Twin hearts, one challenge: safe anesthetic care for thoraco-ischiopagus conjoined twins requiring emergency colostomy in resource-limited setting

Conjoined twinning represents a rare and complex congenital anomaly arising from incomplete embryonic division after the 13th day of fertilization. The condition occurs in approximately 1 in 50,000–200,000 live births, most commonly among females. Successful perioperative management requires multidisciplinary planning and precise anesthetic coordination to address unique physiological challenges, including potential cross-circulation and shared organ systems. We report the anesthetic management of six-hour-old male conjoined twins joined from the mid-chest to the pelvis (thoraco-ischiopagus) admitted for emergency colostomy due to absent anal openings and urine mixed with meconium. They were delivered via elective cesarean section at 37 weeks to a 24-year-old para II mother. Bedside echocardiography revealed two structurally separate hearts with normal function. Two distinct external genitalia were present, with one well developed and the other rudimentary. Separate anesthetic teams managed each twin with dedicated anesthesia machines and monitors labeled “Twin A” and “Twin B.” Sequential induction was performed using halothane and ketamine, followed by succinylcholine for intubation. Atropine administration to Twin A increased its heart rate without affecting Twin B, suggesting minimal cross-circulation. Anesthesia was maintained with isoflurane and vecuronium, and both twins were extubated successfully at the end of a 40-minute surgery. Postoperatively, they were transferred to the neonatal intensive care unit on supplemental oxygen in stable condition. Conjoined twins present extraordinary anesthetic challenges requiring meticulous preparation, coordinated teamwork, and careful assessment of shared physiology. Bedside testing for cross-circulation, individualized monitoring, and dual anesthesia setups are critical to avoid intraoperative complications. Early multidisciplinary planning and vigilant intraoperative communication remain the cornerstones of safe perioperative management in conjoined twins undergoing surgical intervention.