The highly complex medical procedure separated the twins, who hailed from Roraima in rural northern Brazil and were born kraniopag, meaning they were linked with fused skulls and intertwined brains that shared vital veins. Only 1 in 60,000 Births result in conjoined twins, and fewer still are conjoined cranially.
Medical experts had described the operation to separate the brothers as impossible.
But medical staff at Rio’s Instituto Estadual do Cérebro, Paulo Niemeyer, worked with London-based surgeon Noor ul Owase Jeelani of Great Ormond Street Hospital to rehearse the tedious procedure using advanced virtual reality technology.
It included detailed imaging of the boys’ brains, including CT and MRI scans, as well as checks on the rest of their bodies. Health workers, engineers and others collected data to create 3D and virtual reality models of the twins’ brains so teams could study their anatomy more closely.
The international teams then spent months preparing for the procedures corresponding to the British charity Gemini Untwined, who made the operation possible and obtained Founded by Jeelani, a renowned British-Kashmir neurosurgeon.
The surgical teams performed a cross-continental “trial operation” using virtual reality, the first time such technology has been used for this purpose in Brazil, according to the charity. They then performed seven surgeries to completely separate the twins, requiring hours of surgical time and nearly 100 medical staff.
“The breakup has been the most difficult yet,” Gemini Untwined said in a statement Monday. “At almost four years old, Arthur and Bernardo were also the oldest Kraniopag twins with a fused brain that needed to be separated, which created additional complications.” The optimal age for separation is between 6 and 12 months, he said.
Although the successful surgery took place in June, medical teams were reluctant to publicize it so they could focus on the boys’ recovery, Francesca Eaton, a spokeswoman for Great Ormond Street Hospital, told The Washington Post on Wednesday.
Children with craniopagus simbioses have usually never sat, crawled, or walked and require intensive rehabilitation after surgery. Arthur and Bernardo will undergo six months of rehabilitation in the hospital and are excited to soon be celebrating their fourth birthday together, Gemini told Untwined, “finally being able to see each other face to face,” along with their parents Adriely and Antonio Lima.
Jeelani, a specialist in craniopag twin separation, called it a “remarkable achievement.”
“As a parent, it is always a special privilege to be able to improve outcomes for these children and their families,” he said in a statement. “Not only have we offered the boys and their families a new future, we have given the local team the skills and confidence to continue to successfully master such complex work.”
jeelani said British media reported this week that the last operation took place “seven weeks ago” but that it would be some time before a full prognosis could be made about the twins’ future – as older children tend to heal more slowly. He said the coronavirus pandemic also delayed the surgery.
“In a way, these operations are considered the most difficult of our time, and doing them in virtual reality was just really Man on Mars stuff,” he told the Press Association. Jeelani said the risky surgery was complicated by scar tissue from previous surgeries on the boys.
He added that using virtual reality techniques meant surgeons could see anatomy and practice procedures without “putting the children at risk,” which he says is massively “reassuring” for medical specialists. “It was wonderful to be able to help them on this journey,” he added.
The Brazilian hospital said it will continue to work with the British charity to treat other rare, similar cases of conjoined twins in South America.
“This is the first operation of this complexity in Latin America,” said Gabriel Mufarrej, head of pediatric surgery at the Instituto Estadual do Cérebro Paulo Niemeyer.
He said the boys had “become part of our family here at the hospital” after more than two years of medical care. “We are delighted that the surgery went so well and that the boys and their families had such a life-changing outcome.”