time, because he was dissecting around the dura for hours. There were many times for, actually fortunately, seconds of which Anias’ blood pressure might fall fairly precipitously as well as require multiple vasoactive substances being administered. We had probably about a few hours of intermittent, fairly profound blood pressure modifications to deal with to the point where Dr. Mann was refilling my syringes for me because I was going through them at such a fast pace.
“Sometimes, we just have to say, ‘Stop or get control of the bleeding, hold pressure, give me a minute!’ as well as of which’s what they do.”
Dr. Joaquim Farinhas, a neuroradiologist, was credited by many from the operating room as being the key in helping the surgeons navigate through what he called the “lake of veins.” He deflects such praise, saying he was simply doing his job.
“the idea’s a combination of what I provide them as a map as well as my confidence in their skills. I can tell them, ‘Please, you know what’s on the left side here. This kind of can be delicate; stay away by of which side.’ yet they’re the ones who are doing of which final decision. We’re just trying to keep them on track as well as give them as much confidence as we can.
“I think of which was the most important part. I had to take a role there, as well as of which was my job, to give them the confidence. Dr. Goodrich cut of which connection as well as had to be confident of which the idea was going to be successful. as well as I think of which worked out well.”
When ‘one turned into two’
Dr. Carrie Stern, senior resident of plastic as well as reconstructive surgery, participated throughout the surgery. She made the official final cut to separate the boys. At 2:11 a.m., the twins became officially separated. of which was about 16½ hours into the surgery.
“All the difficult aspects of the surgery had been completed by the entire team — by splitting the bone, the brain, all the difficult blood vessels of which needed to be separated between Anias as well as Jadon — as well as actually the only part of which remained was a smaller skin bridge. Dr. Tepper had asked, ‘Who wants the final cut?’ as well as I just seized the moment: Grabbed the scissors as well as cut.
“the idea felt Great. the idea was exciting. the idea was amazing to see the two beds slowly pull apart. As Dr. Goodrich said, 1 millimeter at a time. the idea was just incredible to see the one turn into two.”
‘Very, very rewarding’
Dr. Michael Ushay, director of the pediatric critical care unit, says the idea was an awesome moment the 1st time the boys were from the same room “in separate beds as well as separated by each various other.”
“This kind of can be pretty extraordinary. I remember when Dr. Goodrich did his last conjoined twins here, as well as of which was before I’d actually come to Montefiore, as well as the idea was very, very exciting. today, to be part of the idea on such a complicated case can be very, very rewarding. I’ve always enjoyed working with kids through complex operations. This kind of has got to be one of the most complex operations, as well as to have them come through the idea. When they’re together as well as you’re meeting them, you wonder, ‘How are they ever going to do This kind of?’ yet they did the idea. of which was great. The kids look actually Great.”
sy88pgw’s Roni Selig contributed to This kind of report.