And Death Did Them part

By Obong Akpanekong
Monday, July 14, 2003

The world prayed and hoped thet they lived, but Ladan and Laleh Bijani, 29-year-old Siamese twins failed to survive a surgery to separate them

The news of their death was painful and represents a disappointing failure on medical science last week. Despite enormous preparations, commitment and expertise, the world's best brains in neurosurgery and specialists in nursing failed in a historic first attempt to separate adult Siamese twins.

Ladan and Laleh Bijani, the celebrated 29-year-old Iranian born Siamese twins died during a 72-hour operation to separate them at Raffles Hospital in Singapore. Keith Goh, a neurosurgeon and chief surgeon at Raffles, who was assisted by 28 doctors from parts of the world and 100 medical assistants had expected the surgery to last 48 hours. The exercise extended to 72 hours, compounding the fear of the medical team that the Bijani sisters had a 50-50 chance of survival.

Goh is a very courageous doctor. This is not the first time he separated Siamese twins. In 2001, he successfully separated Ganga and Jamuna Shrestha, 11months old Siamese twins, who were brought to his hospital from Nepal. The twins had similar brain structure as Ladan and Laleh. The difference between the Iranian sisters and the Nepalese twins was that the sisters were adult craniopagus. Although he succeeded last year in separating what nature has joined together, he could not for several reasons, repeat the feat last week. After having lived together for 29 years, the brains of Ladan and Laleh though separate, had by so lying side-by-side in the fused skulls, become enmeshed. The shared blood vessels including one large artery and nerve connections had to be cut during the operation.

The biggest challenge of the operation was how to deal with the shared vein that drained blood from the brains. The exercise involved vascular surgery taking a large vein from Ladan's thigh for use as graft for the by-pass to replace the shared vein and re-route blood flow within both brains. The brains were also to be separated before the final surgical process of skin reconstruction.

The operation that took the lives of the sisters was not an easy task. If he had his way, Goh, who was sufficiently backed by Benjamin Carson, director of paediatric neurosurgery at John Hopkins Hospital in Baltimore, United States, would have resisted operating on the twins.

"We spent three months trying to dissuade them and we spelt out the down side of the surgery in very explicit terms. But their resolve to go ahead was never wavered." Goh said of the sisters in June.

Goh said they were moved to carry out the surgery to improve the quality of life of the sisters, which he said was too poor. "We have to be convinced that the present quality of life is so poor, this huge operation, this immense surgery, is justified and should be performed," he said, before the operation begun.

Ladan and Laleh arrived in Singapore, in November for medical and psychological tests after hearing about the successful separation of Ganga and Jamuna. Since then, Goh had seen them daily and insisted their pitiable condition warranted the surgery.

Before arriving Singapore, every specialist they consulted had tried to dissuade them from the operation. The Bijani sisters would not take it. "We don't have any fears and we are putting our faith in God. We want to be positive. We don't like to think about who will die or who will be saved," Ladan and Laleh always responded.

They had enough cause to insist on the surgery. Since they were born in Tehran in 1974, Ladan and Laleh have been together. They slept on the same bed. Walked up and down the staircase together. As adults they suffered from terrible headaches. They could not have intimate relationships and had no hope of marrying. Ladan was said to be bubbling and a talkative, while Laleh was quieter, loved animals and video games, which her sister hated. Ladan wanted to be a lawyer in her home town of Shiraz. She went ahead to study law. Laleh wanted to practice journalism in Tehran. But because of their Siamese status, she was forced to study law. It was these handicaps that forced the Bijani sisters to go all out for the surgery, which German doctors they had gone to see in 1996 refused to do because of the risk involved.

Ladan and Laleh died on June 8, after they had been separated. Laleh died first. Ladan followed suit two hours later. Goh wept. He later explained that apart from the twins losing so much blood as a result of the exercise, blood could not flow into their brains any more. The unfortunate operation was the first such exercise on adult craniopagus since 1952.

Siamese twins are said to occur in every 200,000 live births. But fewer than 200 pairs around the world have been separated. Only a fraction of that number have survived. Anna and Barbara Rosycki from Coventry were the first Siamese twins to be separated in Britain. They lead independent lives now, and Barbara has two children . Earlier this year, Russian-born Asha and Dasha Krivoshlapova, the world's oldest Siamese twins died at 53.