WCC Nurses Part of History-Making Conjoined Twin Separation

Two WCC nurses reflect on the historic procedure that successfully separated 10-month-old conjoined twins, Ximena and Scarlett Hernandez-Torres.

WCC Nurses Part of History-Making Conjoined Twin Separation


When nurses Roxana Reyna and Kirby Wilson went to work on April 12, 2016, it was anything but an ordinary day. In fact, before entering the doors of the Driscoll Children’s Hospital in Corpus Christi, Texas, they already knew it would be nothing short of historic.

The two joined a team of surgeons, nurses, and other medical professionals with one goal in mind: to separate 10-month-old conjoined twins, Ximena and Scarlett Hernandez-Torres. It was the regional hospital’s first such operation, and a rare occurrence by any standard, as the incidence of a triplet birth involving conjoined twins is believed to be about 1 in 50 million.

Ximena and Scarlett were born May 16, 2015, fused below the waist and sharing a colon and bladders. Their identical triplet sister, Catalina, was born without serious health issues. So less than a year later, with months of research, hard work and preparation behind them, the team began the complex and delicate separation process at 8:37 a.m., finishing at 8:47 p.m.

Roxana Reyna and Kirby Wilson

Left: Roxana Reyna, BSN, RNC-NIC, WCC, CWOCN
Right: Kirby Wilson, MSN, RNC-NIC, WCC

Reyna and Wilson typically work as a team, so their high level of comfort was an asset as they performed side-by-side in this high-stakes environment. Reyna, who has been a nurse for 16 years, is experienced in neonatal, pediatrics and the NICU. She is a neonatal certified nurse, was WCC certified in 2007 and became a CWOCN in 2014. Wilson has been a nurse for nine years (eight of them in neonatal ICU), and has been in wound care at Driscoll for 18 months, earning her WCC in 2015.

We spoke with Roxana and Kirby by phone, eager to hear what it was like to be involved in such a ground-setting medical event – with the eyes of the world watching. Here’s what they had to say.

Question: What were your roles within the team?

RR: Our goals preoperatively were to protect the skin and keep it free from breakdown, and our roles were to also assist with any recommendations needed for wound care. We conducted extensive pre-op research and prepared the skin – beginning right after the girls were born.

Every step required thought and strategy. For instance, we used a pressure redistribution mattress before the procedure, and since we knew the operation would be lengthy, we used a pressure mapping system normally used for wheelchairs to monitor each baby during surgery. After surgery, we monitored the babies with a continuous monitoring system. In terms of skin care, we didn’t know whether or not the skin from their back would later be used as a graft, so it was a big deal during surgery to make sure it was protected.

Ultimately, our goal was to prevent skin issues and manage their skin. We were also involved in the preparation for surgery, and assisted in monitoring the pressure mapping systems in order to offload them. We assisted the plastic surgery team with the closure of each baby and initiated negative pressure wound therapy. We continue to care for them post-op, changing dressings regularly.

KW: The pressure-mapping device was key, enabling us to see if the girls were offloaded. We came up with the unique concept of using the same pressure-mapping system used for patients in wheelchairs. We also carefully studied the different types of systems typically used for adults – like when monitoring liver transplant patients – and then adapted them for the twins to be used first while they were conjoined, and then later, once they were separated. It’s important to note that our team was the first to use this type of system in such a way. The average table time for kidney transplant patients using the same system in an adult facility is 10.2 hours, but this procedure took 12 hours.

What were your experiences with this process in terms of wound care?

KW: Fortunately, the triplets were stable when they were born pre-term at 34 weeks. The conjoined twins both had vaginas but shared one anus and a colon, so pre-op skin care was crucial in preventing breakdown of the perineum. We took care of the stoma, which like most appliances we used was adult-sized, because infant-sized ones weren’t suitable for the area.

The plastic surgeons placed tissue expanders on each baby and filled them with fluid until they could get a good expansion and be ready for surgery. We had to be vigilant in caring for the stretching and changing skin. For instance, one time we had to apply a sugar scrub and exfoliate scaly skin – we like to say it was their first spa treatment. The tissue expanders took lots of space, so we worked hard to prevent yeast infections, intertrigo and pressure from the resulting skin folds.

RR: Our lead surgeon, Dr. Patel, live-streamed the procedure so other physicians and nurses could watch every step along the way. This enabled us to visualize what we were going to be dealing with before we went into the operating room.

We took an active part in the case for about two hours for each patient, including assisting the plastic surgeon at the end. Each patient had a 30 cm incision, from the mid-gastric region to the perineum, along with a g-tube and colostomy. One baby also had a ureterostomy. The babies also had casting on the legs made to keep their newly sutured pelvis in place. So, we faced challenging dressing changes for sure. Because surface areas on babies are so small compared to adults, some of the devices were actually overlapping. We had to be very precise while working in tiny surfaces, and our ability to sort of read each other’s minds and know what each other was thinking or going to do was important.

Infant skin is not at all the same as adults – it’s much more fragile. Sometimes, pediatric patients don’t heal any faster, and they can have the same issues that adults might have, like poor nutrition or poor perfusion, for example. In post-op, infants having gone through such a lengthy surgery can have lots of swelling and pressured areas making, them at high-risk for breakdown.

In this case, because much of the devices we had to use weren’t made for babies, we made them work as long as they were safe and provided a positive outcome. We first researched outcomes in adults and utilized the properties to make them work in infants.  We’ve kept the girls healthy so far, and obviously our goal is to continue doing so.

What was it like to be a part of such an historic medical event?

RR: For me, the most important thing was making sure we could do what we needed for the kids. I didn’t really think about it as being such a high profile event. But in the weeks before the procedure, I experienced lots of anxiety. There was so much research and planning involved, and we spent hours anticipating any potential problems and possible options or solutions. We thoroughly explored case scenarios and what we might need. I mean, this is something we’d never done! What would happen?

But then a team leader pointed out that we’ve all done complex cases before, and so we just needed to look at it as another complex case, only multiplied by two. This helped. As soon as the girls were separate and it really did become two different cases, it was such a relief. At the end, we actually had extra skin from the tissue expanders. It was amazing how it was so seamless … it all went perfectly.

KW: In terms of the actual separation, Roxana and I worked so well together. We both knew what to do, but it was definitely a psychological challenge. We just didn’t know how the closure would happen. We went in as a team and did the wound VACs at the end for each patient. Working together, we can sort of read each other’s minds, and know what each other is thinking.

The physicians were so open to our thoughts and ideas, and our administration supports us so much – their support makes us successful. Other clinicians in different environments might not experience that. The entire team was amazing to work with, and no one felt afraid of the physicians, and were free to speak up with ideas, knowing others would be receptive.

What were your overall emotions and reflections on the surgery?

KW: I got to see the parents reunite with the girls, and to watch the mom react with such emotion was amazing – I still get goose bumps. The experience changed me. Honestly, it’s kind of a miracle in my eyes. For everything to have gone so seamlessly well, and the teamwork was amazing – such that I’ve never seen in my career in nursing – was just overwhelming. We definitely proved that it can be done.

RR: If I had to use one word to describe it, it would be teamwork, because it took every single person involved to make it happen. We practiced, reviewed and worked together, helping each other at every turn. And we were able to discuss everything together and freely make recommendations.

When we wheeled the girls out of surgery and into the PICU, it was kind of like handing over the baton. That was big – everything else is extra, like the icing on the cake. The media coverage was international, and so it was exciting for people all over the world to see what kind of hospital we have – that we can take care of people so well. Now that it’s over and I look back and think wow, it was amazing to be a part of that. It probably won’t ever happen again but if it does, we’ll be ready.

How did your experience with WCEI and being WCC play a part of this experience?

RR: Our physicians have always opened and encouraged WCC nurses to have input in the care of any patient. That is what has helped us to have positive outcomes, because we share what we know, and if we don’t know it, we go research it. We are respected for our abilities, and it all started with the mentorship we received from WCEI.

We are able to do lots of evaluations and case studies so we can make change, grow and advance our wound care. There’s really not that much information out there for pediatrics, so I share my experiences with other community programs and help educate others.

KW: The mentoring I’ve received from Roxana and other WCEI members and programs has helped me prepare for this, and if I can do this, I feel like I’m capable of doing anything.

What do you think?

Did you follow this historic medical story in the news? What do you think of Roxana and Kirby’s account, and have you ever worked on a particularly challenging, high-profile or notable case? We’d love to hear any reflections or comments that come to mind –  please leave them below.


Wound Care Education Institute® provides online and onsite courses in the fields of Skin, Wound, Diabetic and Ostomy Management. Health care professionals who meet the eligibility requirements may sit for the prestigious WCC®, DWC® and OMS national board certification examinations through the National Alliance of Wound Care and Ostomy® (NAWCO®). For more information see wcei.net.

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