Thu, Jul 10, 2003 page5

• Doctors tell of their surgery dilemmas

  IRANIAN TWINS The surgeons trying to separate Laleh and Ladan Bijani, who were joined at the head, came across a number of surprises during the failed operation

  • AP
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  Fifty grueling hours into an unprecedented operation to separate adult twins conjoined at the head, Dr. Keith Goh's heart sank.

  He was working furiously Tuesday to save Laleh Bijani, who began bleeding profusely the moment surgeons made the final cut to separate her from her sister, Ladan.

  Gone was the sound of classical music that played the day before in the small, gleaming operating room crowded with doctors and assistants. The room now was mostly silent except for the surgeons' instructions and the beeps and pulses of the monitors.

  

  A friend of conjoined Iranian twins Laleh and Ladan Bijani, who died during separation surgery, mourns their death during a prayer ceremony in Singapore yesterday.

  PHOTO: REUTERS

  Then Goh glanced over at Ladan. She was losing blood even faster.

  The 29-year-old Iranian twins died shortly later. Both were still under anesthesia.

  "I was very saddened," said Goh, the lead surgeon. "I saw them struggling -- of course at the same time we were struggling too."

  "At least we helped them achieve their dream of being separated," he said.

  In their homeland, Iranians cried out in shock or wept as state television announced the deaths of the twins from a poor family who touched the world with their determination to lead separate lives -- and to see each other face-to-face, rather than in a mirror.

  "Is my beloved Ladan really not with us anymore?" Zari, an elder sister, said after the first death was reported in Iran. Seconds later, she fainted.

  In Singapore, dozens of people, mostly Iranian expatriates, gathered yesterday for prayers at a Muslim school. A bouquet of white and yellow carnations was placed near the entrance. Ladan and Laleh are the names of delicate flowers in the Farsi language.

  "We are all very sad," said 14-year-old Elham Komjka. "I think they were happy they went together."

  Their bodies were due to be flown to Tehran early this morning on a commercial fight, said Hasan al-Attas, a member of Singapore's Iranian community.

  The twins were aware of the operation's high risks but had pressed for surgery anyway.

  Ladan, the more talkative of the two, had studied law and wanted to become a lawyer. Laleh, also a law school graduate, had hoped to become a journalist.

  The operation -- the first attempt to separate a pair of adult twins born joined at the head -- was fraught with difficulties. Previous operations have been on infants, whose brains can recover more easily.

  Surgeons repeatedly encountered surprises that preoperative tests couldn't detect. The skulls were harder to cut than expected, the twins' distinct brains had fused and their blood pressures were unstable.

  It was the unpredictable changes in how their blood flowed, and surgeons' inability to cope with those changes, that killed the sisters, Goh said.

  Over three days, the team of 28 doctors and about 100 medical assistants worked in the tight space surrounding the twins, who were braced in a sitting position.

  Surrounded by a dozen nurses and technicians, surgeons stood Tuesday on either side of the sisters, cradling their heads to support them as the final cut was made.

  The blood started flowing uncontrollably the instant the surgeon cut through the point where the bottom of the brain touched the bone.

  The twins were delicately placed on their sides on opposing operating tables as surgeons administered blood transfusions and battled to stabilize them.

  Rerouting a finger-thick vein shared by both women's brains was considered the biggest obstacle in the surgery. German doctors told the twins in 1996 that the vein made surgery too dangerous.

  As difficulties mounted the Singapore surgeons had faced the dilemma of leaving the twins joined and hoping they would recover -- or pressing ahead, "which we knew would be very, very risky," said Dr. Loo Choon Yong, chairman of Raffles Hospital, where the surgery was performed.

  The team consulted with friends of the twins who had come from Iran and stayed at the hospital.

  "The team wanted to know once again, `What are the wishes of Ladan and Laleh?'" Loo said. "We were told that Ladan and Laleh's wishes were to be separated under all circumstances."

  The surgeons devised new ways to tackle the vein problem, and kept going.
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