"ouston, we have separation," plastic surgeon Vincent Yeow announced, as he made the final snip at 1.42am, 16 days ago. And with that Ganga and Jamuna Shrestha, who were born sharing a skull, officially became two.
The joke eased the tension in the packed operating theatre in Singapore general hospital - and what tension there had been. That final snip came after more than 84 hours of unprecedented, non-stop surgery, and 11 months to the day of barely imaginable hardship for two Nepalese babies from a remote mountain village who had never been able to roll over, sit up or even see each other.
Any thoughts of breaking out the champagne never even occurred, however, says Dr Ho Lai Yun, the man in charge of their post-operative care: separating the babies was only the beginning. "It's like climbing Mount Everest," he says. "You have reached the peak and that's an achievement in itself but you still have to get home."
It all began last August when Dr Keith Goh, a consultant neurosurgeon at the hospital, was told about Ganga and Jamuna by a former tutor, Dr Upendra Devakota, who was then practising in his home country of Nepal. "He did not know what to do with the babies," Goh says, "but knew that we had previously treated complex cases, so we got talking about it."
After much arm-twisting and cajoling of hospital administrators and colleagues, Goh decided to bring over the twins, along with their mother Sandhya Shrestha, father KC Bushan, and her father Arjun Dev Shrestha for the operation.
"The large Nepali community here was a big factor," he says. "The family were simple people and if you had placed them in a huge, western city in those circumstances, I think they would not have been able to survive."
Sandhya had already endured an awful ordeal. Not only had the kindergarten teacher had a crude caesarean in a rural hospital, but it had been three months before she found out that her twins were conjoined. "She was very ill to begin with," says a hospital source. "And then when she recovered she was at home but the girls were still at the hospital and the family, including her husband, kept deceiving her about the true state of the girls." Eventually they ran out of excuses and took Sandhya to see her daughters. "She burst into tears when she saw them." By that stage Jamuna was much larger than Ganga because the latter has a cleft palate and was having trouble feeding.
When they arrived in Singapore, the family settled in with the Gurkha community while the honoury consul, MN Swami, started raising funds for the medical expenses. "The initial goal was about 100,000 Singapore dollars (£38,000)," he says. "But the response was so overwhelming we eventually stopped at S$650,000." Four thousand Singaporeans gave money.
Meanwhile, Goh and his team were getting to know the girls. "Jamuna is more introvert and behaves like a lady while Ganga is more like a man or a tomboy. She calls people to play with her while the other is more fussy with her food," says Dr Chumpon Chan, the leading vascular neurosurgeon on the team.
"They were obviously aware of each other," Dr Goh says. "We sometimes saw them reaching out towards each other and feeling the other's head. When one was crying the other would be asleep and when the other made noise the one that was asleep would wake up and get angry. They would try and turn over and find that they couldn't, and get so frustrated."
The doctors faced several major problems. The first was that the girls shared a common skull cavity with nothing between the two brains. Then the team discovered the girls shared veins - blood entered their brains via separate arteries but drained by a common vein. But the biggest challenge was finding a way to create enough skin to cover the two brains once they had been separated.
"We knew Jamuna could get complete skin cover," Goh says. "Did that mean we should ensure 100% survival for her and let Ganga take her chances? Or should we treat them as equal and risk losing both?"
After countless discussions, the family made the decision - they wanted both to have an equal chance. Creating extra scalp cover was done by implanting balloon-type expanders into the girls' heads and injecting saline into the sacks. Meanwhile the medical team prepared with the help of nylon composite models and a cutting-edge 3D computer system called a Dextrascope, that superimposed images of the skull, the brains and the blood vessels on top of each other.
Everything appeared to be going well until two days before the planned operation date in January, when Dr Lee Seng Teik, the leading plastic surgeon, discovered Ganga's skin expander had stretched the scalp too far and caused an infection. "There was no way we could go ahead," Teik says. "So we took everything out, allowed the infection to settle and then went in a second time and inserted a second expander."
Finally they were ready. As Goh stood above the anaethsetised twins at about 4pm on Friday April 6, to make the first incision, he realised he was terrified. "We were trying to dismantle something that God had put together. I'm not sure about the ethics of that, but there was soul-searching and mental anguish the weekend before."
Separating them was far from easy. Not only were the two brains lying half on top of each other, but Teik needed the cutting to be done in a certain way to preserve as much skin cover as possible. Initially everything went very smoothly - the surgeons found a clear plane of separation between the brains. "Each brain was protected by a membrane," Goh says. "It was like a wall between two rooms." But the wall ended about a quarter of the way into the brain. The separation then became "like walking along a garden path covered in leaves and branches and having to decide which to keep and which to move to which side," Goh says. "Except that we were moving a millimetre at a time." They helped make decisions by sending electric pulses to different parts of the mass of brain in front of them to see which limb of which girl responded.
Chan, who did most of the vascular work, says he had no idea of time passing. "When you're doing the operation, you're just focusing on what's in front of you," he says. "You hear noises but you don't know what's being said or how long you're taking."
Seventy-two hours into the operation, after turning the twins over a couple of times - a process which took several hours each time - crisis struck. Blood was flowing from Jamuna to Ganga but not back again. Ganga appeared to be in the most critical condition so the doctors drew blood from Jamuna and physically pumped it into Ganga. They also tilted the operating table to let gravity help. After a couple of hours calm was restored and the girls' vital signs returned to normal.
Once separation was completed, Jamuna was covered first because she had the smaller brain and the better natural coverage. Ganga was more problematic because there was eventually a patch of brain the size of a 50p coin that could not be covered. Teik resolved this by using a piece of Integra, an artificial fibrous tissue.
The babies' recovery since then has been far from trouble-free. Ganga initially appeared to be in greater peril - she had a more serious infection and persistent fever. But then, last Saturday, during a regular examination, Dr Teik discovered that a 12cm-square section of the pericranium flap on Jamuna's head had not survived. "The skin graft was lost and we were virtually back to square one," he says. "We had to go in again or we would have lost her." "Going in" entailed a 19-hour operation on Sunday during which muscle was taken from her back along with more skin from her thigh for a fresh graft. It appears this second graft is healing as it should, he says, touching wood.
"They've come a long way but they're not out of danger yet," he says. "The next six to eight weeks are going to be critical." With luck the girls will be heading home in about six months.
By then the neurosurgeons should be able to have an idea of how much motor damage the girls have suffered. Goh says the signs so far are promising - neither girl is paralysed. "We believe we're over the worst, but we have no idea where the end will be or when we will get there."
