Anaesthesia for separation of conjoined twins *PAN Lochanie 1 , IACL Perera 1 , PMS Wijayasuriya 2 , HDD Mendis 2 , A Perera 3 , A Abayadeera 4 Registrar in Anaesthesiology 1 ,Consultant Anaesthetist 2 , Consultant Anaesthetist, Cardiothoracic Unit 3 , Lady Ridgeway Children’s Hospital, Colombo, Sri Lanka, Professor in Anaesthesiology 4 , Faculty of Medicine, University of Colombo, Sri Lanka. *Corresponding author: lochanie1981@yahoo.co.uk Thoraco omphalopagus type accounts for about 74% of all conjoined twins. This is the first reported case of successful separation of conjoined twins in Sri Lanka. Need of detailed preoperative assessment, multidisciplinary team approach, pre- operative meetings to collate information, formulating an agenda and developing a plan of action, organised approach to anaesthetising two individuals simultaneously and meticulous postoperative care is emphasised. Responsibility of anaesthesia team in anaesthetizing two individual patients simultaneously is highlighted. Keywords: conjoined twins, thoraco-omphalophagus, general anaesthesia Case history 41 year old multigravida was in labour on admission to local hospital at 37 weeks of POA, with an undiagnosed twin pregnancy. Emergency lower segment caesarean section was performed due to obstructed labour. Thoraco – omphalopagus conjoined twins with APGAR score of 10 at 1 and 5 minutes were delivered. Combined birth weight was 4.5kg. Twins were transferred to the Intensive care unit (ICU) at the Lady Ridgeway Hospital which is the tertiary referral hospital for children. They were cared for 9 months till they were physiologically stable for separation. Several multidisciplinary team meetings were conducted to plan pre-operative optimization and intra- operative management. CT scan revealed ventral fusion from the manubrium sterni to umbilicus with shared pericardium. Cardiac catheterization revealed two separate hearts, small Patent Foramen Ovale (PFO) in twin 1(T1) and mid juxta ductal coarctation and a small PFO in twin 2(T2). There was no cross circulation. They had separate gastro intestinal tracts and hepato- biliary drainage systems. Haematological and biochemical tests were normal At 9 months combined body weight was 13kg. T1 was estimated as 7.5kg and T2 5.5kg. Figure 1: Twins prior to separation Figure 2 : Twins after separation