The parents of conjoined twins Ahmed and Mohamed Ibrahim knew the risks of trying to separate them were extremely high. But the alternative - doing nothing - was unacceptable.
Last night the traumatic gamble appeared to be paying off. While surgeons were still advising caution, they revealed that the most difficult part of an extraordinarily complex and lengthy operation being carried out in Dallas, Texas, to separate the two-year-olds joined at the head appeared to have been successful.
"They are now within striking distance of living independent lives," Dr Jim Thomas, chief of critical care at the Dallas Children's Medical Centre, said as he announced that the boys had been separated. The next procedure, which could take three to five hours, would involve reconstructing their skulls and covering the wounds with skin, he said. He added: "We planned meticulously for this and things are going according to plan."
The operation to separate the two boys is among the most ambitious that has yet been attempted by experts in this most specialised and risky area of surgery. Earlier this year, two 29-year-old Iranian sisters died after a lengthy operation to separate them was attempted in Singapore. Doctors in Texas had warned the odds of both of the boys surviving was no more than 10 per cent.
The Dallas operation, involving up to 60 doctors and which experts had said might last up to 90 hours, is more than just the latest attempt to advance the boundaries of medical science. The effort to separate the twins has brought two worlds together.
Ahmed and Mohamed were born by Caesarean section in June 2001 in al-Homr, an Egyptian village near the city of Qus, 400 miles south of Cairo. The decision to take them to the United States for surgery has captivated - and divided - Egyptian society. The boys' parents, Sabah Abu al-Wafa and her husband, Ibrahim Mohammed Ibrahim, both said that, although the operation carried very high risks, they had no alternative.
Last night, as news of the breakthrough was relayed to the boys' village, family members expressed optimism, even though experts warned that there was still a long way to go before the operation could be declared a complete success.
"If this is true then this is very good news. We are waiting for any good news from over there," Nasser Mohammed Ibrahim, the twins' uncle, told reporters. But he said he would not be satisfied until the boys' father called him from Texas. "I will not rest until I hear my brother's voice," he said.
"I'm sure that everyone loves Ahmed and Mohammed, but I can only trust my brother to tell me the news." The boys were moved to Texas in June 2002 with the help of the World Craniofacial Foundation, a non-profit group that helps children with deformities of the head and face. For the past year the twins have been evaluated by a team of specialists planning the procedure to separate them.
The first step in the operation was to remove skin expanders that were inserted into the boys' heads about five months ago to make extra skin and tissue that will be used to cover their head wounds now the operation to separate them has been completed.
On the right side of each boy's brain, the blood flows in a normal fashion - into the brain and back to his body. On the left side, however, the blood flows from one boy into the other.
Dr Dale Swift, one of five paediatric neurosurgeons involved in the operation, had warned in advance of the dangers at this part of the procedure. "During the operation, the left hemisphere is going to be at risk," he said, explaining that doctors hoped the blood would drain into other deep veins. The worst result, he had warned, was that blood would not drain and the hemisphere could became swollen and damaged.
The twins suffer from an extremely rare condition known as craniopagus twinning. Such joining at the head happens in about 2 per cent of conjoined twins or about one in 10 million live births. Worldwide, surgeons have operated at least five times in the past three years to separate twins joined at the head, including the unsuccessful operation to separate the Iranian women. Of the others, three were successful and one resulted in one twin dying.
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