Successful Anesthetic Management from Separation Surgery of Pygopagus Conjoined Twin; Lesson-Learning With A Teleanesthesia
Introduction: The management of conjoined twins requires multidisciplinary teamwork. The complex problems in conjoined twin separation surgery are challenging for anesthesiologists without experience in the management of conjoined twins. Objective: To describe anesthetic management and utilization of teleanesthesia in conjoined twin separation surgery. Case Report: Sixty days-old pygopagus type conjoined twins, with a total body weight of 7030 grams. Both babies looked healthy, moved actively, found no respiratory function disorders, were hemodynamically stable and had no congenital abnormalities. The sacral region's computerized tomography scan (CT-scan) reveals conjoined twins with skin unification and subcutaneous in the perianal region and no internal-vertebral-spinal fusion. Two anesthesia teams performed the management of anesthesia. After confirming there was no cross-circulation with the atropine test, we alternately induced anesthesia by inhalation technique while maintaining spontaneous breathing. Anesthesia was maintained with sevoflurane 2.0-3.0 vol%, in a mixture of oxygen and air with a flow of 4 L/min using Jackson Reese. Circulating volume, hemodynamic stability, and normothermia were maintained intraoperatively. The separation surgery lasted 20 minutes, and the total surgical time for each baby was two hours. Awake extubation was performed immediately after the surgery was complete. Both babies underwent postoperative care at the PICU and were discharged on day 11. During the pre-operative for surgery, the local team conducted telemedicine consultations with the pediatric anesthesia team at Dr. Soetomo hospital and performed intra-anesthesia telementoring. Conclusion: Careful preparation and pre-operative evaluation, proper intra-anesthesia maintenance and monitoring, as well as good communication and teamwork, are keys to successful anesthesia management in conjoined twin separation surgery. Consultation and assistance from an experienced team during surgery using teleanesthesia are significantly beneficial to the anesthesiologist without experience in conjoined twin separation surgery.
Utariani A. Anestesi Dan Aspek Lain Pada Pembedahan Kembar Siam. Surabaya: Airlangga University Press; 2020.
Frawley G. Conjoined twins in 2020 – state of the art and future directions. Curr Opin Anaesthesiol. 2020 Jun;33(3):381–7.
Rochadi. Parapagus dicephalus conjoined twins and evaluation of ischiopagus tetrapus conjoined twins in Indonesia: a case report. J thee Med Sci (Berkala Ilmu Kedokteran). 2013 Sep 1;45(03):146–50.
Sara J-P, Kydes A, Pryjdun O, Jacoby M, McBride W, Pandya S, et al. Anesthesia for Pygopagus Conjoined Twins During Single-Twin and Simultaneous Pneumoperitoneum: A Case Report. A&A Pract. 2018 Aug 1;11(3):71–2.
Jain P, Kundal AK, Sharma R, Khilnani P, Kumar P, Kumar P. Surgical separation of pygopagus twins: A case report. J Pediatr Surg Case Reports. 2014 Mar;2(3):119–22.
Deepak C, Vandana S, Pradeep B, Nikhil K. Anesthetic management of separation of conjoint twins: Challenges and limitations. Saudi J Anaesth. 2019;13(2):140–3.
Bansal R, Paliwal N, Karnawat R, Kothari A. Anesthetic management of parasitic conjoined twins’ separation surgery. Saudi J Anaesth. 2018;12(3):485–7.
Sato Y, Iura A, Kawamoto Y, Yamamoto S, Iritakenishi T, Fujino Y. Successful anesthetic management of separation surgery for pygopagus conjoined twins: a case report. JA Clin Reports. 2021 Dec 6;7(1):6–9.
Kaniyil S, Pavithran P, Mubarak K, Mohamed T. Anaesthetic challenges in conjoined twins′ separation surgery. Indian J Anaesth. 2016;60(11):852–5.
Zhong H-J, Hong L, Du Z-Y, Huan H, Yang T-D, Qi Y-Y. Anesthetic management of conjoined twins undergoing one-stage surgical separation: A single center experience. Pakistan J Med Sci. 2013 Mar 11;29(2):509–13.
Stuart GM, Black AE, Howard RF. The anaesthetic management of conjoined twins. Semin Pediatr Surg. 2015 Oct;24(5):224–8.
Richardson E, Aissat D, A.Williams G, Fahy N. Keeping what works: remote consultations during the COVID-19 pandemic. Eurohealth (Lond). 2020;26(2):73–6.
Eusuf D V, England EL, Charlesworth M, Shelton CL, Thornton SJ. Maintaining education and professional development for anaesthesia trainees during the COVID-19 pandemic: the Self-isolAting Virtual Education (SAVEd) project. Br J Anaesth. 2020 Nov;125(5):e432–4.
Bridges KH, McSwain JR, Wilson PR. To Infinity and Beyond. Anesth Analg. 2020 Feb;130(2):276–84.
Wong DT, Kamming D, Salenieks ME, Go K, Kohm C, Chung F. Preadmission Anesthesia Consultation Using Telemedicine Technology: A Pilot Study. Anesthesiology. 2004 Jun 1;100(6):1605–7.
Cone SW, Gehr L, Hummel R, Rafiq A, Doarn CR, Merrell RC. Case report of remote anesthetic monitoring using telemedicine. Anesth Analg. 2004 Feb;98(2):386–8.
Fiadjoe J, Gurnaney H, Muralidhar K, Mohanty S, Kumar J, Viswanath R, et al. Telemedicine Consultation and Monitoring for Pediatric Liver Transplant. Anesth Analg. 2009 Apr;108(4):1212–4.
Chatrath V, Attri J, Chatrath R. Telemedicine and anaesthesia. Indian J Anaesth. 2010;54(3):199–204.
Eddie A. Kepulangan bayi kembar siam dempet setelah operasi pemisahan [Internet]. Kalsel Antaranews. 2020. Available from: https://kalsel.antaranews.com/berita/221108/kepulangan-bayi-kembar-siam-dempet-setelah-operasi-pemisahan.
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