Staged separation of craniopagus conjoined twins: a multidisciplinary approach.

During 2003 and 2004, a multidisciplinary team at the Children's Hospital at Montefiore, Bronx, New York, successfully separated twin infants who presented with a total craniopagus vertical O'Connell type 1 conjoining. The twins underwent a series of four staged separation procedures over 10 months. The first three stages involved performing gradual circumferential craniotomies, dividing the dura, ligating large and small bridging veins, separating abutting brains, and inserting skin expanders. The fourth stage involved dividing the remaining dura and veins, transecting shared brain tissue not detected in preoperative imaging, replacing dura in twin B, and replacing skin over native dura in twin A. Planning and carrying out separation of the conjoined twins required organization and cooperation of all the disciplines involved to prepare the children preoperatively, care for them perioperatively and postoperatively, and support the mother during the process.