University of Otago medical graduate Dr Andrew Greensmith,
now a Melbourne-based plastic surgeon and consultant at the
Royal Melbourne Children's Hospital, played a leading role as
part of the surgical team that recently separated the
conjoined Bangladeshi twins, Krishna and Trishna. Reporter
John Gibb talked to him about the challenges of the landmark
operation, which was the culmination of two years of
painstaking medical preparation.
The consequences could have been "catastrophic" if the
initial separation of the conjoined Bangladeshi twins,
Krishna and Trishna, had not gone to plan, Dr Andrew
Greensmith, one of the key plastic surgeons involved in the
landmark operation, says.
An Auckland-born New Zealander, Dr Greensmith completed an MB
ChB at the University of Otago in 1993, studying initially in
Dunedin and completing his Otago clinical studies in
Christchurch.
He later completed postgraduate training in surgery in
Christchurch and Auckland, becoming a Fellow of the Royal
Australasian College of Surgeons in 2001.
He has also undertaken further surgical training and studies
abroad, in Mexico, France and Britain.
Dr Greensmith, now based in Melbourne, Australia, made the
first incision in the marathon 31-hour operation to separate
the twins at Melbourne's Royal Children's Hospital, giving
them the chance to lead separate lives.
And he was also closely involved when the twins were first
separated surgically during the complex procedure.
"Yes, I was holding both heads at the moment of separation -
a surreal experience and a mix of relief and elation but
knowing that we then needed to immediately repair the massive
defects.
"For the twins the difference is life and death - a life
together would have been fatal within some months or years.
They are now ready for a life as individuals with normal
potential to contribute to society and normal life
expectancy.
"It has definitely been the pinnacle of my career so far and
an absolute privilege to be undertaking such a procedure and
to be part of the team in the last two years."
The experience has also reaffirmed some important life
lessons.
"My father, who is a dentist in Auckland, always taught me
that in life much more is gained in terms of personal
development from giving rather than receiving.
"This case is the perfect example - the support before and
after the operation and the gratitude extended to us by the
carers has been overwhelming and this experience will change
us all."
Among the challenges faced by the surgical team was the poor
health of the now 3-year-old children who had arrived in
Australia from Bangladesh in a rather perilous state.
"They were moribund and dying because of how they were
sharing their circulation through their blood vessels
connecting their brains - one was pushing the other into
heart failure."
Another huge challenge was the complexity of the way the
twins were joined: "the sheer surface area, the size of a
small dinner plate on each and the various types of tissue
that make up that - brain, brain lining (dura), hard tissue
(bone) and soft tissue (skin with scalp hair and fat and
fascia of the scalp)".
"What we did to fix this had to work well the first time or
else the result would have been catastrophic.
"As plastic surgeons when we face complex problems we often
look back to the philosophies of Sir Harold Gillies, the
father of modern plastic surgery and an Otago graduate who
worked during both world wars in the UK.
"He stated you must always have a lifeboat for every
operation, i.e. a plan B if plan A is not working.
"We had plan A, B, C, and D.
"Luckily plan A worked fabulously well - plan B would have
been to add skin grafts to any areas we could not close, plan
C to bring in some other [skin] flaps from locally in the
neck or back to close other areas.
"Then plan D would have been to use more distant tissue and
transfer it by microsurgery moving a sheet of muscle with its
blood vessels and join it to blood vessels in the scalp,
neck/face.
"We call this type of plan a reconstructive `ladder' with
each `rung' being our plan A, B etc."
The operation went on longer than expected, with some
Australian media outlets saying it was initially expected to
run for only 16 hours.
But Dr Greensmith says he was not surprised by the extra time
needed.
"In fact, I personally anticipated more like 24-30 hours and
had cancelled two days of private practice to accommodate
this.
"We are used to complex operations in plastic surgery and
neurosurgery taking longer than expected."
He noted that he had done a year of neurosurgery training in
Auckland and now regularly combined on cases with another New
Zealander, neurosurgeon Allison Wray, with whom he had
trained.
"My philosophy is that speed is not always of the essence.
"We are more goal-focused - extra time spent can make all the
difference.
"This is the same attitude my surgical mentors in New
Zealand, Mexico, France and Australia have taken - this
`surgical stamina' is vitally important.
"If things in plastic surgery are not right at the end of the
operation we think nothing of taking the stitches out and
getting it right before we finish.
"Young trainees often find this difficult as they assist us
in the operating theatre but it is one of the most important
things they can learn.
"Physical fitness and emotional wellbeing is also important.
I have a very supportive wife and two lovely children who
were a major part of my support team during these two years.
"I apologised to my son who is 11 for missing two of his
soccer training sessions this week as I had not missed one
for three years."
Dr Greensmith says he misses life in the South Island
"incredibly" and still keeps in touch with surgical
colleagues in Christchurch.
During his early years in Auckland he attended King's School
and then Westlake Boys' High School.
His father was an Otago University graduate in dentistry and
he was proud to follow in that tradition.
"I believe that an Otago degree is a significant factor in
helping me to face these sorts of challenges - the culture of
the university seemed always one of striving for excellence."
