Third Case of Conjoined Twins Separation at Hualien Tzu Chi Hospital
By: Wei-Yun Peng
When they were born, Jerrelyn and Jennelyn were conjoined at their stomach. While other children sit and crawl, they could not even make a turn. From Philippines to Taiwan, from Pangasinan to Hualien, in three months time they become independent from one another, eager to walk their new lives, together and apart. April 2003, we have Lea and Rachel, conjoined at the stomach; June 2010, we have the Rose sisters, conjoined at the hip; and in January 2015, we have Jerrelyn and Jennelyn, conjoined at the stomach.
All three sisters came from the Philippines, baring witness to the love beyond boundaries. We would like to bestow our blessings upon you, may you be free in your form, and remain bonded by love.
Companioned for 15 months, the conjoined twins Jerrelyn and Jennelyn Mendoza De Guzman from the Philippines finally received the separation surgery on March 13, 2015. This is Taiwan’s 10th case of conjoined twin separation, and the 3rd of Hualien Tzu Chi Hospital.
Ludy De Guzman, the mother of the twins, is a devoted Catholic. After a pious prayer, she held her daughters, walked all the way from the ward to the operating room, and handed them over to the medical staff. “I have waited so long for this day,” she said.
The conjoined twins were born in a small village of Bautista, Pangasinan, the Philippines. A primitive house with almost no decor shelters this family of five. The father worked odd jobs, and the mother a domestic worker. After they were married, she gave birth to a girl, followed by the twins. The family lost its stable income when the mother had to stay at home to take care of the children. The Tzu Chi volunteers heard of their predicament and soon visited the family.
The mother, holding her twins tightly in her arms, travelled thousands of miles from the Philippines to Taiwan. To share her burden, Supt. Ruey-Ho Kao(Right), Vice Supt. Peir-Rong Chen(Left) and Pediatrician Yun-Chieh Chang(Middle) took turns to carry the twins and soothe the girls’ agitation.
On Nov. 15, 2014, Supt. RueyHo Kao and the team traveled to the Philippines on a long term medical health collaboration project. When the local Tzu Chi members introduced the twins to the medical team, Jerrelyn and Jennelyn were barely a year old. Supt. Kao brought the medical report back to Hualien and called a interdisciplinary meeting. After careful study of the report, the medical team believed that, aside from the liver, all the internal organs were independent, therefore the chance of a successful separation surgery was high. On Jan 9, 2015, the twins arrived at Hualien Tzu Chi Hospital, in preparation of a life-changing surgery.
Experienced with nursing the Rose Sisters in 2010, Head Nurse YaChun Cheng offered more than just her professionalism. To ensure that Ludy and the twins could feel comfortable during their stay, she assigned a team of nurses to them, so that the family would only see familiar faces. Then she added English to the nurses’ name tags, had everyone studying the basic greetings in English and in the family’s native language, and design a deck of cards written in the family’s native language for Ludy and the twins to communicate their daily needs.
photo1: Dir. Chun-Ta Lee(Right) and Dr. Chien-Hsing Wang(Left) of the plastic surgery team wore the blue and red surgical caps, which represent Jerrelyn and Jennelyn respectively, as they proceeded with the first phase of the surgery - tissue expansion.
photo2: Jerrelyn and Jennelyn, a year and three months old, were conjoined from the xiphoid process to the umbilicus. Aside from the kidney, all the other internal organs were independent. However, the blood vessels of the kidney are densely distributed, a slight mistake during the incision may lead to profuse bleeding.
After a week of examination and rest, the twins were in excellent health and spirit. The medical team then prepared for the first phase of the separation surgery - to implant a tissue expander. “The separation surgery is not as clear cut as it sound. To incise the skin directly would create a huge empty space that could harm the twins, therefore it is vital to grow the skin that would cover the cavity. In this surgery, we will first insert the tissue expander into their stomach, and then pour in a total of 410cc of physiological saline, in an attempt to gradually distant the twins from the stomach; at the same time, we will grow 90cm2 of skin that will envelop the cavity after the separation.” Said Vice Supt. Peir-Rong Chen, the convener of the medical team.
In preparation of the first phase of the surgery, Ming-Che Lee, the director of the department of surgery, assembled the surgical team, the anesthetic team, and the surgical nurses to simulate the surgery. “Because conjoined twins are two attached individuals, the needed apparatuses and its placements, the method and workflow of disinfection and draping are different than operating on a single patient. We also need double the surgical team, the anesthetic team, and the surgical nurses as well. Also, to maximize the surgical efficiency in a limited space, these are all of our focuses during the surgical simulation.” Director Lee said.
A week after the tissue expansion, the cosmetic surgery team assessed the adaptation of the twins, and Dir. ChunTa Lee(First left) decided to inject an additional 25cc of saline solution.
The separation surgery posed a major challenge to the anesthetic team as well. Considering all the facts, the administration of anesthesia during the separation surgery is minimized to only a few times, Vice Supt. TsungYing Chen pointed out. The anesthetic team, therefore, seized the opportunity to practice the disinfections of the twins, to apply color-labelling to each tube, to monitor the vital signs of each sister, and to accurately administer the appropriate anesthetic dosage.
With all things prepared, on the morning of Jan. 21, the surgical insertion of tissue expander began. Approximately two dozen of medical professionals, from the department of surgery, plastic surgery, anesthesia and the nursing team, awaited for the twins inside the operating room, wearing color labelled surgical caps - blue for Jerrelyn and red for Jennelyn. Vice Supt. Peir-Rong Chen, joined by Dr. Hai-Chyi Peng, who operated on the Rose Sisters, arrived early at the operating room, providing support to the team.
After anaesthetization and disinfection, Chun-Ta Lee, the director of the department of plastic surgery, Dr. Chien-Hsing Wang and Dr. Li-Fu Cheng implanted the tissue expander in the stomach of the twins. “In our first surgery, we will inject 60cc of physiological saline into the tissue expander, keeping it half inflated. After that, we will add more saline solution when needed to further expand the surface area of the skin and soft tissues.” Said Dir. Chun-Ta Lee.
Dr. Yun-Chieh Chang was inspired by rocking horses, and came up with the design of a creative rocking horse trolley that allows the twins to sit together.
A week after the surgery, the plastic surgery team evaluated the twins’ condition, and concluded that they had adapted well to the surgery. Dir. Chun-Ta Lee then decided to inject an additional 25cc saline solution. “The twins’ wound recovered relatively well. From now on, we will inject more saline solution twice a week, for approximately seven to eight weeks.” Explained Dir. Lee.
A Creative Inspiration
The twins, by then a year and two months old, could barely walk because of their shared physical restraint, but even that could not hold them back. As Jerrelyn’s legs grew stronger by the day, she would turn over whenever she found a suitable footing. When she does, though, she ends up on top of her sister, Jennelyn. To avoid the tissue expander from been pressured, Section Chief Ying-Chi Liu of Rehabilitation, Physical Therapist Chia-Chun Hung, Jui-Chu Lin, and Chi-Wei Ting collaborated in a design of torso splints for the twins.
When the rocking horse trolley appeared in the ward, Jerrelyn was so thrilled to take a ride out the ward. Even Jennelyn, who was so attached to her mother, was clapping in joy.
Pediatrician Yun-Chieh Chang had been contemplating on a way to allow the twins to sit together on a chair with handles, while avoiding pressurizing the tissue expander. The inspiration came when he saw a rocking horse. He took a pencil and sketched out his ideal chair that would allow the twins to sit happily together, and with an additional safety device to secure the wheels when needed.
Life of Independence
On March 4, the medical team called a preoperative meeting, and decided to perform a simulation of separation surgery on March 11.
“Once the sisters are separated, they will be placed on two surgical tables, attended by two teams of medical professionals. Factoring time and spatial constraint, the teams have to proceed in sync, even the placement of each medical staff has to be carefully evaluated.” Explained Dir. Hai-Chyi Peng. Blood loss, Dir. Ming-Che Lee mentioned, was another critical factor that they had to keep their eyes on throughout. With the simulation, he said, the team could reevaluate every procedure to minimize blood loss.
photo1: On March 13, 8:47am, Dir. Ming-Che Lee(Second left) made the first incision.
photo2: At 12:17pm, the conjoined twins were finally separated into two independent individuals. Dir. Ming-Che Lee and Dr. HaiChyi Peng closed the wound for Jerrelyn and Jennelyn respectively.
Finally, on March 13, the twins received the separation surgery. The surgery lasted for more than five hours. At 12:17pm, the conjoined twins was successfully separated into two independent individuals; at 02:30pm, the wound closure was completed. To the conjoined twins, this was a historical moment that marked their rebirth; to Hualien Tzu Chi Hospital, it marked the third successful separation of conjoined twins.
When the separation surgery was over, Ludy burst into tears as she saw her baby girls as two individuals.
“They are finally separated!” Ludy cried. When the sisters were born, the neighbors always mocked them for their uniqueness, she said. To avoid those verbal harassment, she and the twins locked themselves away from the world for almost an entire year. The successful operation allowed the twins to be like any other normal child, who can walk into the world without the fear of being ridiculed.
Group photo of the separated twin babies, their mother, the medical team, and Philippine Tzu Chi volunteers at the farewell party in Hualien, Taiwan. April 8, 2015.
The good news soon arrived at the Philippines and attracted the attention of local media. Out of all the people who received the news, the happiest among them must be the father, Jayson de Guzman, and the Panda fire brigade of Dgupan that first discovered the predicament of the twins.
With a month of rest, the twin’s appetite and vitality fully recovered. Their adorable gestures always amused the nurses. “Normally, about ten days of rest after the surgery is sufficient for the patient to recover and be discharged. The twins, though, are from overseas. Considering the difficulty for them to revisit, we kept them for about a month before discharging them. It was to provide a comprehensive care and to confirm their preoperative conditions.” Dir. Ming-Che Lee said.
Jerrelyn and Jennelyn with Tzu Chi volunteer Liqun Zhen in Philippine. Nov. 10, 2015.
On April 8, 2015, Hualien Tzu Chi Hospital held a farewell part for the De Guzman family. Fr. Joyalito Tajonera, representing the Philippine Representative Office in Taiwan, came to give his blessing. “The sisters look very health, and their smiles so bright cheerful. They have been under great care.” Father Tajonera said.
When the family arrived at the airport in the Philippines, where the reporters from DaAi T.V. awaited. The twins’ stories attracted over 29 local media, 64 reporters to cover the story. “Out of all the stories we covered, only few of them are about people helping each other. The topics nowadays are mostly about crimes, poverty and politics. And that makes this particular story extraordinary.” Said Katrina, a local reporter.
As extraordinary as their separation may be, the life stories of Jerrelyn and Jennelyn de Guzman have only begun.