World's first separation of adult Siamese twins in Singapore

Background

Iranian twin sisters, Laleh and Ladan Bijani, were the world’s first adult Siamese twins to undergo surgical separation. The 52-hour marathon operation began on 6 July 2003 at Raffles Hospital in Singapore. However, 29-year-old twins, who were born conjoined at their heads, did not survive the operation, dying within 90 minutes of each other on 8 July 2003.¹

Background
Separation of adult Siamese twins had never been attempted before in the world prior to Laleh and Ladan’s case. Such an operation could kill or disable permanently either one or both of them, as it involves complex brain surgery on the adult twins’ fused brains. Hence, in 1996, doctors in Germany refused to operate on the twins due to the high risk involved. Upon learning of the successful separation of 10-month-old Nepalese twins, Ganga and Jamuna, in April 2001, Laleh and Ladan decided to come to Singapore to determine the feasibility of being operated on by Singapore doctors.²

The twins arrived in Singapore on 20 November 2002, hoping to be operated on by neurosurgeon Keith Goh, a key member of the team that separated the Nepalese twins successfully.³ The operation was to be undertaken by Raffles Hospital, a private hospital opened by Raffles Medical Group in 2001. The hospital agreed to undertake the risky operation for several reasons. Firstly, the hospital wanted to fulfill the desire of the twins to be separated. Secondly, the operation would promote Singapore as a regional medical hub, and the expertise of Raffles hospital’s doctors. Thirdly, it would promote friendship between the peoples of Singapore and Iran.⁴

The twins were aware that this was the start of a long journey to see the biggest dream of their lives come true: to live as two separate individuals as befit their different personalities.⁵ Ladan and Laleh wanted to study law and journalism respectively at university, but both ended up studying law. Laleh wanted to live and work in Tehran, while Ladan had thoughts of returning to their hometown of Shiraz and furthering her studies.⁶

After undergoing seven months of extensive medical and psychological tests as well as consultations with international experts, doctors at the hospital decided to proceed with the high-risk surgery, setting the operation date for 6 July 2003.⁷ A team consisting of 28 Singaporean and international specialists (from the United States, France, Japan and Switzerland) conducted the operation, with their professional fees waived as the sisters could not afford the operation.⁸ In addition, about 100 medical assistants were involved during the operation.⁹ Raffles Hospital bore the hospitalisation cost and the Raffles Medical Group established a Medical Samaritans Fund to help the sisters pay for medication and post-operative care which were estimated to be S$500,000.¹⁰ Later on, the Iranian government announced that they would pay for the twins’ operation.¹¹

Operation
In the early hours of 6 July 2003, Laleh and Ladan Bijani were wheeled into the operating theatre to begin their marathon operation.¹² The operation comprised three stages: a test to determine the pattern of blood flow in the veins, the opening of the skull and separation of the brains, followed by the reconstruction of the skin and soft tissue on the exposed area of their heads. The entire process was estimated to last four days, and involved about 12 specialists in neurosurgery, plastic surgery, radiology and anaesthesia.¹³

On the first day, a team of five neurosurgeons worked on the first stage of the operation led by Goh. Vascular surgeon Chia Kok Hoon from Tan Tock Seng Hospital and general surgeon Eric Teh worked on removing two sections from Ladan’s leg to be used to create a critical blood vessel in the brain of one of the sisters.¹⁴

Once this was done, nurses and technicians moved the unconscious twins, who were lying on their backs, into a sitting position in a special chair for the neurosurgery. At 8.15 pm, the critical second stage of the operation began. For about an hour, a team of five plastic surgeons led by Walter Tan cut through the twins’ skin, muscles and tissues to expose their skulls.¹⁵ However, the operation took a drastic turn at 6.30 pm on Monday, 7 July 2003, when doctors found that the new vein they had created in Ladan’s brain using a graft from her right thigh was blocked. At this point the team had to review the three options available to them: stop surgery; put them in intensive care after getting them out of anaesthesia, plan the next stage while risking their death and infection; or continue with the final stage of the separation.¹⁶ After speaking with the twins’ closest friends and being told that the twins wanted to be separated under all circumstances, the medical team persevered with the surgery.¹⁷

In the early afternoon of 8 July 2003, a Raffles Hospital spokesman broke the news that the twins had been separated, but they had lost a lot of blood. Amidst the cheers, he requested those present to pray for the sisters as the operation was still underway. At 2.30 pm on 8 July 2003, he returned to announce that Ladan had died due to failure in her blood circulation. At 3.45 pm Laleh’s blood circulation also failed and she died 15 minutes later.¹⁸

Aftermath
News of the twins’ deaths was received with shock, grief and sadness from Iranians and Singaporeans who were touched by their unyielding spirit and determination to pursue their dream.¹⁹

On Thursday, 10 July 2003, the twins’ bodies were flown back to Iran in separate coffins.²⁰ Thousands of mourners lined the 10-kilometre street leading to the twins’ birthplace of Lohrasb, where they were finally laid to rest on 12 July 2003.²¹

With the sisters’ deaths, Raffles Hospital decided to use US$300,000 committed by the Iranian government to set up the Ladan and Laleh Memorial Fund to treat needy patients with chronic and complex neurological and neurosurgical conditions.²²

Following the failure of the operation, an inquest was held to determine the cause of the twins’ deaths.²³ On 6 March 2004, the state coroner gave a verdict of misadventure in his judgement of the case. The coroner was satisfied that the medical team had done their best. The cause of death was due to excessive blood loss through previously undetected blood vessels in the twins’ brains.²⁴



Author
Nureza Ahmad



References
1. Dominic Nathan, “Twins Head Home, Dream Fulfilled in Death,” Straits Times, 10 July 2003, 1; Lee Hui Chieh, “A Kiss, and Twins’ Marathon Begins,” Straits Times, 7 July 2003, 1. (From NewspaperSG)
2. Salma Khalik, “Iranian Twins Arrive Hoping to Be Separated,” Straits Times, 20 November 2002, 6. (From NewspaperSG)
3. Khalik, “Iranian Twins Arrive Hoping to Be Separated.”
4. Salma Khalik, “Second Pair of Siamese Twins Head for S’pore.” Straits Times, 11 October 2002, 1. (From NewspaperSG)
5. Khalik, “Iranian Twins Arrive Hoping to Be Separated.”
6. Salma Khalik, “So They Want Separate Lives,” Straits Times, 4 December 2002, 1. (From NewspaperSG)
7. Lee Hui Chieh, “Twins Get Nod for Risky Surgery,” Straits Times, 3 June 2003, 2; Lee, “Kiss, and Twins’ Marathon Begins.”
8. Lee, “Twins Get Nod for Risky Surgery”; Lee Hui Chieh, “Bijani Sisters’ Deaths: Docs Not to Blame,” Straits Times, 7 March 2004, 8. (From NewspaperSG)
9. Lee, “Bijani Sisters’ Deaths.”
10. Lee, “Twins Get Nod for Risky Surgery.”
11. Lee Hui Chieh, “Twins’ Surgery in Critical Phase,” Straits Times, 8 July 2003, 1. (From NewspaperSG)
12. Lee, “Kiss, and Twins’ Marathon Begins.”
13. Lee, “Twins Get Nod for Risky Surgery.”
14. Lee, “Kiss, and Twins’ Marathon Begins.”
15. Lee, “Kiss, and Twins’ Marathon Begins.”
16. Dominic Nathan, “In the end, It Was Not to Be,” Straits Times, 9 July 2003, 1. (From NewspaperSG)
17. Nathan, “Was Not to Be.”
18. Nathan, “Was Not to Be.”
19. Nathan, “Twins Head Home”; Nathan, Was Not to Be.”
20. Nathan, “Twins Head Home.”
21. Sadroddin Moosavi, “Thousands Bid Twins Farewell in Hometown,” Straits Times, 13 July 2003, 6. (From NewspaperSG)
22. “Iran to Honour Ladan, Laleh with War Dead,” Straits Times, 11 July 2003, 3. (From NewspaperSG)
23. Karen Ho, “Inquiry into Iranian Twins’ Deaths,” Straits Times, 11 February 2004, 2. (From NewspaperSG)
24. Lee, “Bijani Sisters’ Deaths.”



The information in this article is valid as at 2016 and correct as far as we are able to ascertain from our sources. It is not intended to be an exhaustive or complete history of the subject. Please contact the Library for further reading materials on the topic.