The Separation of AmieLynn and JamieLynn

It had only been 16 weeks since they were born, but the personalities of twins AmieLynn and JamieLynn, both sporting big brown doe eyes, were on full display. Sure, they were both doing all the normal things babies do — smiling, crying, eating, and crying some more. They communicated annoyances, hunger, and joy in the crude yet universal language of infants and took plenty of naps and required lots of diaper changes. In other words, both were a delight and a handful. You know, like babies.

But Jamie was proving spunkier than her sister. She was feisty and sensitive. After she was born, any time doctors would reach for her, she would start to cry. Amie, on the other hand, was “more chill,” appearing to take the pair’s situation in stride. The way doctors speak of them, one might as well have been the proverbial Dr. Jekyll and the other a Mrs. Hyde. And all of this added up — that is, if we are to believe that the Napoleon complex is a legitimate psychological diagnosis. 

You see, despite being identical twins, Amie was a little bigger than Jamie. She came into the world as the gentle giant to Jamie’s plucky underdog. To put it simply, Jamie had to fight like hell to catch up to her sister. In most instances, one would shrug and call this instinctive sibling rivalry. But in this case, for Jamie, catching up to her sister — eating more, gaining weight, being a bit of a bully — was a necessity to survive.

While the two don’t share a personality, they do share a few things: an unfortunate plight and a liver. While in the womb, Amie and Jamie began as one — a single egg that, after it was fertilized, split into two embryos. But these embryos wouldn’t separate entirely. They would remain partially connected, refusing to break apart as the early stages of Amie and Jamie began to form. In the coming weeks, Amie and Jamie would grow separate heads, hearts, arms, and legs. But all of this growing happened while they were fused near their bellies, face-to-face, appearing as though they were in a constant state of embrace. As it turns out, these seemingly normal babies had a very abnormal condition: thoraco-omphalapagus — this being the technical term for twins conjoined at the lower chest and abdomen. 

After 34 weeks in their mother’s womb, a full month before the two were at full-term, Amie and Jamie were delivered via a Cesarean section at Texas Health Harris Hospital. In the weeks and months after their delivery, the two would remain in the hospital (being transferred next door to Cook Children’s Medical Center) with feeding tubes, ventilators, and beeping machines attached to their small, delicate bodies. Throughout this time, in the sterile environment of a hospital room — their separate heart rates and blood pressures on perpetual display — the two were, both literally and figuratively, inseparable. 

But behind the scenes, Dr. José Iglesias, a pediatric surgeon at Cook Children’s, was prepping an entire team of physicians for a procedure that would separate the conjoined twins. After weighing an improved quality of life against any potential risks that come with such a complex procedure, the family and the team decided that AmieLynn and JamieLynn, autonomous and unique in so many ways, deserved to be separated physically. By making it this far — most conjoined twins don’t survive past the first day of life — giving each girl the chance to live a life with greater possibilities seemed the only reasonable choice. And because Amie and Jamie were thoraco-omphalapagus twins (representing 28% of conjoined twins), and shared only a liver and lower chest, the conditions seemed tilted in Amie and Jamie’s favor. While it’s difficult to describe circumstances that still require a high-risk procedure as good, they were as good as one could hope. In other words, the deck wasn’t stacked against them.

But Amie and Jamie would have to place their trust in the hands of a team of doctors, a hospital, and a city that had never performed a procedure like this before. Such miraculous medical outcomes are typically reserved for the Hippocratic hubs of Houston, Cleveland, New York, Los Angeles, the Mayo Clinic, and Johns Hopkins. But the team at Cook Children’s, a nationally recognized hospital in its own right, were confident that Amie and Jamie would be separated, and they would be the ones to do it. 

The team, led by Dr. Iglesias, had already had a couple of dress rehearsals, using dolls they had Velcroed together to fill in for the real-life bodies of Amie and Jamie. Such an operation required a certain amount of medical choreography, but the team also had to prepare for the unknown, for complications. The list of potential risks and outcomes was nearly infinite, and those in the room had to know how to think on their feet. 

Recalling the day of the surgery, Dr. Iglesias is honest about the nerves he and his crew of 20 surgeons, nurses, anesthesiologists, and surgical technicians felt. “For me, it was a component of, like, they’re all my babies,” he says. “And the higher the risks, the more butterflies you get. I still get butterflies even 20-something years into this.”  

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It’s one of the great paradoxes that the very nature of bringing life into the world carries a significant risk. Miscarriages, preterm labor, and stillbirths are all possible outcomes of a pregnancy for which, despite their frequencies, a family cannot prepare. These potential complications are typically washed away by pure elation once a family finds out they’re having a baby.

James Finley and Amanda Arciniega had been hoping to add another child to their family and were overjoyed to learn that Amanda was pregnant. Having already had three children, the couple knew the drill and had little reason to suspect that this pregnancy would be any different from their previous experiences. As most hope and presume, the pregnancy would last nine months and, while feelings of nausea and discomfort were inevitable, the baby would be delivered healthy and happy. 

The first surprise came at 10 weeks during the first ultrasound — Amanda was pregnant with twins. While not an unpleasant surprise, the unexpected announcement of twins is a surprise, nonetheless. But this wouldn’t be the only revelation from this first ultrasound. The twins were also conjoined. The feeling of elation that had turned to shock ultimately became sadness and concern. 

“I mean, you go from this very high, ‘Yeah, we’re pregnant,’ to the shock of having twins, then get slammed with, ‘Well, they’re conjoined, and we’re not sure they’re going to make it,’” Dr. Bannie Tabor, the obstetrician-gynecologist at Texas Health Harris Methodist Hospital who delivered Amie and Jamie, says. “It’s the ultimate high to the ultimate low.”

According to a 2022 study by King Edward Medical University, only 7.5% of conjoined twins survive, with most being stillborn and many dying soon after delivery. So, news that Amie and Jamie were conjoined meant one of three things: a death sentence for the twins; lives with several inherent difficulties; or a risk-laden procedure. No potential outcome could be described as good.

The ultrasound did show that the two were connected at the abdomen and that, in all likelihood, they each had their respective vital organs. This meant separation following delivery was still on the table.

At 65, Dr. Tabor has been in the business of delivering babies for decades, and he’s a man who’s confident in who he is and what he does. He has long locks of straight silvery hair and manages to sustain an expression of aloofness while simultaneously being incredibly attentive. To get an idea of who he is, just Google his name and see his five-star rating on U.S. News and World Report right next to a bio pic of him sporting a black tee, goatee, and Oakley sunglasses. Yeah, he’s seen a thing or two, but he had never seen or delivered conjoined twins.

While Tabor drolly admits that the delivery was not nearly as complex as the separation Amie and Jamie faced in the coming months, he had been coordinating and working closely with the neonatal team of Dr. Chad Barber and Dr. Fran Lynch from Cook Children’s to ensure a successful delivery.

And that delivery had to come early. As Dr. Tabor puts it, there were potential mechanical issues if Amie and Jamie entered their mother’s birth canal — if she went into labor. So, only 34 weeks into Amanda’s pregnancy — full-term is 40 weeks — Amie and Jamie were born via a Cesarean section and weighed a collective 8.8 pounds.

 “It was a difficult delivery,” Dr. Tabor says. “We just made it look easy.”

When I asked about his feelings following the delivery, he gets a little tongue-tied and freely admits he can’t form the right sentence. Whether it’s due to tiredness or being overwhelmed, I can’t tell, but he finally finds the right words. “It was reassuring that what I’ve devoted my life to has a purpose.”

Despite the absence of complications during the birth, this wasn’t an outpatient procedure for Amie and Jamie. No, being both premature and conjoined meant they would be spending significant time in the neonatal intensive care units of both Harris Hospital and Cook Children’s to ensure proper care and to prepare for their potential separation.

Directly after the birth, Dr. Lynch and Dr. Barber painted the fingernails of Amie and Jamie, each with a different color — green for Amie and purple for Jamie. The neonatologists did this so they could tell the two apart — remember, they are identical twins — and the hues have since become synonymous with each girl. If you see a doctor in the NICU or OR wearing a green cap, you’ll know they care for Amie, and the same goes for Jamie and the color purple. 

“Instead of using their names or A and B like we would typically do with twins, because they were conjoined, we didn’t want any type of chance of anything getting mixed up or confused,” Dr. Barber says. “We didn’t want to accidentally double dose or anything like that.”

It also ensures they won’t have to struggle when the day comes that they’re inevitably asked, “What’s your favorite color?”

Even as the doctors and nurses grew accustomed to Amie and Jamie, becoming more aware of each baby’s peculiarities — even if they could guess who was who 10 times out of 10 — the twins would remain marked with their respective color until the moment they separated.

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Dr. Ben Gbulie admitted that Jamie always cries when he reaches for her belly. He said that Amie never cries around him, but with Jamie, it’s an everyday thing. During the separation procedure, when Amie and Jamie had their own respective teams, Gbulie was on team Jamie. He’s the one who closed her wound. “But she clearly didn’t get that memo,” Gbulie laments.

Gbulie is a plastic surgeon who has a private practice in Mansfield, but he admits that his work consulting and covering trauma calls at Harris Fort Worth and Cook Children’s takes up 70% of his time. So, he’s in Fort Worth a lot. Born in Nigeria, he came to the U.S. when he was 25 and trained as a general surgeon at Howard University in Washington, D.C. Dr. Gbulie eventually made his way to Cowtown after his wife demanded a metropolitan area larger than the one where they were living — Memphis. It doesn’t take long to gather that Dr. Gbulie’s a lively guy with a quick wit and a sense of humor that has a devious undercurrent, but in the absolute best way possible.

Oh, and he’s done this three times. And by this, I mean been part of a team that successfully separated conjoined twins. Such procedures are far from commonplace, occurring only a few times every year. Yet, in his 20 years of practicing medicine stateside, Gbulie had already been involved in separating conjoined twins twice and was now entering the OR of Amie and Jamie’s procedure as a de facto veteran.

Interestingly, Gbulie’s involvement with Amie and Jamie’s separation began when the twins were still fetal figures on an ultrasound. As it turns out, Amie and Jamie’s grandmother had a best friend who was a patient of Dr. Gbulie’s. Properly vetting her doctor, the friend came across Gbulie’s website, where she saw information about his involvement in the successful separation of two sets of conjoined twins in Memphis. So, when she got wind that her friend’s great-granddaughters were conjoined twins, she said, “Oh, I know someone who does this.”

After a cold call to Gbulie’s office one afternoon, the family began consulting with the plastic surgeon. And he, in many ways, became an advocate for the family — a trusted advisor. He was someone who was going to point them in the right direction.

“They had some concerns because it sounded like the initial thought was that their care would be better by going to Houston,” Gbulie says. “The thought process was that Texas Children’s would be the one place that would probably be able to pull this off.”

According to Dr. Tabor, the family met with Texas Children’s but, ultimately, Amanda “just didn’t feel comfortable down there.”

“I mean, by then, I’d been here for four years and done pretty complicated stuff for Cook,” Gbulie says. “So, I spoke with [Dr. Tabor], and I assured him that if there’s any problems with the pregnancy that requires leaving the area for high-level of care. Absolutely [go to Houston]. If there’s any problems after delivery that requires a high-level of care. Absolutely [go to Houston]. But, if there isn’t, I feel comfortable that we can take care of this here.”

Ultimately, the inclusion of specialists from Cook Children’s came after the parents decided to keep the medical care of Amie and Jamie near home, foregoing the opportunity to work with doctors and staff who might have previously cared for conjoined twins.

“I mean, we had never done this before,” Tabor says. “But I had worked closely with the surgeons at Cook [Children’s], and I knew what we could do and had to offer. And so, I empowered [Amanda] to make the decision and encouraged her to. I felt we could take care of things here where she would be close to home.” 

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Following their birth, there were many faces Amie and Jamie saw regularly. Some of these faces would stay a while, and others would just fly in and out. Some faces, like those of their mom and dad, who visited every day, were there to show affection and calm any fears. Other faces, usually wearing hospital scrubs, might pick and prod, making them cry. And other faces might be doing all of the above. A couple of concerned faces who they saw on a constant basis were those of Dr. Barber and Dr. Lynch, Amie’s neonatologist and Jamie’s neonatologist respectively. When Amie and Jamie were born, weighing just over 4 pounds each, Barber and Lynch were the first people to lay hands on them. The two doctors, who have worked with one another at Cook Children’s for years, were charged with not only keeping Amie and Jamie alive and healthy but also getting both to a place where they were physically prepared — a nice way to say “put on weight” — for a major surgery.

Unfortunately, the team quickly discovered that Amie and Jamie were sharing a blood supply, and it wasn’t being dispersed evenly. Amie, despite her relaxed disposition, was hogging the supply, which made it difficult for Jamie to grow. Jamie, size-wise, was lagging behind and still had some pounds to gain before the separation.

“That was our challenge and, really, that was our most important goal. It’s not very newsworthy or exciting, but the only way these babies get to the point where all of the fancy separation can happen, is if they grow,” Dr. Lynch says. “And not just gain weight. They have to grow in a healthy way.”

Jamie was taking a decent amount of food orally, while Amie had yet to become comfortable with food in her mouth. The irony is that Jamie, despite being smaller, despite being the one who needed to grow, was eating more than her larger sister. As Dr. Iglesias opined, with one glance at Amie, one would think, “Man, you should be really chugging this [food] down.”

“It was like all the groceries had gone into AmieLynn,” quipped Dr. Chandra Reynolds, who would be the anesthesiologist during the separation procedure. “JamieLynn had to fight for ’em. Maybe that’s why she was a little bit feistier.”

Though weight gain was the neonatologists’ main challenge, it was far from the only wrench that had been thrown into their gears. In addition to Jamie’s size, she was also having intestinal issues. There were times when Jamie’s intestines were not working well, and Dr. Lynch had to resort to IV nutrition to help support her growth. Amie, meanwhile, was developing scoliosis. Fueled by her natural inclination to lean back and incessantly pull away from Jamie, Amie’s spine was beginning to curve, which could have a devastating impact on her development. As weight gain can only come with time, and the scoliosis was worsening as time passed, these issues were working against one another. 

“We wanted them physically to get bigger, to mature a little bit,” Dr. Iglesias says. “At some point, that stuff is going OK, but then you start losing ground on other things.”

Finding the right time to pull the trigger on the procedure became a delicate balancing act. Too soon, and there could be complications due to a lack of weight. Too late, and the team is opening themselves up to grim developments from which Amie and Jamie could never recover.

Dr. Lynch and Dr. Barber ultimately wouldn’t be in the room when Amie and Jamie were separated. But they would be some of the first people welcoming the twins once the procedure was over because, for them, the job of caring for Amie and Jamie will continue. As the famous proverb goes, no rest for the weary. Their work is far from finished.

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The first recorded successful separation of conjoined twins took place in 1691, when Johannes Fatio separated Elisabet and Catherina in Basel, Switzerland. The twins were fused together between the middle of the chest and the navel, including their umbilical cords. According to documents recovered after Fatio’s execution as a political prisoner, the surgeon and revolutionary performed the procedure in two separate parts that included cutting and ligating blood vessels followed by severing the connecting tissue nine days later. The twins were reportedly fully healed within two weeks. 

While the procedure Amie and Jamie underwent was different, there is every reason in the world to think the positive outcome will be the same.

Yes, things have come a long way over the past 300 years. Dr. Iglesias and his team used multiple sonograms, echoes, CT scans, and even had a 3D reconstruction to give the operating team an idea of what they were working with. However, imaging only does so much. According to the doctors, there was still some fear that Amie and Jamie could be sharing something else — major vessels or intestines, for instance. So, it remained important to expect the unexpected.

Dr. Iglesias had known that this operation was a possibility since May of last year and had been doing his homework. He had received advice from other pediatric surgeons who had previously been involved in separating conjoined twins, most of whom would tell him to keep an eye out for unexpected things and to not underestimate the amount of media attention he’s going to receive. He and his team had gone through dress rehearsals, choreographing their moves, and had prepped extensively. As one would expect of someone delegating and leading a large team on a journey to accomplish something miraculous, Iglesias speaks with a calm confidence — never too high and never too low, direct without being curt. It’s a pitch-perfect delivery akin to mission control on a tense moon landing.

The son of a vascular surgeon, Iglesias was born in Colombia before moving to the U.S. when he was just a baby and grew up in Houston. He would receive his undergrad at Baylor and attended UT Southwestern for both his medical school and residency. Iglesias, at the time, had always thought he would do what his father did and take over his practice as a vascular surgeon. But, after he began his residency and started rotating at Dallas Children’s Hospital, he found his passion for pediatrics. “I was, like, Dad, ‘I love the kids.’ So I had to have a heart to heart and sit down and tell him I’m not going to take over the practice.” After sneaking out of Texas for a couple years for his fellowship at St. Jude’s in Memphis, where he subspecialized in pediatric surgery, he got what he calls his first job at Cook Children’s in 2001 and has been there ever since.

“Next thing you know, you turn around, and you’re the oldest one in the room,” he says. “I’m not quite sure how that happened.”  

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It’s an early Monday morning in January, and Amie and Jamie receive a bevy of kisses, prayers, and best wishes from nervous family members. The twins are only minutes from being wheeled into the OR, where a painstakingly difficult procedure months in the making would separate their fused bellies. In 11 hours, the length of the operation, any subsequent embraces from the two sisters would be strictly voluntary. 

Clad in blue scrubs, surgical masks, latex gloves, and green or purple scrub hats, a large assembly of physicians, nurses, and other specialists — 20 in total — await Amie and Jamie in the OR. Despite the bevy of people, wires, tubes, and machines, the atmosphere appears surprisingly calm and orderly. The physicians are divided into two groups — team AmieLynn (green scrub hats) and team JamieLynn (purple scrub hats). Each girl gets two pediatric surgeons, an anesthesiologist, a plastic surgeon, two nurses, and two surgical technologists. 

“In the beginning, everything was very focused,” the head anesthesiologist, Dr. Reynolds, says. “It really was rather quiet, which is kind of surprising considering how many people that we had in that room.”

Amie and Jamie arrived in the OR, and the first order of business was the anesthesia. The team would devote the first five hours to prep and the all-important and meticulous process of sedating the twin girls. While the two are conjoined and share blood supply, Amie and Jamie also have separate organs, are different sizes, and have different dispositions, which means that they will require different doses of anesthesia. But, at the same time, if you put something in the bloodstream of one, it will affect the other, too. Not surprisingly, Amie goes to sleep, Jamie does not. Despite being the smaller of the two, Jamie’s natural feistiness is at odds with the sedative, and the anesthesiologist, Dr. Reynolds, is forced to administer more.

“[The anesthesiologist] doesn’t want to put them completely asleep because they don’t know how their reaction is going to be,” Dr. Iglesias says. “And their hearts are in a nefarious position.”

With Amie already intubated, Reynolds’ team — she had an anesthesiologist for each baby — would go through the cycle of giving Jamie a little more medicine and watching to see how Amie would respond. After doing this dance several times, Reynolds was finally able to get Jamie intubated.

The previous day, Dr. Gbulie had marked where the planned incisions would be. With the babies lying on their sides — Amie on her left side and Jamie on her right — Dr. Gbulie makes the incision from lower part of the breastbone (the very top of where they’re conjoined) down to the belly button. Following the initial skin incision, Dr. Iglesias and Dr. Marty Knott, Amie’s lead pediatric surgeon, begin penetrating Amie and Jamie’s abdominal walls. No longer following the S-shaped skin incision, Iglesias and Knott cut right down the middle of where the muscle meets the breastbone. At this point, the doctors have Amie and Jamie’s intestines visualized and breathe a sigh of relief when they discover they’re separate.

Iglesias and Knott then began working on the liver separation, which they meticulously chipped away at layer by layer. “It’s the same type of procedure we would do when we’re taking out a liver tumor,” Iglesias says. “Except this time nothing went to the pathologist.”

Saying that Amie and Jamie shared a liver isn’t entirely correct. They actually shared two livers. While their livers were fused together, the systems that make up this complex organ were entirely separate. The difficult part was finding the little area of their conjoined livers where these systems did not exist and cutting through that part with microscopic precision. Thanks to CT Scans, Iglesias and Knott had a rough idea of where this section of the conjoined livers was located, but they couldn’t just slice through it as if it was a stick of butter. No, they had to carefully divide the liver layer by layer, removing the tissue and sealing the ducts of the liver and blood vessels as they went. Luckily, where the division occurred, there were no big blood vessels or surprises, and the liver was now separated. 

Following a separation of Amie and Jamie’s diaphragms, pericardium sacks — the sack that encases our hearts — and additional muscle, Amie and Jamie were now entirely separated. “We’ve got two babies for the first time rolled onto their back,” Iglesias says. “Wow.”

“Once we had official separation, it was celebratory,” Dr. Reynolds says. “It really was. Everybody was very excited and, granted, there was still work to be done, and important work to be done, but there was just an excitement. There’s not really another way to describe it.

“But, then it’s literally within two seconds you’re right back at work.”

With Amie and Jamie no longer conjoined, Dr. Knott immediately gets to work on Amie in her separate bed, while Dr. Iglesias gets to work on Jamie. The steps for the process of putting Amie on a separate bed was choreographed to waste as few precious seconds as possible. 

“The operation, once they were separated, was focused on getting all of their shared space covered and closed,” Knott says.

And because they were forced to open the diaphragm during separation, both Amie and Jamie have a diaphragm hernia, which requires closing — if left be, the intestines could go up into the chest cavity. So, they had to stitch their diaphragms so each could be closed.

For lack of a better way to phrase this, each surgeon had to shove everything back inside of their respective twin. As Dr. Iglesias reminds me, Amie and Jamie were both born with this essential opening, so each sister was now losing a certain amount of area to contain all of their organs. When they close them up, it’s going to be tight. For Jamie, it was very tight, but everything was able to fit. Amie’s dimensions, however, were not able to contain everything, so they were only able to partially close her and were able to do a temporary patch. (Doctors would close her the rest of the way exactly a week after the separation.)

After 11 grueling hours, the surgery was over. Amie and Jamie, born conjoined, were now separated. Dr. Iglesias, Dr. Gbulie, and Dr. Knott all deliver the news to ecstatic and grateful parents whose daughters they will soon be able to hold, hug, kiss, and dance with separately.

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As of this writing, Jamie has made her way home, and is now under the care and supervision of her mom and dad. Amie, on the other hand, remains in the NICU at Cook Children’s Medical Center, where Dr. Lynch and Dr. Barber continue to care for her. But, every day, Amie inches toward a full recovery.

Doctors appear confident Amie and Jamie will be able to live long, happy, healthy lives, and to be kids, teenagers, and adults who are free from the devastating hardship that was thrust on them at birth. The only remnant of their journey will be the inevitable scar on their abdomens, showing where they were once attached, and will serve as a friendly reminder for each to be nice to her sister.