Six-month-old conjoined twin sisters separated in Haiti

Marian Dave-Nouche Bernard and Michelle Dave-Nouche Bernard, born as one on Nov. 24, 2014, were separated after a seven-hour surgery at University Hospital of Mirebalais (HUM), in Mirebalais Haiti, a poor rural community in the country's Central Plateau, about 36 miles northeast of the capital city of Port-au-Prince.

"The girls are doing fantastic," said surgical team leader Henri Ford, MD, MHA, the Haitian-born surgeon in chief at Children's Hospital Los Angeles and vice dean for Medical Education, professor and vice chair for Clinical affairs, Department of Surgery, Keck School of Medicine of USC. "It was an extremely exhilarating day; not only did our preparations pay off and the surgery succeed in spectacular fashion, but this was also a time to put politics aside and celebrate our national pride."

Marian and Michelle -- "omphalopagus" twins since they are connected at the abdomen -- are actually triplets (sister Tamar is healthy and normal). The two sisters had faced each other since birth, but recuperated in separate beds in HUM's neonatal intensive care unit. They were ready to be discharged 12 days after surgery. "We anticipate Marian and Michelle will recover fully and go on to lead healthy and happy lives," Ford says.

Conjoined twins occur in roughly 1 in 200,000 births and omphalopagus twins represent about 30 percent of all conjoined twin births. As triplets, these girls are considered even rarer, occurring 1 in an estimated 1 million births. Fused together by the breastbone (or xiphoid bone) in the lower portion of the sternum, Marian and Michelle also had attached livers that would be separated during the procedure.

It took the international surgical team almost seven hours to separate the conjoined twins.

The mother, Manoucheca Ketan, 35, gave birth to all three of her daughters at HUM after carrying them for 36 weeks. The twins shared a crib until 10 a.m. on May 22, when Ketan and her husband, David Bernard, 31, watched as their infant daughters were wheeled into surgery as one. Ten hours later, after the surgery, the parents wept when they next saw the twins -- resting in separate cribs.

By then, the girls were already feeding on formula and breast milk. "It was an extraordinary moment," Ketan said, describing her reaction when she first laid eyes on her separated daughters. "When I first met Dr. Ford, he told me he was confident we could separate my children, but I didn't know how it would turn out when the day started. Now I am feeling a lot of joy and want to recognize and thank the hospital for everything."

The complex surgical procedure got underway within 24 hours of the arrival of the 18-member surgical team of surgeons, anesthesiologists and nurses from Children's Hospital Los Angeles. The Los Angeles team was joined by 12 medical staff from Centres GHESKIO, Hospital Bernard Mevs-Project Medishare and Hopital Universitaire de Mirebalais (HUM), led by Dr. Maclee Jean-Louis, director of Surgery at HUM. The group comprised what Ford described as an international medical "Dream Team."

The family received free treatment from HUM, which is supported by the Haitian Ministry of Health and Partners in Health, an international health organization. Keck Medicine and CHLA covered the travel expenses of the medical team and donated supplies to ensure the success of the operation.

Anticipating a six- to eight-hour procedure, doctors made the first incision along the abdominal wall that connected Marian and Michelle at 1:14 p.m. At 2:50 p.m., the girls were surgically separated to a burst of applause from the team and Marian was moved to an adjacent table. Donning red caps, Marian's team of six doctors and nurses hovered over her to close her incision, while Michelle's team worked in yellow caps -- ironically reflecting the colors of USC. "The mom gave them red and yellow bands months ago to identify them," Ford explains. "They were destined to be separated by Trojan surgeons."

Michelle was wheeled out of the surgery suite at 4:45 p.m., followed by Marian at 4:58 p.m.

"This surgery took less time than previous conjoined twin separations we have performed at CHLA, since there was no pelvic attachment," explains James Stein, lead surgeon during the separation and associate chief of surgery at Children's Hospital. Stein, an associate professor of surgery at Keck School of Medicine, has now separated six pairs of conjoined twins. "There are surgeries that require the expanded expertise of a place like CHLA, but the twins' anatomy and our team's expertise allowed us to undertake the surgery in Haiti, and compile the appropriate resources to do the surgery there safely."

Ford said that by doing the operation in Haiti, the children would benefit emotionally from the proximity of their parents and the surgery could be done more cost-effectively than if it were done in Los Angeles.

After completing the first ever surgery in Haiti to separate conjoined twins, part the international team takes a break in the surgery suite at University Hospital in Mirebalais.

During the seven-hour operation, the girls underwent 11 separate procedures, with only a few minor complications. Early on, surgeons and anesthesiologists encountered a "cross circulation" -- when fluids, blood and medication pass through one twin's liver to the other without benefiting the first.

Michelle's heart rate elevated, but the surgeons -- Stein, Ford and Aaron Jensen, MD, along with CHLA anesthesiologists Duc Nguyen, MD, and Joanna E. Green, MD -- remedied the situation by expeditiously separating the livers and individually hydrating the girls intravenously.

Doctors also removed an ovarian cyst in Michelle and surgically inserted patch material in both girls to reconstruct their abdominal walls after separation. They also formed new belly buttons for the twins, whose midline vertical scars should nearly disappear over time, Stein says.

One moment during the operation seemed to sum up the enormity of the procedure for Ford. "Their lower chests were connected so we had to remove a piece of the sternum, the breastbone, and then you could see their lungs and their hearts beating," he recalled.

Once the girls were moved to intensive care, a team of intensivists led by a graduate of CHLA's pediatric residency program, Peggy Han, MD, now an attending intensivist at Weill-Cornell, and neonatal intensive care unit nurses worked with HUM staff to oversee the twins' recovery. Volunteers from two other U.S. hospitals would fly in later to join the team and help oversee care after the CHLA team departed. Forty-eight hours after surgery, the girls were breathing independently, and after 72 hours they were being fed with a combination of breast milk and formula, Ford says.

Ford started recruiting his team back in September after his first conversation with the twins' doctors at HUM. Ford and team members would make almost monthly trips to Haiti between the November births and the May 22 surgery, checking up on the health of the girls and making sure that the proper human and material resources or equipment were available to safely do the surgery at HUM. By March, the team was set and the girls, strong and healthy, were scheduled for the May procedure.

Hours after the surgery, the Haitian media reported on the milestone operation and, three days postoperatively, the famous twins were paid a visit by Haitian First Lady Sophia Martelly and Minister of Health Florence Guillaume.

In the coming weeks, the girls will recover from their incisions and undergo physical therapy to help strengthen neck muscles weakened due to facing in a single direction for such a long time. "The girls look great; we don't expect any more surgeries," Stein says. "This was all about planning and organization. The amazing part for all of us is conducting seven hours of surgery, and then seeing two kids side by side, when they used to be just one. It's just awe-inspiring."

"I liken the entire international team of surgeons, anesthesiologists, intensivists, respiratory therapists and nurses to a symphony orchestra," says team leader Ford, who no doubt would make Gustavo Dudamel proud.