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18-hour surgery gives conjoined twins lives of their own

Conjoined twins Alex Mendoza (left) and Angel Mendoza at Phoenix Children's Hospital in Phoenix on Jan. 8. The boys were successfully separated during an 18-hour operation  Thursday.

Conjoined twins Alex Mendoza (left) and Angel Mendoza at Phoenix Children's Hospital in Phoenix on Jan. 8. The boys were successfully separated during an 18-hour operation Thursday.

Dr. Stuart Lacey stood over the table and looked down at the boys.

Around him, Operating Room 5 at Phoenix Children’s Hospital was a blur.

Nurses finished draping the patients, anesthesiologists monitored their vital signs, scrub techs checked, and checked again, that all the equipment was ready.

Lacey stood perfectly still.

He was saying goodbye.

In the five months since Alex and Angel Mendoza were born, their bodies fused together below the chest, Lacey had come to love them.

He would slip into their room at the Neonatal Intensive Care Unit at Phoenix Children’s Hospital just to hold them.

He watched when Alex would cry and Angel would reach across, rub his brother’s cheek, and soothe him.

On Thursday morning, Lacey put that all aside.

Alex and Angel were no longer babies he loved. They were patients. He had work to do.

“All right,” he said. “We’re beginning.”

• • •

In May 2008, Ashley Frank went to her doctor’s office in Kingman for an ultrasound to find out the sex of her baby.

The technician doing the scan told Frank she was having twins. A few moments later, the technician got very quiet and went to find a doctor.

Conjoined twins are created when a fertilized egg, on its way to becoming identical twins, fails to split completely.

Typically, identical twins divide within a day of conception. Conjoined twins’ incomplete split usually happens about two weeks later.

Where the split stalls will define the resulting anatomies.

Sometimes the twins are joined at the head. They can be born side by side or facing.

The condition is rare. The University of Maryland Medical Center says fewer than one in 200,000 live births are conjoined twins.

Their prognosis is usually not good. Only 35 percent of those born survive the first day.

• • •

Lacey was there on Aug. 13, 2008, when Alex and Angel were born, strong and healthy.

They had two beating hearts, and four healthy lungs. They had the proper number of kidneys and bladders, arms and legs. They cried loudly.

But the news was not all good.

Alex and Angel were joined from their chests all the way to their bottoms.

Their pelvises were fused, their phalluses were fused, and their livers were fused.

Their kidneys did not function ideally, their lower intestines were entwined and their hips were splayed at bad angles.

That day, Lacey knew that separating the two boys would be complicated. He also knew he could do it.

The surgery began at 7:30 in the morning. The start revealed exactly how slow and painstaking the work would be.

Because the boys were so small, and their bodies so combined, the anesthesiologists could only work on one at a time.

Although in some ways the boys were one body, medically they were two.

For three hours doctors, nurses and scrub techs worked. Pop music played on a radio.

At the end of the surgery, the boys would be on their own tables.

At 10:48 a.m., surgeons Michael Ritchey, Mike Nguyen and Kathy Graziano would do something that had never been done before. They separated the boys’ combined phalluses and started to rebuild one for each boy, leaving each with his own urethra.

For two hours, the loudest sound in the room was the methodical beep of the boys’ heart monitors. Sometimes they beeped in unison. Sometimes they were a little bit off.

They were never far apart.

At 12:15 p.m., Lacey prepared for the next step: cutting apart the skin, fat and muscle that held two bodies together.

“So far, no surprises,” he said. “But of course we are now entering the more variable part of the procedure.”

Everybody in the room knew it.

Eyes darted from Alex and Angel to their monitors. Voices took on a nervous tone.

The boys were re-draped and repositioned. The equipment tables were switched out for new tools.

An electrical surgical unit looks like a soldering pen. It uses finely calibrated charges to cut through skin and tissue. It is better than a scalpel because it cauterizes as it cuts, burning the tissue closed to reduce the bleeding.

Lacey asked that the music be turned off. Then he picked up the electrical surgical unit and began to cut.

He followed Alex and Angel’s twisted contours to cut through skin and muscle. Smoke rose up from the boys, and an acrid smell filled the room.

The two bodies were coming apart.

At 1:09 p.m. came the next step, the livers. This was where Lacey expected he might find a surprise.

He hoped the organs would be mostly distinct, with independent blood supplies coming in and separate tracts for bile coming out.

But that would be the best-case scenario.

He started cutting.

“If at any point you guys have any concerns,” he said to the doctors and nurses around him, “you let us know.”

Lacey held an argon-beam coagulator and made the fine cuts into the livers.

The organs looked healthy. Just some shared tissue. The two began to separate. It was working.

At 1:29 p.m., he looked up from Angel and Alex and said: “The liver is divided.”

“Many of the things we were worried about have been good news,” he said through his mask. “So we are in a very good mood at this point.”

• • •

Even before the boys were born, Lacey knew they would be a lot of work.

He didn’t foresee how he would be so taken by them.

Lacey has four children, all boys. He is also married to an identical twin, and works every day with her sister.

That may explain some of why he fell so hard for the boys.

When Alex began to cry, Angel raised his tiny hand to rub his brother’s tear-stained cheek.

Alex and Angel’s parents have not played a consistent role in their lives.

The couple’s relationship is sometimes troubled; Ashley is busy taking care of her two other children. Much of her life remains in Kingman.

The staff at Phoenix Children’s filled the void. Particularly Lacey.

“These boys are impossible to walk away from,” he would say.

But on the day of the surgery, all that would be gone.

“I will be completely disassociated from my feelings,” he said as he prepared for the surgery. “There is a task at hand.”

• • •

Only when they saw inside the boys did doctors see what was wrong. It was 5:32 p.m.

“We have known there are four kidneys and they drained into bladders,” Lacey said after an hour of looking inside the boys. “What we had no way of knowing, until today, was this.”

One of Alex’s two kidneys drained to his own bladder. The other drained to Angel’s.

Angel’s kidneys were the same way. The systems were shared and confused.

Lacey, Ritchey, Graziano and Nguyen decided what to do.

They would cleave each bladder in half. They would swap the halves so each set of kidneys aligned.

Then they would stitch the halves back together.

It was an improvisation, but it worked.

At 7:21 p.m., it was time to begin the final separation of Alex and Angel. At 7:48 p.m., Dr. Lacey made the final cut.

He looked up and spoke softly.

“That’s it.”

Ten minutes later, Alex and Angel were on separate tables. They were three feet away from each other – the farthest they had ever been apart.

Nurse Kathy  Abbott transfers conjoined twins Alex and Angel Mendoza to the  operating table for anesthesiologist Dr. Casey Lenox (left) for their  separation surgery at Phoenix Children's Hospital Thursday.

Nurse Kathy Abbott transfers conjoined twins Alex and Angel Mendoza to the operating table for anesthesiologist Dr. Casey Lenox (left) for their separation surgery at Phoenix Children's Hospital Thursday.

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