Anesthetic planning and management for successful separation surgery of pygopagus conjoined twins: a multidisciplinary approach

Conjoined twins are rare and present significant challenges for surgical and anesthetic teams. Pygopagus twins, fused at the pelvis and lower spine, require meticulous planning, and multidisciplinary collaboration. This report describes the elective separation of pygopagus twin girls, involving advanced imaging, 3D anatomical modeling, and simulation-based preparation. A color-coded system differentiated anesthesia teams, equipment, and monitors, ensuring clarity during the 27-h procedure. Anesthesia was maintained with sevoflurane and remifentanil, with individualized fluid and hemodynamic management. Surgical steps included separation of shared spinal, rectal, and urogenital structures, followed by soft tissue reconstruction. The surgery was completed without major complications. Both twins were extubated within seven days, recovered well in the pediatric ICU, and were discharged on postoperative day 56 without neurological deficits. This case highlights the value of thorough planning, advanced imaging, and a structured multidisciplinary approach. Color-coded systems and simulations enhanced coordination, reduced risks, and improved outcomes.