Anaesthetic Challenges in the Perioperative Care of Ischiopagus Twins with Shared Circulation During Kidney Repositioning; a Case Report

Background Conjoined twins are rare, occurring in approximately 1 in 200,000 live births. Ischiopagus twins represent a small subset and pose significant anaesthetic challenges, particularly when vital organs and vascular structures are shared. Case presentation We report the anaesthetic management of three-year-old ischiopagus twins weighing 17 kg, who shared the bladder, rectum, urethra, and a single kidney supplied by an aberrant arterial connection between both aortae. Preoperative imaging guided surgical planning. Anaesthesia was induced simultaneously using inhalational agents due to shared circulation, followed by individual endotracheal intubation. Separate anaesthesia workstations and teams were assigned to each child. Anaesthesia was maintained with isoflurane and target-controlled remifentanil infusion. During ligation of the aberrant vessel, Twin 1 developed haemodynamic instability, managed with fluid resuscitation, fresh frozen plasma, and noradrenaline. Intraoperative monitoring relied on frequent venous blood gas analysis. Both children were transferred to intensive care and successfully weaned from vasopressor support within 12 hours. Conclusion This case highlights the importance of meticulous planning, multidisciplinary coordination, and vigilant intraoperative management when caring for conjoined twins with shared circulation.