Multidisciplinary Preoperative Evaluation and Ethical Decision-Making in Thoraco-Omphalopagus Conjoined Twins: A Case Report

Abstract

Background: Thoraco-omphalopagus conjoined twins present extreme surgical and ethical complexity due to shared thoracoabdominal structures, most notably the liver and chest wall. While hepatic separation has been widely emphasized, the role of chest wall reconstruction as a determinant of postoperative physiological viability remains underreported. Aim: Thoraco-omphalopagus conjoined twins represent one of the most complex congenital anomalies due to shared thoracoabdominal structures and the need for multidisciplinary decision-making. This report aims to describe the preoperative multidisciplinary evaluation and ethical considerations in the management of thoraco-omphalopagus conjoined twins. Presentation of Case: We report thoraco-omphalopagus conjoined twins diagnosed antenatally and delivered at a tertiary referral center. Postnatal evaluation revealed a shared sternum, contiguous rib cage, common diaphragm, and extensively fused liver with complex vascular interconnections. Imaging using contrast-enhanced CT and CT angiography was performed to delineate the anatomy and assess feasibility of separation. Multidisciplinary evaluation involving pediatric surgery, hepatobiliary surgery, neonatology, radiology, intensive care, and clinical ethics guided management. Due to neonatal pneumonia and physiological instability, definitive surgical separation had not yet been performed at the time of reporting. Discussion: This case highlights the importance of comprehensive preoperative evaluation in thoraco-omphalopagus twins, particularly regarding hepatic vascular anatomy, chest wall integrity, and postoperative respiratory mechanics. Multidisciplinary collaboration and ethical deliberation were essential in balancing surgical feasibility with patient safety and anticipated quality of life. Conclusion: Thoraco-omphalopagus twin management requires careful integration of anatomical evaluation, multidisciplinary planning, and ethical decision-making. Reporting preoperative assessment and planning may contribute valuable insights for future surgical management of similar cases.