Specify OR setup with specific location for each individual and piece of equipment.
Walk-through with turn on and test of all equipment (may need more electrical supply).
Select OR date and start time to ensure availability of all needed support and minimize disruption of OR and hospital operations.
Limit entry to OR to authorized individuals with a clinical need.
Provide audio–video feed to a designated viewing area.
Identify two separate anesthesia and operating teams.
Identify each individual’s responsibilities and functions well in advance.
Ensure adequate warming during prep and monitor insertions.
Ensure adequate padding of all pressure points.
Anticipate meticulous hemostasis from initial incision.
Open “upper” portion of connection by entering at umbilicus and remove tissue expanders.
Open abdomen and chest to assess degree of visceral fusion.
Divide any intestinal connection reserving restoration of continuity until separation complete.
Divide diaphragm and dissect posterior surface of fused liver.
Divide liver using hydro-dissector, coagulation devices, or suture ligature and use argon beam.
Divide posterior body wall to diaphragm.
Assess cardiac connection and position bypass/pacing personnel.
Test clamp before dividing cardiac connection.
Divide remainder of posterior body wall, removing any remaining tissue expanders.
Rotate patients supine and cover with sterile occlusive dressings.
Move one twin with team to adjacent OR.
Re-prep and drape.
Re-inspect abdomen and chest for hemostasis and complete any needed reconstruction of GI or biliary tracts
Close abdomen without tension, which usually requires a soft-tissue patch.
Mold rigid chest wall material to bridge sternal defect.
Drain mediastinum and subcutaneous spaces.
Mobilize and close skin flaps with minimal tension.
Coordinate staggered transfer to critical care area.
Predesignated postop care teams with predetermined order sets.