Maliyah and Kendra Herrin are in separate beds for the first time in their lives. At 10:50 p.m. Monday, surgeons made the final cut that separated the 4-year-old, formerly conjoined twins.
Erin and Jake Herrin spent Monday trying not to watch the clock as surgeons painstakingly worked on the little girls. Maliyah and Kendra were born joined together at the abdomen and pelvis. Each tick of the clock brought them closer to a moment their dad predicted would be like a "rebirth."
Separation did not, however, mark the end of the surgery, which began at 7 a.m. Monday and was expected to last into the wee hours today. Once separated, one of the twins was moved to a different operating room and it became two separate surgeries. Since birth, the girls shared a liver, pelvis and part of the large intestine. Kendra has a kidney that both girls accessed through the liver, to which both supplied blood. Each of the girls has one leg.
For the Primary Children's Medical Center surgical team, the day was about precision: making each cut exactly where it was needed as they divided and reconnected intestines and other organs and stapled tissue.
For the family, a lot of the day was about distraction and trying not to think too much about what was going on one floor down and around the corner in the operating room. But at 11 p.m., a beaming Jake Herrin was able to say, "We haven't had one bit of bad news the whole time."
Erin Herrin called their other daughter, Courtney, 6, who was staying with an aunt, to share the news. The Herrins, of North Salt Lake, also have twin year-old boys, Justin and Austin.
Friends and extended family spent Sunday evening in a celebration of the girls, during which their maternal grandfather, Jeff Warren, gave them a blessing.
But though Kendra and Maliyah told everyone repeatedly that they were excited by the prospect of being separated, they were apprehensive when it was time to go to surgery Monday morning.
Hospital staff distracted them with a scavenger hunt that celebrated their differences. As they were being wheeled down the hall, they'd spot pieces of colored paper with clues: Whose favorite bug is a caterpillar? Maliyah. Who likes butterflies? Kendra.
At the door to the operating suite, though, they were all tearful as they said their "see you laters."
"They were great," Jake Herrin said later. "More brave than us."
"It was worse than I thought," Erin Herrin said.
Surgeons spent the first three hours draping and positioning the girls, making sure to protect their skin, made more delicate by use of 17 expanders designed to stretch the skin so it could be used to cover their wounds. Every hour through the course of the operation, the girls were being lifted to make sure the skin was holding up. Then the surgical team, working in specialty pairs depending on whose skills were needed, began the separation and reconstruction.
For weeks, the surgeons have been examining MRI and CT scans of the girls, including contrast tests that define which girl supplies blood to different organs.
They were prepared for major surprises but hadn't found any by nightfall, although the bladder was more complex than they'd expected, said Dr. Rebecka Meyers, coordinating surgeon and chief of pediatric surgery at Primary Children's Medical Center.
Their shared large intestine was divided in half and connected up. Doctors spent most of the evening reconstructing the rest of the pelvis, but the Herrins asked that intimate details of Kendra's and Maliyah's anatomies be kept private. After they separated the liver — done immediately before the total separation because it provided Maliyah access to Kendra's kidney — the surgeons planned to begin cutting the remaining soft tissue that united them.
How long the surgery would last depended in large part on what the surgeons found when actually inside the pelvis. They planned to do as much reconstructive work as they could but said the girls would require more surgeries down the road. Part of the planning and decision-making involved deciding how to do things to make those future operations less complicated.
With rare exception, they didn't have to decide which girl would get which organs or tissue. That is determined by who supplies the blood.
The surgery itself is not unique. At least a dozen pairs of twins joined in the abdomen have been successfully separated in the past couple of decades. But surgeons said they have not found another separation surgery that involved a single kidney. And each pair of twins is slightly different, "variations on a theme," Meyers said. The different procedures are also commonly performed in patients who are not conjoined, but not in a marathon surgery like the one the girls have endured.
Conjoined twins make up about 1 in 50,000 to 100,000 births. Most of the time, separation surgeries are done when the twins are 6 to 12 months old. But the fact that Maliyah has no kidney forced the delay. Infants typically don't do very well on dialysis, Meyers said. And they needed to wait until Maliyah was big enough to receive a donor kidney. That has been helped along by placement of an expander in her abdomen that will be filled will saline to gradually enlarge it to hold a kidney. Plans are for Erin to donate a kidney to her daughter in a few months, when Maliyah has healed from the separation surgery. Until then, she will have dialysis.
"I would give both my kidneys if I knew it would make Maliyah better and she would never have to do anything hard in her life ever again," Erin Herrin said.
At press time early today, it was expected that the two girls would sleep in separate beds for the first time but sharing the same room. For some time, they will be kept sedated because of the magnitude of the ordeal.
By the time they wake up, though, hospital spokeswoman Bonnie Midget said, they will be close enough to see and perhaps touch each other. While the girls have made it clear they see themselves as not joined physically, they've been equally clear they want to keep each other close by.
The tenderness they show each other is, in fact, something hospital staffers say they'll never forget.
Warren, their grandfather, describes a recent moment. Maliyah's leg was aching but she didn't want to take any more medicine for it. Kendra reached over and tenderly brushed the hair from her twin's cheek. "It's OK, Maliyah. I'll take your medicine so your leg will stop hurting."
The family maintains a Web site about the family, herrintwins.com. And they are asking that anyone who wants to help make a donation in the girls' names to Primary Children's Medical Center or the Make-A-Wish Foundation.