The separation surgery was more than satisfactory. Rachel and Lea, a pair of Siamese twins from the Philippines, won independent new lives.

It was the peak of summer. Twilight was still lingering in Hualien, eastern Taiwan, and the evening sky was scattered with beautiful clouds. Marieta was seated in the pediatric ward at Tzu Chi Hospital, holding one of her daughters, Rachel, and feeding her tenderly with a small spoon. Occasionally, she threw a gentle glance upon Lea, her other twin daughter, who was playing with a stuffed toy on a bed. Marieta's eyes beamed with the light of a loving mother.

Rachel and Lea had been recovering quite satisfactorily since the separation surgery performed half a month before, on June 28. Marieta was happy and contented. It had been three months since she had brought the twins from the Philippines to Taiwan on April 16 for the separation surgery. The trip to Taiwan proved to be a major turning point for her and her twin daughters.

A chance encounter in times of despair

One evening early this year, six-month-old Siamese twins Rachel and Lea had a seriously high fever. The next day, their parents, Andy and Marieta, took them to a children's hospital in Manila. The family, who lived in Kalinga, a mountainous village to the north of Manila, had to travel more than ten hours on bumpy roads to reach the hospital. The medical treatment that ensued cost a lot of money, which constituted a heavy burden on the financially strained couple. What was even more discouraging was that even the physician who treated their daughters tried to persuade the couple to give up on the twins. This was the saddest and most distressful moment in Marieta's life after giving birth to the pair of abnormal children.

Fortunately, Rachel and Lea's health recovered after treatment. But the doctor told the parents that if they wanted to have the Siamese twins separated, the surgery should be carried out as soon as possible. That was, however, beyond the means of Andy and Marieta, who farmed for a living, since the surgery would cost over a million pesos [US$22,857]. All they could do now was leave it to fate.

The children's hospital in Manila tried to raise funds for the couple, but it did not go well. At a crucial moment, Marieta came across Tzu Chi volunteer Li Wei-sung, who had come to the hospital with an indigent boy afflicted with hydrocephalus. After learning of the desperate situation the couple was in, Li had a discussion with the hospital and decided that Tzu Chi could provide assistance for Marieta's family.

Li reported the case to the Tzu Chi headquarters in Hualien. In order to save time, the Hualien Tzu Chi Hospital sent Dr. Peng Hai-chi, head of the surgical pediatrics department, and Dr. Li Chao-chin, head of the image diagnosis department, to the Philippines in February to conduct a preliminary check-up on the twins. Assisted by Dr. Lu Hsiu-chuan, head of the Philippine chapter of TIMA [Tzu Chi International Medical Association] and vice superintendent of a hospital in Manila, Peng and Li used a high-resolution ultrasonic imaging system to examine the twins. The examination results showed that the twins stood a good chance of surviving the surgery because they were joined at the livers and the pericardia, but not the hearts. The decision was made to arrange for the twins to come to the Hualien Tzu Chi Hospital for separation surgery.

Siamese twins occur due to the incomplete division of a zygote 13 days after the conception of identical twins. The chance is one in every 50,000 to 100,000 births. Thanks to advanced prenatal diagnosis in Taiwan, similar cases have not occurred in Taiwan for years. However, the occurrence rate is comparatively high in the Philippines, where the distribution of medical resources is uneven and prenatal examination is not thoroughly carried out.

"Generally speaking, there is a 60 to 80 percent chance of success for twins that are joined at the abdomen to be successfully separated," remarked Peng, who once received professional training on the separation of Siamese twins at a medical center in Philadelphia. "Siamese twins can be conjoined at the heads, chests, hips, etc. Rachel and Lea were joined at the chests and livers, the most optimistic for separation surgery."

Peng emphasized that the prime time for a separation surgery to take place is three to twelve months after birth. If the operation is carried out later than that, it will not only result in deformity of the spine, but there will also be foreseeable impact on the psychology of the twins. Since Rachel and Lea were less than one year old, the timing was just right for them to undergo the operation.

Li added that Siamese twins cannot exist without each other--when one passes away, the other will die immediately. That was another reason why Rachel and Lea had to be split from each other.

The separation surgery

For the separation surgery at the Hualien Tzu Chi Hospital, a team was formed of doctors from various departments including general surgery, pediatrics, anesthesiology, plastic surgery, image diagnosis, nursing, and humane care. The team made an exhaustive evaluation of the surgery and repeatedly carried out simulated surgeries on model dolls which had been especially made for the occasion. The hospital purchased many precision instruments that could also be used to treat similar cases in the future.

After full preparation, Rachel and Lea were escorted to the surgical room at 7:45 a.m. on June 28.

At 10:17, Peng made the first incision. Following the procedure enacted in the simulated surgeries, the medical team cut open the abdomen and then dissected the connected pericardia. Stitches were then made to mend the separated pericardia to prevent fluid from flowing.

"Leakage of fluid might have affected the hearts of the twins, so the separated pericardia had to be mended immediately," noted Dr. Peng. The pericardium is the membrane that surrounds the heart; it provides room for the beating of the heart and prevents the heart from rubbing against other organs. The fluid inside the pericardium works as lubrication for the heart.

After the conjoined pericardia were split, the most important part of the surgery ensued: the separation of the livers. Dr. Li Ming-che took over. Li had had surgical experience in liver transplantation, so severing the livers was not such a hard task for him. Nevertheless, he made every incision with the utmost care. In order to minimize hemorrhaging, he intentionally carried out the procedure very slowly. To fully concentrate on every touch of his scalpel, he rarely blinked his eyes during the two-hour liver separation operation. The livers were successfully divided at 1:58 p.m.

After that, the other doctors of the surgical team, Chang Yao-jen, Li Ming-che, Chen Hua-tzung, and Peng Hai-chih, proceeded in two groups to mend the wounds of the twins by applying artificial membrane and skin and suturing the cuts.

Rachel, who had a smaller wound that took less time to sew up, was delivered out of the surgical room first. The crowd waiting outside the room applauded cheerfully. Lea came out 20 minutes later. The six-hour operation had ended successfully.

Dr. Chang Yao-jen, vice superintendent of the hospital and head of the surgical team, commented that the success of the separation surgery could be attributed to the close cooperation of the team members. What was also worth mentioning was the small amount of hemorrhaging during the surgical process. Actually, the bleeding was so minimal that there was no need for blood transfusions. This was truly remarkable, he noted.

According to Li, who had assumed the major task of separating the livers, the minimal hemorrhaging was a result of the accurate evaluation carried out by the image diagnosis department beforehand, which allowed him to make every cut with precision. The proper dosage of anaesthetic administered by the anesthetists also freed him from worry in the surgical process. Furthermore, the utilization of advanced medical equipment also contributed to the efficient control of bleeding.

Wishes and blessings

Rachel and Lea were kept in the intensive care unit for close observation during the first few days after the surgery. Because they recovered well and were able to eat and eliminate normally, they were soon transferred to the children's ward.

Lu Chi-yen, chief nurse of the children's ward, said that in order to give the best care to the twins, nurses responsible for taking care of them had read through all related nursing information. She also asked Dr. Chen Jui-hsia and staff worker Tsai Sheng-lun, who could speak the Philippine language, to translate for Marieta and the hospital staff and to teach the staff simple dialogues to facilitate communication.

After Rachel and Lea were separated, they became very active and often fought for the attention of their mother. In order to ease Marieta's burden, Tzu Chi volunteer Chang Chi-hsueh often went to the ward to help take care of the twins.

Usually children can walk by the time they reach one year old. Because Rachel and Lea were conjoined for a long time, their limbs did not have the chance to develop properly. The Tzu Chi Hospital therefore arranged for a physiotherapist to teach them to sit. After a few days' training, Rachel made considerable progress. She learned to ride a roller walker, although she often rolled backwards. Lea, who was thinner and smaller, had gained some weight and was catching up with her twin sister. The twins are expected to be able to walk in two or three months.

Rachel and Lea were the first Siamese twins that the Hualien Tzu Chi Hospital has successfully separated. They were also the ninth separation surgery case in Taiwan. Although Nature played a joke on them, the medical team at the Tzu Chi Hospital made the best use of their skills to give them new lives. The twins, with their big, bright eyes, looked so innocent and lovely. Did they know the separation surgery had completely changed their fates?

Many people in Taiwan expressed care and concern for the twins. Marieta said that never in her life had she felt so much warmth and love. "I will do my best to educate my daughters so that when they grow up they will do their best to help others."

Marieta and her twin daughters returned to the Philippines on August 21. There, local Tzu Chi volunteers will continue to care for them and follow up on the condition of the twins. A brand new life is waiting for the family.