Chief Medical Director of Federal Medical Centre, Yola in Adamawa State, Prof. Auwal Mohammed Abubakar has narrated how he led a team of 26 medical personnel that successfully carried out the separation of conjoined twins.
The surgeon who have, in the past, operated successfully three cases of conjoined twins and his team separated Fatimah and Maryam on May 14, 2018 at the Federal Medical Centre, Yola.
In an interview with TheNation, Prof. Auwal speaks on the process of the operation; what was involved, how long it took for the preparation of the babies before the surgery, what were the risks and the organs the babies shared that needed to be separated among other things. He also bares his mind one the need for our professionals to believe in themselves and the political will of the government to drive healthcare delivery in the country to world standard.
Conjoined twins before the separationWhat informed your interest in these kinds of cases?
These are very rare problems and any time they happen, they usually make the parents very anxious and agitated because of their very poor background. Some of them have few places where they could look for help and this is also a problem that tests the team work of the healthcare service.
So what do you need to do first?
In this kind of problem, you need to have good coordination in the different members of the team. All over the world, when you have conjoined twins, you will need to meet and assign roles and get the different parts of the teams to work together because if there is any problem of prolong surgery then you tend to have complications and as you know, there are many other successful separations in Nigeria so this is not the first time. One other thing is interest and that interest has to be proper and total interest. You need to have the interest of the patient, his background, his problem because you need to keep them very close so that you monitor their growth and attend to health issue that may arise. With that, you will determine the chances of success which is usually higher. This helps the team to get accustom to them and members of the team will be able to fine tune their plans. These cases are not common so we are very privileged to have them.
How was this particular surgery done despite the fact that JOHESU was on strike as at that time?
The doctors were all working. We had the surgical team and the anesthetic team and those ones are basically doctors so they were around. For the theatre nurses, we actually have contract staffs who are retired nurses with vast experience and many of them were around. Some members of the striking workers even volunteered to join us and the lab was handled by lab scientists who are youth corps members and interns. We also had cleaners that didn’t join so they were part of us. We decided to do it because we didn’t want to lose time. The babies gained weight and their condition was optimal so we wanted to seize that time and thank God we did successfully.
How long did it take for you to prepare them for surgery?
Six weeks. They were here for six weeks. At that time, we did the investigation, the CT scan, ultra sound and other radiological investigations. This was to establish the organs involved and the extent of their conjoining. We were able to successfully bring that out clearly. It also gave us opportunity to meet several times. In fact we also took the babies to the theatre at different times to rehearse positioning, what we need to do, where we need to keep this and that, etc.
How do you get to identify the babies since they are identical?
That is why the rehearsing exercise is critical because you also have to identify the babies. In this case, one was called ‘Baby Red why the other one Baby Blue’. So we had color body for their drugs and everything and even the people handling them. If you look at the video, you see some red and blue. The baby on the left blue and the one on the right red. We also use R for red and B for blue. Because you don’t want to be confused. Drugs were calculated half for each of them because their combined weight was close to 12kg so we give each of them drugs by 6kg. This is very important because these are areas you can make mistakes. You can over dose because it’s combined weight. You have to divide everything carefully including the IV fluids. Even the teams and everybody knew that he or she is for baby blue or red for easy identification so there was no waste of time when we went into the operation. Each team already knew their roles and what to do. For the surgeons, we were together initially but when we finished the operation, we broke into two groups for the closure. I did closure with some of the team, and then Dr. Wabada did for the second baby with his team. After that they were transferred to the intensive care unit (ICU) and the recovery was very fast. We thought they will spend some days but after the second day they were ok and we just transferred them to the ward. The post operation recovery both anesthesia and surgery was very impressive beyond our expectation.
How many hours did the surgery take?
The surgery lasted for only four hours and we were done with everything.
Fatimah and Maryam after the surgery
During investigations and scan, what were the likely risks you noticed regarding the organs that the babies shared?
For these particular babies, it’s merely the liver. Luckily, the bile dots were separate and the main blood vessels were also not conjoined but they were so close so much that if you are not so careful you can just get into those big vessels and it will be catastrophic. Even the liver dissection was done carefully so blood loss was very minimal. The main challenge with this particular type is bleeding but with proper technique, we were able to avoid major bleeding. Though we had volunteers who were ready to give us blood but at the end we didn’t even use more than two units of blood because the blood loss was not so much.
You said the babies shared liver, how were you able to apportion a fair share of the liver to both in the course of the surgery?
There was a thin line of demarcation between the two livers so it’s difficult to say that you are dividing one liver but to the best of our ability, I think we tried to do that. The liver is one organ that regenerates so even if you remove a large chunk of it, it will still regenerate but in this case, we divided it equal and nicely sutured it back because there was challenge of leakage of bile and bleeding. We were tackling those issues in the process and luckily there was no complication from the division of the liver. In many of them, the conjunction of the liver is just small but here it was extensive from above down. Also from the lower part of the chest, some ribs bones called the xiphoid were joined and we divided that as well. The other problem we had was closure but in this case, the abdominal wall for both of them was well developed so we didn’t have problem with closure and there was also no problem with closure of the skin.
How were you sure that the babies were not sharing other organs
We were able to establish that even before the surgery because we gave one of the babies barium contrast and it did not appear in the other one.
What do you mean by barium contrast?
They swallow something that when you take x-ray it shows whitish. When we gave one, it did not show in the other. Both intestines were just in the two places and what we needed to do was to push them back but they were not conjoined. The bile dots were separate, the intestines were separate. Each of them have their own guile bladder.
Is there any medical risk that the babies may face as they grow?
Not at all. As far as we are concern, they just need to continue with their immunizations. Otherwise, there is no risk at all from the surgery. They have normal function of any other organ so the risk is like any other normal baby.
How many people were involved in this surgery?
About 26 people. But I must say that everybody is important. We had cleaners, surgeons, anesthetists, ICU nurses. The number could be more but the main people are 26. Before the surgery we had people from the laboratory and radiology who helped in the investigation.
What do you call this type of conjoined twins?
This is omphalopagus. When you say omphalopagus is above the umbilical cord up to the lower chest. When it extends up the chest then is thoracopagus.
Would you like to disclose the total cost of this operation?
Well I don’t want to go into that. We didn’t even look at that. I felt these people needed help and the hospital took up the responsibility so we didn’t even look at that. Like I told you, they have been here for six weeks and now is more than three weeks post-surgery. It’s good to acknowledge the Federal Neuropsychiatric Hospital Maiduguri and Adamawa German Medical Centre who did the CT scan free. We don’t have a CT scan here at the hospital. You can see they are still here.
Is medical tourism outside the country for this kind of cases necessary?
I think for most of them, people who may want to sponsor may also want to get some benefit from the travel because sometimes you see government or some organizations will want to take some responsibility. But like you know, there are many successful separations in the country. We have capable hands who will handle this. We may not have some of the highly technical gadgets but for the human resources we have them in abundance.
As a surgeon, what first comes to your mind when you take a knife to perform an operation?
The truth is, even in ordinary surgery, there is no surgery that a surgeon will want to do without his adrenaline going up. But with team, you are actually positive and looking forward to when they will be separated. For these babies, for most of the time they have been together but they cannot sleep on their backs until after they were separated and you could see the excitement even within the theatre. Everybody was happy. The joy was spontaneous especially that we broadcasted the operation live within the hospital for other people to watch. The thing with our country is for us to believe in ourselves and for us to equip our health institutions to the standard that we have like in other parts of the world. I believe if we give attention to health, we should be able to upgrade some centres – maybe at regional levels that we can find anywhere in the world. If you go to US and UK you find many top Nigerian professionals there.
What do you lack here at FMC Yola?
What we lack here is the modern imaging equipment machines. CT, MRI and other radiological equipment. You can see that in this case, we depended on other facilities to do CTs. We need to upgrade other areas like; theatre, lab etc. we are doing well but we can do better.