Stanford Medicine Newsletter Updates For the Local Community

Independence day

A successful separation of conjoined twin girls

Erika Sandoval (in orange) and her twin, Eva, are adjusting to life as separate individuals.


Conjoined twins Eva and Erika Sandoval are now adapting to life as individuals following a landmark 17-hour separation surgery at Lucile Packard Children’s Hospital Stanford. The girls have been handling their recovery cheerfully and progressing well with help from physical and occupational therapists in preparation for a return to their home near Sacramento, said lead surgeon Gary Hartman, MD.

“They’re way ahead of our expectations,” said Hartman, a professor of surgery at Stanford Medicine.

In the early morning of Dec. 6, the 2-year-old girls were wheeled into the operating room as one. Nearly 12 hours later, Eva was moved to an adjacent operating room so that both girls could undergo reconstructive surgery, the first time in their lives they had been in different rooms.

“We know that this is the right path for them: to be independent, to have the chance to succeed and explore on their own everything the world has to offer,” said their mother, Aida Sandoval.

Long-term planning

The surgery, Hartman’s seventh conjoined-twin separation, was the culmination of plans launched when Aida was referred to Packard Children’s during her complex pregnancy. More than 100 hospital staff in nearly every department have taken care of Eva and Erika, who were born there in August 2014.

As they prepared for surgery, doctors warned the family that there was a 30 percent chance one or both girls would not survive separation. The main risk was possible bleeding during division of their shared pelvis.

“Before separation, you could think of their anatomy as two people above the rib cage, merging almost into one below the belly button,” said Peter Lorenz, MD, chief of the Division of Pediatric Plastic Surgery, who led the reconstructive phase. The girls had separate hearts, lungs and stomachs; a shared diaphragm muscle; one liver, one bladder, two kidneys and three legs. Comprehensive CT and MRI scans were used to print 3-D models of the twins’ pelvic bones and blood vessels to help plan the separation.

“We had amazing information from our radiology colleagues but even with that there were some surprises,” Hartman said. “There was only one large intestine. It appeared that it all belonged to Eva but had some blood supply from Erika, so we had to do some testing in the operating room to clarify that.”

Once the exploratory phase was complete, the team divided the twins’ liver and split their gastrointestinal and urinary tracts. The single bladder was made into two bladders, and each child received a colostomy. The pelvic bones were then divided. The final incision that officially separated Eva and Erika was made by James Gamble, MD, professor of orthopedic surgery, and Matias Bruzoni, MD, assistant professor of pediatric surgery, at 4:34 pm Dec. 6.

After the girls were separated, Lorenz led the team that performed Eva’s reconstructive surgery. Erika’s reconstructive surgery was led by pediatric plastic and reconstructive surgeon Rohit Khosla, MD, assistant professor of surgery. To help complete Erika’s reconstruction, the bones from the girls’ third leg were removed, and skin and muscle from the leg were used to close Erika’s abdominal wall. The surgeons had considered keeping the leg if it was not needed for reconstruction, but it would likely not have been useful for walking because of its abnormal anatomy.

Rapid recovery

Now that the twins are separated, each child has one kidney and one leg. Recovering at the hospital, Eva and Erika have been happy and chatty, and are doing well in physical and occupational therapy.

“It’s amazing how strong these girls are, and it’s amazing what their team performed,” their mother said.

Although it is a struggle for the girls to sit up since they lack the abdominal muscles used to maintain balance, the team is helping both sisters learn to sit up and stay in that position, reach for their toys and develop functional mobility so they can move through their surroundings. Therapists also are working with the family on strategies to train the twins to eat more.

“Their progress has just been tremendous,” said occupational therapist Kelly Andrasik. “Eva loves it when we play with our wooden pizza set, and Erika has been really motivated by different things she wants to play with. We’re learning from her how she is best able to use her body.”

The team is committed to helping the girls gain as much mobility and independence as possible. “They are highly motivated and hard workers,” Andrasik said. “That’s going to carry them really far.”

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