title: Separation of Thoraco-Omphalo-Ischiopagus Conjoined Twins: Surgical Planning, Management, and Outcomes.
abstract: BACKGROUND
  Conjoined twins are a rare medical phenomenon that offers a unique challenge for medical professionals. The complex anatomy of conjoined twins dictates their survival and amenability to separation, making each case different in terms of medical management, surgical planning, and patient outcomes. Thoraco-omphalo-ischiopagus twins, joined from the thorax to the pelvis, are one of the rarest orientations recorded in the medical literature, and successful separation of this subset of conjoined twins has not been documented. This report presents a novel case of thoraco-omphalo-ischiopagus tetrapus twins who were successfully separated at 10 months of age. The preoperative planning, operative details, and postoperative course are discussed as they relate to the reconstructive effort.
  
  
  METHODS
  Three-dimensional medical modeling was pursued early in the planning process and was used to estimate the soft-tissue requirements for reconstruction and to design custom tissue expanders.
  
  
  RESULTS
  The reconstructive effort required postponement until respiratory status was optimized. Even with elaborate preoperative planning, primary closure of the abdomen was limited because of tissue edema and other less predictable patient factors. Delayed closure of the abdominal wall was made possible with negative-pressure wound therapy and secondary flap advancements.
  
  
  CONCLUSIONS
  Preoperative coordination with necessary vendors, a multidisciplinary surgical effort, and optimal timing of the surgical intervention all contribute to the successful separation and long-term survival of thoraco-omphalo-ischiopagus conjoined twins.
  
  
  METHODS
  Therapeutic, V.
authors: Houston, Texas.|From the Division of Plastic Surgery, Texas Children's Hospital; and Michael E. Debakey Department of Surgery, Baylor College of Medicine.
authors: Jeffrey G
authors: JG
authors: Trost
authors: Houston, Texas.|From the Division of Plastic Surgery, Texas Children's Hospital; and Michael E. Debakey Department of Surgery, Baylor College of Medicine.
authors: Lawrence O
authors: LO
authors: Lin
authors: Houston, Texas.|From the Division of Plastic Surgery, Texas Children's Hospital; and Michael E. Debakey Department of Surgery, Baylor College of Medicine.
authors: Sarah Jane
authors: SJ
authors: Clark
authors: Houston, Texas.|From the Division of Plastic Surgery, Texas Children's Hospital; and Michael E. Debakey Department of Surgery, Baylor College of Medicine.
authors: David Y
authors: DY
authors: Khechoyan
authors: Houston, Texas.|From the Division of Plastic Surgery, Texas Children's Hospital; and Michael E. Debakey Department of Surgery, Baylor College of Medicine.
authors: Larry H
authors: LH
authors: Hollier
authors: Houston, Texas.|From the Division of Plastic Surgery, Texas Children's Hospital; and Michael E. Debakey Department of Surgery, Baylor College of Medicine.
authors: Edward P
authors: EP
authors: Buchanan
mesh_terms: D000005:Abdomen / Q000002:abnormalities / Q000601:surgery; D058107:Abdominal Wound Closure Techniques; D004065:Digestive System Abnormalities / Q000601:surgery; D004200:Diseases in Twins / Q000000981:diagnostic imaging / Q000601:surgery*; D004487:Edema / Q000209:etiology / Q000628:therapy; D004867:Equipment Design; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional; D007223:Infant; D054843:Negative-Pressure Wound Therapy; D010496:Pericardium / Q000002:abnormalities / Q000601:surgery; D011183:Postoperative Complications / Q000601:surgery / Q000628:therapy; D011300:Preoperative Care; D019651:Plastic Surgery Procedures / Q000379:methods*; D012120:Respiration Disorders / Q000628:therapy; D013909:Thorax / Q000002:abnormalities; D015626:Tissue Expansion / Q000379:methods; D015625:Tissue Expansion Devices; D014428:Twins, Conjoined / Q000196:embryology / Q000473:pathology / Q000601:surgery*; D016216:Ultrasonography, Prenatal; D014564:Urogenital Abnormalities / Q000601:surgery