The highly complex medical procedure separated the twins, who hail from Roraima in rural northern Brazil and were born craniopagus, meaning they were linked together with fused skulls and entangled brains that shared vital arteries. Only 1 in 60,000 births result in conjoined twins, and even fewer are cranially connected.
Medical experts had called the operation to separate the brothers impossible.
But medical staff at Rio’s Instituto Estadual do Cérebro Paulo Niemeyer teamed up with London-based surgeon Noor ul Owase Jeelani of Great Ormond Street Hospital to use advanced virtual reality technology to practice the arduous procedure.
It included detailed imaging of the boys’ brains, including CT and MRI scans, as well as checks of the rest of their bodies. Health professionals, engineers and others gathered data to create 3D and virtual reality models of the twins’ brains so the teams could study their anatomy in more detail.
The international teams then spent months preparing the procedures, according to British charity Gemini Untwined, which facilitated the operation and was founded by Jeelani, a renowned British-Kashmiri neurosurgeon.
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The surgical teams performed a cross-continental “trial operation” using virtual reality, the first time such technology had been used for this purpose in Brazil, according to the charity. They then performed seven surgeries to completely separate the twins, involving hours of surgery time and nearly 100 medical staff.
“The divorce was the most challenging yet,” Gemini Untwined said in a statement Monday. “At nearly four years old, Arthur and Bernardo were also the oldest craniopagus twins with a fused brain that had to be separated, which brought additional complications.” The optimal age for divorce is between 6 and 12 months old, it said.
Although the successful surgery took place in June, teams of doctors withheld it from publishing so they could focus on the boys’ recovery, Francesca Eaton, a spokeswoman for Great Ormond Street Hospital, told The Washington Post on Wednesday.
Craniopagus Siamese children have generally never sat, crawled or walked and require intensive rehabilitation after surgery. Arthur and Bernardo will undergo six months of rehabilitation in the hospital and look forward to celebrating their fourth anniversary together soon, said Gemini Untwined, “finally able to see each other face to face”, along with their parents Adriely and Antonio Lima .
Jeelani, a specialist in separating craniopagus twins, called it a “remarkable achievement.”
“As a parent, it is always such a special privilege to be able to improve the outcome for these children and their families,” he said in a statement. “Not only have we provided a new future for the boys and their families, we have also equipped the local team with the capabilities and confidence to successfully perform such complex work again in the future.”
jeelan told British media reported this week that the last surgery was “seven weeks ago” but that it would take time for a full prognosis of the twins’ future – as older children tend to heal more slowly. He said the coronavirus pandemic had also delayed surgery.
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“In some ways, these operations are considered the most difficult of our time, and to do it 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 the anatomy and practice procedures without “putting the kids at risk,” which he said was hugely “comforting” for medical specialists. “It was great to be able to help them on this journey,” he added.
The Brazilian hospital said it would continue to work with the British charity to treat other rare, similar cases of conjoined twins in South America.
“This is the first surgery 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 in 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.”