Surgeons successfully remove parasitic rachipagus twin

Baby Dominique carried to surgery

A team of more than 50 clinicians at Advocate Children’s Hospital, Chicago, USA, have successfully separated a 10-month old patient from a parasitic rachipagus twin joined at the back of her neck. A few days following surgery, the hospital reports that the patient—known as Baby Dominique—is thriving.

“The fact that the twins were conjoined at the spine makes Dominique’s condition exceedingly unique and rare,” paediatric neurosurgeon John Ruge said. “It also made the separation surgery complex.”

The parasitic twin’s legs can be seen attached to Dominique’s back pre-procedure

Born with two extra legs and an extra spine, a team of five surgeons were tasked with Dominique’s treatment, including paediatric neurosurgeons Ruge and Robert Givens Kellogg, paediatric plastic/reconstructive surgeons Frank Vicari and Jordan Steinberg, and paediatric and adult orthopaedic surgeon Eric Belin.

Addressing a press conference postoperation, Ruge discussed the potential consequences for Dominique if the surgery was not performed. “The highest risk was paralysis,” he said. “Her anatomy… made her very vulnerable [to] pressure or pulling by her parasitic twin one [her] spinal cord.” As well as paralysis, Dominique was at risk of serious heart and lung problems given her support for the extra limbs, longstanding issues with balance and gait as she grew, as well as a life exposed to intense social stigma, Ruge explained. By treating Dominique at such an early age, the surgery should prevent her from developing these complications.

Imaging showed the extent of deformity at Dominique’s spine

“There also was a chance of impacting shared functions, such as the urinary function,” Vicari said in the hospital release. “Before going into the operating suite, our interdisciplinary team identified where the dangers would be and how we would minimise them. That way we were prepared for anything that could occur.”

Prior to surgery, the team of experts created a 3D model of Baby Dominique’s two spines from imaging studies, which was used to guide both extensive surgical planning, and the procedure itself. “[There are] two spinal cords,” Vicari explained to the press conference. “Attached to them… [is] the abnormal bony attachment from the parasitic twin’s pelvis. That critical area is what we needed to safely approach.”

The 3D model designed by surgeons; red lines denote the two spinal cords

Collaborating with paediatricians, radiologists, nephrologists, anaesthesiologists, intensivists and geneticists, the surgical team spent weeks developing, “a systematic approach to address the various neurosurgical, orthopaedic and plastic surgery issues,” according to the press release.

“We met several times during the work-up. That allowed us to define exactly what problems we anticipated facing. We found out that sitting up in…the area behind the bony attachment was [a] second bladder. So, we had to have nephrology and a number of additional studies to say ‘Is this functional?’, ‘Is this not functional?’ [and] ‘Can we simply remove it?’” Vicari said to the conference. “Once all those questions were answered, we devised a strategy to approach it.”

Kellogg explained the six-hour surgery, in which Vicari and Steinberg performed the initial incision. They were tasked with removal of both the parasitic twin and soft tissue flaps which were used for reconstruction. “Belin helped us to achieve the bony disconnection of the parasitic twin’s pelvis, where it was attached to Dominique’s spine, and then Ruge and I worked to dissect out the different connections between Dominique’s…two spinal cords,” Kellogg said. “In the end we were able to remove [the twin] all in one piece, essentially, which I think is a testament to all of the planning and thought that went into this early on.”

Dominique’s back post-surgery

Dominique was discharged from hospital on 13 March, five days after the complication-free surgery. Doctors have given her an excellent prognosis, expecting her to make a full recovery and, according to Kellogg, live “an essentially normal life from here on.”

Dominique will recover with a local host family, before flying home to her own family in Côte d’Ivoire. Her procedure was organised by Children’s Medical Mission West, a charity (non-governmental organisation) which arranges treatment for children with serious health conditions from around the world in US hospitals, who might otherwise struggle to receive medical care.