For 29 years they have eaten together, studied together, prayed together, even breathed in the same air — forced to live as one by a twist of fate. But at 1 o’clock this morning, Laden and Laleh Bijani were due to be put under anaesthetic at the start of a grim ordeal that could leave either or both of them dead — or liberated to begin a new and independent life.
For four days teams of surgeons, headed by Dr Keith Goh from Singapore, will undertake the most complicated medical procedure ever carried out to separate Siamese twins, despite fears about the dangers of the operation.
Every specialist the twins had seen, in clinics across the world, tried to persuade the 29-year-olds that the risk of one, or both of them, dying or being left brain-damaged was too high to perform the surgery. But the Iranian sisters were determined that they would rather risk death than go through the rest of their lives joined at the head, compelled to exist in a physical union which had become increasingly painful and distressing.
Last night, they had last-minute blood tests and counselling as they prepared to go into theatre. They prayed and told friends that it was now up to God to decide whether they would survive.
Ladan phoned a friend in Tehran to tell her: ‘If God wants us to live the rest of our lives as two separate individuals, we will.’ But she sounded happy rather than fatalistic, and added: ‘We’ve never been as confident as we are now. We are prepared by all means to embrace the risks and walk into the operation room.’
For the doctors, the surgery presents enormous, untested challenges. The women’s skulls are fused just above the ear. Their brains are intact and lie next to one another but there is one large artery that drains blood from both. There are also enmeshed nerve connections that will have to be cut.
Over the next four days, 28 doctors will be involved in the surgery. More than 100 specialist nurses have been drafted in to take turns in the theatre during the 40 hours of surgery.
If they succeed, it will be the first time surgeons have separated adult craniopagus twins — siblings whose brains are joined. Child twins with the condition have been successfully separated.
But the procedure is far harder in adults because they have developed differences in their anatomy and physiology. Babies also tend to make a quicker recovery, partly because their personalites have not yet developed — a psychological consideration that surgeons have had to take into account with the Bijanis.
Yesterday the twins spent the morning with friends from Iran, having their hair cut to make into wigs that they could wear after the surgery.
A spokesman for the Raffles Hospital in Singapore, where the operation is being carried out, described the twins as ‘visibly nervous as the big day approaches’. One of the team, the eminent American neurosurgeon Dr Benjamin Carson, told a news conference last night that he had done his best to reassure them.
A four-hour test was also carried out yesterday, before the surgery began, in order to map the flow of blood to the brains. Led by the French neuro-radiologist Dr Pierre Lasjaunias, the team repeated detailed scans of the brains to look at the vascular anatomy of the head and neck. The team also carried out a test to identify alternative blood channels, to determine if some kind of bypass of the main artery may be necessary. However, yesterday’s tests revealed that the pressure inside the brains was twice the normal rate. Goh told the news conference that this led them to believe the operation was ‘something quite necessary, not cosmetic or frivolous’.
The twins will remain seated for some of the operation, which is standard practice in brain surgery and they may remain conscious for part of it, although they will not feel any pain. Surgeons will have to give one of the sisters an arterial graft to replace the major vein that they share, probably using a blood vessel taken from the leg.
At a news conference, Carson said he believed that each sister had a 50-50 chance of survival.
The team of international experts that has been brought together for the surgery is impressive. Apart from Goh and Carson, there are five neurosurgeons, six plastic surgeons, a vascular surgeon, nine anaesthetists, five radiologists and a psychiatrist. The cost of the entire surgery, as well as the use of computer images and post-operative care, is coming to around $500 000. All the staff have waived their own fees and the expenses are being paid for by a charity set up by the hospital group.
Today’s historic operation is the end of a long road for the Bijanis. For years they have lived in hope of separation but it is only relatively recently that the medical advances have made it appear a possibility.
In 1996, the twins went to Germany to meet specialists but were told that the procedure was far too risky. Then they heard of Goh, after he successfully separated Ganga and Jamuna Shrestha in 2001, during a 97-hour operation.
Goh has been realistic about the Bijani’s chances of survival, and the risks have always been foremost in his mind. He said recently: ‘We’ve spent the past three months trying to dissuade them and we spelled out the downside of the surgery in very explicit terms. But their resolve to go ahead has never wavered.’
It seems to be the twins’ adamant desire to lead their own lives that swayed him in the end. Goh said: ‘Many of the things we take for granted are not what these girls enjoy. Their present life is a very restricted one, confined by physical restrictions, significant deformity and sometimes even ridicule.’
The slim chance that they might be able to lead normal lives, have a career and even have boyfriends is worth everything to them. Laleh, who is much quieter than her sister and wants to be a journalist, put it succinctly at a recent press conference.
‘We want to see each other face to face — to see each other without the mirror.’
They were born in southern Tehran in 1974. They have very different personalities and different friends. Laden is bubbly and talkative and is determined to become a lawyer. That meant that Laleh was forced to study law as well.
The sisters have spent the last week praying, emailing friends and well-wishers and building up their strength at the gym, which will increase their chances of recovering well from surgery. They have also been talking to a counsellor. But there is another area of life which is as yet unmapped: how to cope with freedom after 29 years of mutual dependence. – Guardian Unlimited Â