The chance of its happening is one in 200,000. And yet happen it did, to Sandhya Shrestha and Bhusan KC. The first child after their love marriage was not one child, but two. But two that were completely fused at the head.
Ganga-Jamuna, as they were first called, were born to Sandhya in May 2000, through caesarean section performed by Dr Diveshwari Malla and her team at Prasuti Griha in Thapathali. The birth of the babies made headlines. It was a nice human interest story, but few would have thought that some months later, the twins would also be making medical history.
Soon after the birth, Sandhya and Bhusan went through a difficult period. Sandhya was distressed because she did not even get to see her babies for some time. Meanwhile, the twins remained at the maternity hospital, cared for by paediatrician Dr Dhanraj Aryal who, with other doctors, nurses and auxiliary staff, worked hard to save their lives.
Since it was such an unusual case, people went out of their way to help get the twins to the Singapore General Hospital, the nearest feasible location for separation surgery. Dr Upendra Devkota helped prepare them for the trip with his vast experience and able leadership. On 11 October, 2000, Singapore Airlines transported the five-month-old babies, their family and the medical team for free. There, too, Ganga-Jamuna generated great public interest, and MN Shawami, Nepal's Counsul-General in Singapore mobilised the goodwill of the Nepali and non-Nepali Singaporean public to collect enough donations for the treatment of the children and the stay of their family in Singapore for as long as it took. Those who have followed the saga from the beginning are quick to point to positive attitude and charisma of the babies' grandfather, Arjun Shrestha, in keeping everyone's spirits up.
Once in Singapore, paediatric neurosurgeon Dr Keith Goh of the Singapore General Hospital led the team that was to take care of the twins and explore the possibility of separating them. An amazing number of people were involved in Singapore to give Ganga-Jamuna a shot at becoming Ganga and Jamuna-four neurosurgeons, five plastic surgeons, five anaesthetists, two neurologists, three paediatricians, three radiologists, a computer engineer, a speech therapist, a physiotherapist and veritable armies of nurses and volunteers. 
They all knew what they were up against. Similar surgery had previously been tried at least 13 times in different parts of the world, and the rate of failure was dauntingly high. The first such successful separation was carried out in 1997 by Dr Ben Carson of John Hopkins Hospital, but the present status of those twins is not known. Since Carson was the only person who had experience of such surgery, the team in Singapore began communicating with him.
Ironically, their task was greatly complicated by the fact that both Ganga and Jamuna were in good health, with no neurological or other medical problems. This made the surgery extremely dangerous-chances were high that either or both twins could be disabled in the process, or even die.
The Singapore General Hospital team was taking no chances, and spent six months preparing for the final show in the operation theatre. Starting with extensive diagnostic and exploratory procedures-the twins underwent an MRI (Magnetic Resonance Imaging, which produces detailed high-quality images of anything inside the human body), angiography and a Magnetic Resonance Angiography (normal and three-dimensional X-ray exams of the the arteries and veins to diagnose blockages and other blood vessel problems, and a three-dimensional CT scan, which is not only a real-time view of what is going on inside the body, but also allows observers to view the different functions from any angle, with cut-outs rendered to show relative volume.
All these were to help determine whether at all the twins could be separated with some degree of safety, and what the best way to do that would be. Once analysed, the images from these procedures were fed into a computer, which then aided in constructing four plastic replicas of Ganga-Jamuna, showing in detail the form of the bone, brain and vesicles in place. The models were one hundred percent accurate and the team even referred to them during the surgery.
Once this was done, the experts turned to another wonderful machine called the dextroscope, that a student of Carson's had developed for use in the procedure in South Africa. This machine was like a repository of every possible image of the insides of the babies' bodies-and the team had many, accounting for all three dimensions of every possible inch they might have to work on. The dextroscope did justice to the images-for a screen it has a special kind of glass that shows the image in 3-D. Goh and the other surgeons practised virtual surgery on the dextroscope for the next four months, performing every step from skin incision, removal of bone, brain dissection and ligation of vessels. 
Going into the theatre, they had the entire, complicated procedure memorised. And it was a good thing they did that, for without these practice runs there was no way they would have realised that although there was a plane on which they could dissect the two brains, at one point the two brains were, in fact, fused. And through that point ran the largest vein of the brain, called the superior-sagittal sinus. Like the rivers they were named for, at this point Ganga and Jamuna had a single common vessel. In order to know the exact plane they needed to dissect along to avoid cutting through to the wrong side of the brain, Goh and the other surgeons decided to use a neuro-navigating system, which tells the surgeon exactly where he is manipulating on an MRI screen. This sounds like it simplifies matters, and it does. But not a great deal-it is still like navigating your ship into the eye of a storm.
The team decided there was nothing to do but go for it, and so the other preparations went ahead full steam. The next problem they had to tackle was how to cover the defect that the babies' heads would have after they were separated. The plastic-surgery team led by Dr ST Lee started inflating a silastic balloon under the skin of each child. Ganga and Jamuna lived with this for three uncomfortable months, before the team decided that enough new skin had been generated for the repair work. In addition, the surgeons would need to harvest bone and artificial membrane to cover the brain.
All this went on simultaneously, but little of it was made public. Even so, there was an enormous amount of anticipation. Behind the scenes, everything was falling into place. Goh and Carson did a final rehearsal on the dexstroscope-together, through an Internet teleconference. They manipulated the same model in real time, thousands of miles apart. There were multiple rehearsals of the actual surgical preparation that would have to be done in the operation theatre. It was like rehearsing a particularly tricky Broadway show with a huge cast, they had to plan all the transportation moves, the seating arrangement, the layout of the equipment, and the distribution of the team.
Finally, after six long months of preparation, the surgery began on 6 April, 2001. It was meant to take 30 hours. It lasted much, much longer-94 hours for Jamuna and 102 hours for Ganga. Some 20 surgeons were involved. Goh and Dr Chumpon worked through, with others working on a rotational basis. Dr ST Lee and his team were involved in the opening and final closure of the defect.
As in every surgery, but playing an even more critical part than usual, was the anaesthetist. The babies had to be turned three times through 180 degrees, with one facing up and the other down, to approach the brain from different angles. Already a delicate and dangerous process, each turn was complicated by the fact that the anaesthesia tube in each baby had to be placed with pinpoint accuracy. Since the anaesthetist did not know exactly how blood was flowing through the head, it was something of a gamble to ensure that the drug pumped into one baby did not go into the bloodstream of the other. The twins were anaesthetised six times before surgery for different investigative procedures-the CT MRI, for example, would have been impossible without this because of the motion factor, so the team was not without experience.
For the five days that the surgery took, all the vitals functions of the babies had to be monitored. Towards the end, things started to look bad-Ganga's blood started flowing into Jamuna. As a result, Ganga was becoming anaemic and Jamuna was receiving more and more blood. The anaesthesia team had to draw blood from Jamuna and transfuse it into Ganga. They were ready for any eventuality and had even prepared for a cardiac standstill technique, where the heart stops for a few minutes and there is no flow in the vessels and surgeons can repair the damage without bleeding. Luckily, the team did not have to do this and complicate an already exhausting procedure.
On 10 April, after five days of surgery and the intricate and careful work of more than 40 people, the babies were separated. Ganga-Jamuna were now Ganga and Jamuna, but the surgery was not over yet. The team was immediately divided into two groups to close the defect in each child. They started covering the brain opening with the help of artificial membrane and prosthetic bone. Finally, skin grafts were harvested from the backs and thighs of the babies.
After the surgery, came another massive challenge. The separated twins had to be put on ventilators and their health monitored by the minute-Jamuna for seven days and Ganga for 17. The most serious post-operative danger was the infection the babies had contracted, most likely due to prolonged surgery. Most of the artificial covering had to be removed, which left them with large bony defects. In addition, fluid started collecting in their brains, which needed tubes to be inserted to bypass the fluid into the abdomens. Ganga's cleft lip was repaired a few months later. For their last three months in Singapore, both the babies were doing well, and being looked after by their parents.
Thirteen months after they left their home country, Sandhya, Bhusan, and their twins were back on a Singapore Airlines, but this time they were looking out of windows on opposite sides of the aircraft. They left Nepal on a single passport as Ganga-Jamuna, but they returned, each with their own passport, proudly proclaiming themselves to be Ganga and Jamuna, respectively.
What's next for the twins?
Now the responsibility for the well-being of the children rests with Nepali physicians. At present, paediatrician Dr Parash Mani Bhattarai, physiotherapist Dr Ravi Thapalia, speech therapist Captain Bhawani Pradhan, nurse Bindu Gurung and I, as a neurosurgeon, are responsible for the day-to-day care and treatment of the children. Ganga and Jamuna live at home and we visit them regularly. Our role is also to rehabilitate the whole family so that they can take care of their own children. Institutional responsibility for the children has been taken on by the Kathmandu Model Hospital, and more experts will come on board as and when the situation requires it.
As with the Singaporean team, the medical community here also needs the support of the Nepali people to treat Ganga and Jamuna. The role of the media in this case has been extremely important and creditable, seeing how much it did to generate interest in the case the world over. These children will need this support in the future as well. Right now, neither child has a skull on the top of her head-they are only covered by skin, and this needs to be fixed. We have six months to decide on when, how and where to cover this defect. This will be decided after careful discussion with the Singaporean team.
The night before I flew back to Kathmandu, I had dinner with Keith Goh and his wife. During the conversation Mrs Goh told me how stressed and overworked her husband had been all through the run-up to the surgery and after, and how she used to support him. It was then that I realised how many people are responsible for such a venture, but who are not in the public eye. Given how stressful the whole exercise was, I asked Keith Goh whether, given a chance, he would conduct such an operation again, and whether he would change his technique at all. "Certainly," he shot back promptly, "I would certainly do it much better next time." This, I think is the contribution of Ganga and Jamuna, and all those involved in giving them a brighter future, to medical science. The next time babies like them are born, they will have a better chance to be operated upon, and successfully, with all the experience of the past year and a half to draw upon. I feel that all those who were and still are involved in this case are privileged, and this privilege has been given to us by these children and their parents.
