Conjoined twins Amari and Javar were separated by surgeons at Children’s Hospital of Philadelphia (CHOP) on August 21, 2024. This video is their family story, including tragedy in their mom's family and her struggle with postpartum depression. http://chop.edu/ruffintwins

The boys shared the lowest part of the sternum (connected like a U of cartilage at the bottom), diaphragm, abdominal wall and liver, a condition known as omphalopagus conjoined twins.

During her first trimester of pregnancy, Philadelphia couple Tim and Shaneka learned Shaneka was carrying twins and that their twins were conjoined. Their medical provider did not know if the twins could be carried to term, so the couple sought a second opinion at CHOP.

Conjoined twins are very rare, occurring roughly once in every 35,00080,000 births. CHOP is one of only a few hospitals in the country with experience separating conjoined twins. Thirtytwo pairs of conjoined twins have been separated at CHOP since 1957, the most of any hospital in North America.

The couple met with a team at the Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment (CFDT) that included maternalfetal medicine specialist, Nahla Khalek, MD, and pediatric general, thoracic and fetal surgeon, Holly Hedrick, MD, who has led many of the separation surgeries at CHOP. A lengthy evaluation, including an ultrasound, MRI and fetal echocardiogram, revealed each of the babies had all their limbs, and separate healthy hearts. They each had equal parts of the large liver, and their equal parts were normal sized, so it could be split between the two. All of this meant they had excellent chances for a healthy life outside the womb, and for viable separation.

Shaneka continued her prenatal care at CHOP, under Dr. Khalek’s care. When she was 30weeks pregnant, her water broke. She got to her care team at CHOP right away, where she was initially told she would remain on the Garbose Family Special Delivery Unit (SDU) until she was at least 34weeks before the team would deliver. But, when one of the babies’ heart rates began dropping, doctors decided Shaneka would deliver the next day.

Led by Dr. Khalek and Dr. Hedrick, the obstetric and neonatology teams delivered twins Amari and Javar on September 29, 2023. They weighed three pounds (about 1.5 lbs. each). The twins were moved to CHOP’s Harriet and Ronald Lassin Newborn/Infant Intensive Care Unit (N/IICU) for care until after their separation.

While they were in the N/IICU, the twins’ care team was focused on making sure they were stabilized and growing. There were MRIs to continue to confirm what was joined and what was separate between them. Cassandra A. Ligh, MD, a pediatric plastic surgeon, placed tissue expanders to maximize the amount of skin available for their separation surgery. Like small, collapsible balloons, the skin expanders gradually expanded through injections, stretching the skin slowly over time so each boy would have enough skin to cover his exposed abdomen after separation.

As Shaneka healed physically at home, she began experiencing symptoms of postpartum depression. She was diagnosed and referred to Joanna C.M. Cole, PhD, PMHC, in Psychosocial support in CHOP’s CFDT and SDU, which addresses our patients’ physical, mental and emotional wellness during their care.

At almost 11 months old, Amari and Javar were ready for their separation day. On August 21, 2024, a team of specialists, including Dr. Hedrick, Dr. Ligh, nurses, anesthesiologists, general surgeons, radiologists and more, was ready for the surgery they had been planning for since before the boys were born. During the 8hour procedure, the surgical team made careful incisions down each boy’s abdomen, sternum and diaphragm to access and separate the liver. During the liver separation, radiologist Edward R. Oliver, MD, PhD, performed realtime imaging of the insides of the boys’ bodies (an intraoperative ultrasound) to define the vascular equator between the two fused liver masses and indicate (delineate) the positions of the connections between each twin’s blood vessels (vascular connections.)

After the twins were parted and moved to separate sterile tables, Dr. Ligh and the plastic surgery team put a layer of absorbable mesh over their stomachs to hold their intestines and internal organs inside. Then they added a permanent mesh over top of that, closed it all with the natural lining of their bodies to heal and created a belly button for each twin.

Amari and Javar are doing well after their big surgery. They moved out of the Pediatric Intensive Care Unit (PICU) in less than one week and are working to meet a few milestones so they can go home to live with their family.