title: Video. Diagnostic laparoscopy and preoperative planning in ischiopagus tripus conjoined twins: a surgical first, with detailed demonstration of the complex anatomical relationships.
abstract: BACKGROUND
  Diagnosis and management of conjoined twins are constantly evolving. New imaging techniques provide important anatomic details and help in planning the separation procedure. Despite these technological advances, however, the complex arrangement of conjoined organs is somewhat difficult to interpret, leaving unresolved questions at time of surgery. The authors present a video demonstrating laparoscopy as an adjunct in the preoperative planning of separation of ischiopagus tripus conjoined twins as well as illustrating the complex anatomy in a combination of video, drawings, and radiologic imaging. To date, this is the first time that laparoscopy has been used in preoperative assessment of conjoined twins.
  
  
  METHODS
  After elective cesarean delivery, ischiopagus tripus conjoined twins were thoroughly evaluated with conventional imaging, including plain radiographs and computed tomography scan with three-dimensional (3-D) reconstruction images. The anatomy of the gastrointestinal and genitourinary tracts was further defined with barium enema, retrograde pyelography, and cystoscopy. In addition to these tests, diagnostic laparoscopy was performed at time of tissue expander placement. An angled scope, introduced through a 5-mm umbilical port, was used to visualize the intraperitoneal organs as well as all accessible retroperitoneal structures.
  
  
  RESULTS
  Laparoscopy provided useful information regarding the bowel distribution between the twins. In addition, it helped demonstrate the relationship of shared solid organs with other intra-abdominal structures and identify anatomic landmarks used in the subsequent separation of the twins. Finally, laparoscopy helped confirm the presence, number, and morphology of the internal female genitalia.
  
  
  CONCLUSIONS
  Diagnostic laparoscopy is a useful tool in evaluation of ischiopagus tripus conjoined twins. It is an important adjunct to preoperative studies in preparing for an expeditious and safe separation procedure.
authors.affiliation: Department of General and Thoracic Surgery, Children's National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010, USA. fblanco@cnmc.org
authors.forename: Felix C
authors.initials: FC
authors.lastname: Blanco
authors.forename: Katherine P
authors.initials: KP
authors.lastname: Davenport
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Kane
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Losee
authors.forename: Francis X
authors.initials: FX
authors.lastname: Schneck
mesh_terms: D005260:Female; D006801:Humans; D007231:Infant, Newborn; D010535:Laparoscopy / Q000379:methods*; D010347:Patient Care Planning; D011300:Preoperative Care / Q000379:methods*; D014428:Twins, Conjoined / Q000601:surgery*