# Anesthetic Management in the Elective Separation of Omphalopagus Conjoined Twins With Shared Hepatic Parenchyma: A Case Report

## TL;DR

This case report details the anesthetic management of separating conjoined twins who share liver tissue, highlighting strategies to manage risks like massive bleeding and hemodynamic instability.

## Contribution

The paper presents a detailed anesthetic approach for elective separation of omphalopagus twins with shared liver tissue, emphasizing multidisciplinary planning and proactive blood management.

## Key findings

- Multidisciplinary planning and simulation-based preparation improved perioperative safety.
- Proactive blood management strategies helped maintain hemodynamic stability during surgery.
- Postoperative intensive care monitoring was crucial for managing complications.

## Abstract

Separation of conjoined twins is a rare and complex surgical endeavor with significant anesthetic implications, particularly in omphalopagus twins, given the risk of massive hemorrhage during hepatic transection and hemodynamic instability from cross-circulation. Blood management strategies include the use of tranexamic acid, viscoelastic monitoring, and preparation for rapid transfusion. We report the anesthetic management of the elective surgical separation of three-year-old female omphalopagus conjoined twins with shared hepatic parenchyma. Extensive multidisciplinary planning, simulation-based preparation, independent anesthesia teams, invasive monitoring, and proactive patient blood management strategies were implemented. Careful preoperative optimization, structured intraoperative coordination, and adherence to anesthetic principles derived from prior case-based evidence were central to maintaining hemodynamic and metabolic stability throughout the perioperative period. This report adds to the limited body of literature on elective omphalopagus separation involving hepatic division.

The key learning points are as follows: Separation of omphalopagus conjoined twins presents significant anesthetic challenges, primarily related to shared hepatic parenchyma and the risk of major hemorrhage. Detailed preoperative imaging, including hepatic angiography, is essential to define vascular anatomy and anticipate transfusion requirements. Assessment of cross-circulation is critical to guide safe anesthetic drug administration and neuromuscular blockade strategies. Multidisciplinary planning with simulation-based rehearsal and strict duplication of anesthesia teams and equipment enhances perioperative safety. Proactive blood management, including viscoelastic-guided transfusion and antifibrinolytic therapy, is central to maintaining hemodynamic stability. Structured postoperative intensive care monitoring is vital for early detection and management of hepatic, renal, and infectious complications.