Mixing hard medical facts with light-hearted humor, surgeons for conjoined twins Erika and Eva Sandoval recounted details Thursday of the risky and intricate surgery that cleaved the girls in two.
Two days after the girls were wheeled into surgery at Lucile Packard Children’s Hospital Stanford, veteran pediatric surgeon Dr. Gary Hartman called the 17-hour separation a success and said the 2-year-olds are “recovering quite well.” He made his first public comments at a packed news conference with four other members of the 50-person medical team.
From the moment Hartman’s team first met the twins’ parents, Aida and Arturo Sandoval, he said the shared goal “has been the same goal we have for all of our children: that we end up with two happy, healthy girls.”
“Anyone who saw the girls before surgery can testify to the happy part,” Hartman said. “We think that this week we made a big step toward the healthy part. The girls are recovering quite well.”
When it was the Sandovals’ turn to speak, the Antelope couple struggled with their emotions.
At first, Aida spoke steadily about seeing Eva and Erika separated after a two-year journey filled with hope, setbacks and prayers. When she switched to Spanish to accommodate the bilingual media, her usually sing-song voice became choppy with emotion.
“It’s been a long journey to get here,” she said, fighting back tears. “The moment we knew we had conjoined twins, we wanted to get them to this place where they can still have an individual life and still be together. That dream came true Tuesday.”
Both parents expressed enormous gratitude to the Stanford medical team, which started working with the couple in 2014, not long after Aida learned – at age 44 – that she was pregnant with conjoined baby girls. The couple also have three adult children, who attended Thursday’s news conference.
On display were 3-D models of the twins’ anatomy, which surgeons used to plan the separation. One was a model of the blood vessels in their pelvic area, while another showed the pelvic bone, spines and legs.
Hartman noted that despite its seriousness, the separation surgery also had its lighter moments.
“My silly part was where we were going to separate the girls: Do we go around the belly button or through the belly button?” Hartman said. “I wanted each of the girls to have half a belly button, so for the rest of their lives, they could each look at it and remember, ‘That’s how I was connected to my sister.’”
The Sandoval girls are the seventh pair of conjoined twins that Hartman has separated. His previous separation surgery, of 2-year-old San Jose girls joined at the chest and abdomen, was performed in 2011.
Hartman said each conjoined twin surgery poses its own challenges. His separation of two Costa Rican girls, for instance, was the “most life-threatening” case because their hearts were joined and had structural disease. The Sandoval twins’ surgery was complicated by the challenge of identifying and separating all their shared organs.
Heading into surgery, “I’m glad to hear that mom and dad were not scared. I was,” he joked.
Erika and Eva were known as thoraco-omphalo-ischiopagus twins, who faced each other and were joined from the lower chest down. They had separate hearts, lungs and stomachs but shared other connections within their digestive system. The girls had one liver and bladder, two healthy kidneys and three legs. Post surgery, each child has one leg and one kidney.
The Sandoval girls were wheeled into surgery preparation around 7 a.m. Tuesday and assigned to a team of anesthesiologists, three for each girl. They attached central and arterial lines to enable blood transfusions and deflated the three saline-filled tissue expanders that had been used to generate new skin in preparation for surgery.
The first incision was made at 11 a.m.; the final incision that officially separated the girls was made at 4:34 p.m. the same day. Immediately afterward, Eva was wheeled into a different room for reconstruction, marking the first time in their young lives that they were apart.
Plastic and reconstructive surgeons stepped in, taking until 12:30 a.m. Wednesday to complete Eva’s wound closure. Erika’s, which was more complicated, took until 1:30 a.m.
Hartman said the people on the reconstruction team “are really the heroes.” Because of the way Erika was reconstructed, she has been removed from her ventilator and is “moving faster than her bigger sister,” he said.
Plastic and reconstructive surgeon Dr. Peter Lorenz, a Kennedy High School graduate from Sacramento, said the team used “skin flaps from the tissue expansion on Eva to close her wound.” For Erika’s reconstruction, bones, skin and muscle from the girls’ shared third leg were needed to close her abdominal wall. Doctors had considered keeping the leg with Erika, but said its “abnormal anatomy” made it unlikely to be useful for walking.
The need for separation surgery became more urgent because Erika was inexplicably growing weaker, Hartman said. “She was basically getting smaller. The more calories we gave her, the bigger Eva got.”
Hartman said nothing was working to correct the situation. “We know that if one twin is critically ill and passes away, the other will die within a few hours. So we certainly didn’t want to get into that situation.”
Hartman said he was concerned whether Erika could tolerate the stress of surgery, but “she’s proved me wrong again.”
The 50-person medical team spent months preparing for the surgery. Even so, there were some surprises.
The girls had only one large intestine, which belonged almost entirely to Eva but had some blood supply from Erika. At the start of surgery, doctors spent about an hour assessing that aspect of their shared anatomy. The team also discovered the girls shared a single pericardial sac around their separate hearts, and that each had her own gallbladder.
After the exploratory phase, the surgery team began its delicate work: dividing the twins’ liver and splitting their gastrointestinal and urinary tracts. The girls’ single bladder was divided into two bladders, and each received a colostomy.
The biggest risk was excessive bleeding from blood vessels and the pelvic area, which is why the Sandovals were told there was a 30 percent chance that one or both girls would not survive surgery. But the pelvic part of the operation proved to be “almost bloodless,” Hartman said.
Looking ahead, “the care for the girls now isn’t any easier than it was before,” Hartman said. “Each girl has a colostomy and a stoma for urine drainage, so that’s new and will require daily care.” There also will be physical rehabilitation and physical therapy.
“They learned to walk together,” Hartman said. “We don’t know what they’ll be able to do separately.”
Going forward, the girls likely will remain at Stanford for another month to be monitored for infection, respiratory problems and other standard complications following major surgery. The doctors said the girls face no life-threatening conditions at the moment.
As for their psychological needs, Hartman said most conjoined twins “do have a separation anxiety, and that is something they will work through. But (Erika and Eva) have a strong, loving family. They’ll have the independence they’ve been looking for, too.”
Their parents, exhausted but relieved, said it’s a chance for their daughters to attain a new type of normalcy.
“They always say when you have twins you’re going to go crazy because one’s over here and the other’s over there,” Aida said. “That’s what I’ve always just hoped for. I want to go chasing after one and then have to go chasing after the other.”