The highly complex medical procedure separated the twins, who hailed from Roraima, in rural northern Brazil, and they were born craniopagus, meaning they were connected to each other with fused skulls and interlocking brains that shared vital veins. Only 1 in 60,000 births result in conjoined twins, and even fewer are conjoined cranially.
Medical experts had said that surgery to separate the brothers was impossible.
But medical staff at Rio’s Instituto Estadual do Cérebro Paulo Niemeyer worked with London-based surgeon Noor ul Owase Jeelani of Great Ormond Street Hospital to use advanced virtual reality technology to rehearse the painstaking procedure.
It involved detailed imaging of the children’s brains, including CT and MRI scans, as well as checks on the rest of their bodies. Healthcare workers, engineers and others collected data to create 3D and virtual reality models of the twins’ brains to allow teams to study their anatomy in greater detail.
The international teams then spent months working to prepare for the proceedings, according to to the UK charity Gemini Untwined, which facilitated the surgery and was established by Jeelani, a renowned British-Kashmir neurosurgeon.
Surgical teams carried out a transcontinental “test surgery” using virtual reality, the first time such technology has been used for this purpose in Brazil, according to the charity. They then performed seven surgeries to completely separate the twins, involving hours of operation and nearly 100 medical staff.
“The split was the most challenging to date,” Gemini Untwined said in a statement Monday. “At nearly four years old, Arthur and Bernardo were also the oldest craniopagus twins with a fused brain to be separated, which brought additional complications.” The optimal age for separation is between 6 and 12 months, he said.
Although the successful surgery took place in June, the medical teams postponed publicity so they could focus on the children’s recovery, Francesca Eaton, a spokeswoman for Great Ormond Street Hospital, told The Washington Post on Wednesday.
Craniopagus Siamese children have typically never sat, crawled or walked before and require intensive rehabilitation after surgery. Arthur and Bernardo will undergo six months of rehabilitation in the hospital and hope to celebrate their fourth birthday together soon, said Gemini Untwined, “finally they will be able to see each other face to face”, along with their parents Adriely and Antonio Lima.
Jeelani, a specialist in separating craniopagus twins, called it a “remarkable achievement.”
“As a parent, it is always such a special privilege to be able to improve the outcome for these children and their families,” he said in a statement. “Not only have we provided a new future for children and their families, but we have equipped the local team with the skills and confidence to successfully undertake such complex work again in the future.”
Jeelani saying British media reported this week that the final surgery took place “seven weeks ago” but that it would take time for a full prognosis on the twins’ future, as older children tend to take longer to heal. He said the coronavirus pandemic had also delayed the surgery.
“In some ways, these operations are considered the most difficult of our time, and doing it in virtual reality was really a man on Mars thing,” he told the Press Association. Jeelani said the risky surgery was complicated by scar tissue from previous operations on the children.
He added that the use of virtual reality techniques meant surgeons could see anatomy and practice procedures without putting “children at risk”, which he said was hugely “reassuring” for medical specialists. “It was wonderful to be able to help them on this journey,” she added.
The Brazilian hospital said it would continue to work with the British charity to treat other similar, rare cases of conjoined twins in South America.
“This is the first surgery of this complexity in Latin America,” said Gabriel Mufarrej, head of pediatric surgery at the Instituto Estadual do Cérebro Paulo Niemeyer.
He said the children had become “part of our family here at the hospital” after more than two years of medical care. “We are delighted that the surgery went so well and that the children and their families had a life-changing result.”