by Wynn St. Clair • Correspondent When a very pregnant Ginady Sabuco learned she was carrying conjoined twins in the summer of 2009, she cried and wondered why her family deserved such a fate. Then she began making plans. Determined to give her daughters the best chance at leading healthy, happy lives, she and her husband, Fidel, sought out medical experts and scoured the Internet. At every turn, they came across the same name: Gary E. Hartman, M.D., FAAP. Dr. Hartman, a world-renowned pediatric surgeon, had successfully separated five other sets of conjoined twins. Ginady was convinced he was the answer to her prayers. The Sabuco family contacted Dr. Hartman to discuss the twins’ case. Born in August 2009, Angelica and Angelina were connected at the chest and abdomen, a condition called tho- raco-omphalopagus. In addition to psychoso- cial difficulties, remaining conjoined carried health risks such as muscular and skeletal deformities that would worsen with time. Dr. Hartman, a clinical professor of pedi- atric surgery at Stanford School of Medicine, suggested the family consult with the uni- versity hospital in Manila, which also has experience with conjoined cases, because it was closer to their home in the Philippines. The family, however, was determined to ensure normal lives for the girls. When they were about a year old, Ginady moved to San Jose, Calif., where Fidel was working and the girls’ grandparents lived. Preparing for surgery In December 2010, they went back to Dr. Hartman, who started developing a plan for the girls’ separation at Stanford’s Lucile Packard Children’s Hospital in Palo Alto. He selected the hospital’s best doctors to assist him and spent months planning the surgery. “The coordination of the people is actually less challenging than what you’d think because everyone is geared up for it,” said Dr. Hartman, a member of the AAP Sections on Critical Care and Surgery. “We had plan- ning meetings for months before- hand, probably more than we needed. We went through every- thing. We had step-by-step plans for each procedure.” After the initial assessment, the team had to figure out the progno- sis and risks. Members consulted with other specialists and met with social workers and health care providers to make sure the twins would have a support system in place after the separation. “It’s very clear that Dr. Hartman is interested in a team approach,” said Frandics Chan, M.D., Ph.D., the lead pediatric radiologist on the case. “I’ve known him for many, many years, and I really respect how he reaches out for recommenda- tions. He asks for advice in a timely fashion, and he makes the final decision. I would never question his final recommendation.” The team’s strategy worked, in part, because of Dr. Hartman’s strong understanding of best management practices. While working at Children’s National Medical Center in Washington D.C., he earned an M.B.A. from George Washington University. To prepare for surgery, Dr. Chan and the radiology team performed extensive imaging. Scans showed the girls had separate hearts. Their livers were tightly fused, and their intes- tines touched, but their digestive systems functioned separately. Though their sternums were joined, their ribs were separate. In July 2011, the team performed surgery on the 2-year-old twins to insert tissue expanders in four places (two per child) under the skin. The expanders were inflated weekly with liquid to encourage the growth of extra skin, which was used to repair their separa- tion. During the procedures, anesthesiologists tightly monitored the twins’ responses to sedation and anesthesia. The final surgery plan involved about 20 physicians and 15 to 20 operating room staff. The team decided where each piece of equip- ©Copyright 2012 AAP News Volume 33 • Number 3 March 2012 www.aapnews.org ‘Bit of serendipity’ Pediatric surgeon makes career of separating conjoined twins Pediatric surgeon Gary E. Hartman, M.D., FAAP, (above) led the 10-hour procedure to separate Angelica and Angelina Sabuco, who were conjoined at the chest and abdomen. Previously, Dr. Hartman had successfully sep- arated five other sets of conjoined twins.
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by Wynn St. Clair • Correspondent
When a very pregnant Ginady Sabucolearned she was carrying conjoined twins inthe summer of 2009, she cried and wonderedwhy her family deserved such a fate. Then shebegan making plans.
Determined to give her daughters the bestchance at leading healthy, happy lives, she andher husband, Fidel, sought out medical expertsand scoured the Internet. At every turn, theycame across the same name: Gary E. Hartman,M.D., FAAP.
Dr. Hartman, a world-renowned pediatricsurgeon, had successfully separated five othersets of conjoined twins. Ginady was convincedhe was the answer to her prayers.
The Sabuco family contacted Dr. Hartmanto discuss the twins’ case. Born in August 2009,Angelica and Angelina were connected at thechest and abdomen, a condition called tho-raco-omphalopagus. In addition to psychoso-cial difficulties, remaining conjoined carriedhealth risks such as muscular and skeletaldeformities that would worsen with time.
Dr. Hartman, a clinical professor of pedi-atric surgery at Stanford School of Medicine,suggested the family consult with the uni-versity hospital in Manila, which also hasexperience with conjoined cases, because itwas closer to their home in the Philippines.The family, however, was determined toensure normal lives for the girls. When theywere about a year old, Ginady moved to SanJose, Calif., where Fidel was working and thegirls’ grandparents lived.
Preparing for surgeryIn December 2010, they went back to Dr.
Hartman, who started developing a plan forthe girls’ separation at Stanford’s LucilePackard Children’s Hospital in Palo Alto. Heselected the hospital’s best doctors to assisthim and spent months planning the surgery.
“The coordination of the people is actuallyless challenging than what you’d thinkbecause everyone is geared up for it,” saidDr. Hartman, a member of the AAP Sectionson Critical Care and Surgery. “We had plan-
ning meetings for months before-hand, probably more than weneeded. We went through every-thing. We had step-by-step plansfor each procedure.”
After the initial assessment, theteam had to figure out the progno-sis and risks. Members consultedwith other specialists and met withsocial workers and health careproviders to make sure the twinswould have a support system inplace after the separation.
“It’s very clear that Dr. Hartmanis interested in a team approach,”said Frandics Chan, M.D., Ph.D.,the lead pediatric radiologist on thecase. “I’ve known him for many,many years, and I really respect howhe reaches out for recommenda-tions. He asks for advice in a timelyfashion, and he makes the finaldecision. I would never questionhis final recommendation.”
The team’s strategy worked, inpart, because of Dr. Hartman’s
strong understanding of best managementpractices. While working at Children’sNational Medical Center in WashingtonD.C., he earned an M.B.A. from GeorgeWashington University.
To prepare for surgery, Dr. Chan and theradiology team performed extensive imaging.Scans showed the girls had separate hearts.Their livers were tightly fused, and their intes-tines touched, but their digestive systemsfunctioned separately. Though their sternumswere joined, their ribs were separate.
In July 2011, the team performed surgeryon the 2-year-old twins to insert tissueexpanders in four places (two per child) underthe skin. The expanders were inflated weeklywith liquid to encourage the growth of extraskin, which was used to repair their separa-tion. During the procedures, anesthesiologiststightly monitored the twins’ responses tosedation and anesthesia.
The final surgery plan involved about 20physicians and 15 to 20 operating room staff.The team decided where each piece of equip-
©Copyright 2012 AAP News
Volume 33 • Number 3March 2012www.aapnews.org
‘Bit of serendipity’Pediatric surgeon makes career of separating conjoined twins
Pediatric surgeon Gary E. Hartman, M.D.,FAAP, (above) led the 10-hour procedure toseparate Angelica and Angelina Sabuco, whowere conjoined at the chest and abdomen.Previously, Dr. Hartman had successfully sep-arated five other sets of conjoined twins.
ment would be placed and implemented a color-coded plan to keepstraight which personnel and tools were assigned to each twin.
Go timeAt 6:30 a.m. on Nov. 1, 2011, the twins were wheeled into the
operating room. Dr. Hartman began the 10-hour procedure knowinghe had given Angelica and Angelina the most talented and best-pre-pared team possible.
“A situation like this brings the whole organization together,” hesaid. “Everyone comes together and puts aside their egos. It’s rein-vigorating to take a case like this.”
A graduate of the University of Wisconsin School of Medicineand Public Health, Dr. Hartman worked on his first set of conjoinedtwins in the 1980s. He had done four other separation surgeries,including a 2007 case involving sisters from Costa Rica.
There are only about six separation surgeries performed each year,statistics show.
“There’s a little bit of serendipity because most of us don’t do thisduring our careers,” he said.
Dr. Hartman made the first incisions in the Sabuco sisters’ skinand muscle. Peter Lorenz, M.D., a pediatric plastic and reconstructivesurgeon, cut through their rib bones. Dr. Hartman separated thegirls’ diaphragms and livers, which were firmly adhered along theirlongest sides. Dividing the girls’ fused liver, the riskiest part of thesurgery, went slowly but smoothly.
He then separated the girls’ bowels, and, about six hours into thesurgery, he cut the last bit of skin that joined the sisters. One sisterwas moved with her team to an adjacent operating room, and recon-structive surgeons began their work.
The operation was completed around 4:30 p.m., according to thehospital.
Angelina was eased off the sedation first and taken off a ventilatorafter 48 hours. Angelica was breathing on her own after 72 hours.The twins went home about two weeks later.
“We were all extremely gratified it turned out well, but it wasn’tjust luck,” Dr. Chan said. “Ultimately it’s a testament to the leadershipof Dr. Hartman. He trusts each and every one of us. We each under-stood our responsibilities, and we understood what would be expectedof us.”
‘Dream come true’In the months since the surgery, the girls have undergone physical
and occupational therapy. They have learned to stand on their ownwithout having the other sister as a counterbalance, and they havelearned to walk forward instead of sideways, according to the hospital.
Like the twins Dr. Hartman separated in 2007, the Sabuco sistershad distinct emotional reactions to the surgery. The more passivetwin was happier after the surgery, as if enjoying her newfound inde-pendence. The more dominant sister was angry and seemed to beexperiencing a sense of loss, he said.
There will be difficulties ahead, but nothing their mother findstoo daunting.
“This is a dream come true,” Ginady said in statement releasedby the hospital after the procedure. “Words cannot express how thefamily feels for the successful separation of our twins.”
Dr. Lorenz said Ginady’s deep gratitude is something he will neverforget.
“She was so happy afterwards,” he recalled. “We get that a lot, butthis was different. The defect was huge, it was basically an oval windowfrom the neck to the belly button.”
For Dr. Hartman, the surgery’s success was born of experience anda prepared team. It also reflects the meaning of pediatric medicine.
“We’ve had good fortune with our sets we’ve done, and we’velearned a fair bit from what we’ve done. Because of all of our expe-rience, we really do have something to offer,” he said. “All of usinvolved with pediatrics want to feel that we’re helping, that we’redoing something to add to the lives of children.”
©Copyright 2012 AAP News
Photo courtesy of Lucile Packard Children’s Hospital
Dr. Hartman led a team of about 20 physicians and 15 to 20 operatingroom staff. They had planning meetings months before the separationsurgery to ensure that the procedure would run smoothly.
Photo courtesy of Lucile Packard Children’s Hospital
Angelica and Angelina had separate hearts and ribs, and their digestivesystems functioned separately. However, their livers were tightlyfused, their intestines touched and their sternums were joined. Inaddition to psychosocial difficulties, remaining conjoined carriedhealth risks such as muscular and skeletal deformities that wouldworsen with time.
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