Q&A: Inside the Historic Conjoined Twin Separation Surgery with Jose Iglesias, M.D.

By Heather Duge

Jose L. Iglesias, M.D., Medical Director of Pediatric Surgery at Cook Children’s Medical Center, was the lead surgeon during the first separation of conjoined twins, JamieLynn and AmieLynn, in Cook Children's Medical Center's 105-year history.

During his 22 years at Cook Children’s Medical Center, Dr. Iglesias has been instrumental in the advancement of surgical procedures through the use of technology and minimally invasive surgery. He also specializes in chest wall deformities, congenital malformations of the abdomen and chest, vascular anomalies, tumors, gastrointestinal and genitourinary issues.

Here are excerpts from a conversation with Dr. Iglesias prior to the surgery to separate the twins on Jan. 23, 2023.

Did you always want to be a surgeon? My father was a surgeon, and when I was young, he would take me with him to observe patient rounds and surgeries. The thought of one day following in his footsteps was always a dream of mine. I thought working with my hands to help people was awesome. In my General Surgery training, I found my passion to care for the youngest of patients.

Tell me about the growth you have seen in the Cook Children’s Surgery program since your arrival in 2001. Here at Cook Children’s our footprint is constantly evolving. Since my arrival, we have made great strides in laparoscopy and thoracoscopy. Technology and the innovation of video and optics have allowed us to better care for all our patients, even the smallest ones. In addition, we have developed a robust Pectus Program offering the minimally invasive Nuss procedure to our patients with pectus excavatum.

An important part of our program here at Cook Children’s is Quality Improvement. To that end, I helped the hospital become part of the American College of Surgeons National Surgical Quality Improvement Program which measures and tracks the quality of our surgical procedures. This supports our goal to enhance surgical care and patient outcomes.

What is the most rewarding part of your job? For me, it’s the interactions and meaningful relationships that develop because somebody has trusted me with the care of their child. One specific instance involved a mother whose baby was born with a congenital anomaly that required surgical intervention. The mom was so touched by her experience that she ultimately applied for and became a nurse here at Cook Children’s. Another instance that I will never forget involved a young lady with a rare cancer diagnosis. I had the privilege of being her surgeon for several procedures and was involved in her care for over three years. Although she passed, the family invited me to her life celebration where I got to offer my heartfelt condolences to family members in person which meant so much to me. Knowing that I may have an impact on patients and families is both humbling and rewarding, and it is an honor that I will never take for granted.

When did you first meet the twins’ family? A longtime close colleague, and maternal fetal medicine physician, Dr. Bannie Tabor, reached out to me to tell me that he was following a mother with conjoined twins. Surprised by this once-in-a-lifetime phone call, I agreed to meet with mom and dad in our office prenatally. At that time, a fetal MRI showed favorable anatomy for separation.

How long did you plan for surgery to separate the twins? It was an eight-month planning process.

Did you choose the teams for the twins’ separation? Yes. I met with Dr. Chandra Reynolds, lead anesthesiologist, and Valerie Gibbs, director of Perioperative Services, and, together, we assembled the large team consisting of three anesthesiologists, four pediatric surgeons, two plastic surgeons and about a dozen additional OR staff professionals. 

How do you plan for a surgery like this? Months of preparation. Given the complexity of the operation, we held several team meetings and mock-up practice runs to formulate a solid plan knowing that we must prepare for unexpected challenges. We perform complex procedures frequently, but they don’t all have as big of a headline as this one.

What were the next steps? Imaging and growth. We obtained ultrasounds, CT scans, 3D reconstructions and met with radiologists to discuss the anatomy and the neonatologist to address the twins’ development. It was also important to allow the twins to grow to a reasonable size.

What are the plans for surgery? The operative plan involves a step-by-step outline of where to make the incisions in order to optimize the success of closure; we did this with the guidance of our plastic surgeons. Next, we will proceed through the abdominal wall and then on to the division of the liver and lower portion of their sternum, all of which the twins share. We will constantly be assessing any other abnormalities that need to be addressed. Imaging shows the intestines to be separate, but we are prepared for any surprises. Finally, options for abdominal and chest closure are addressed.

What happens once the babies are separated? Once separated, one twin will be transferred to a different bed where teams will split into their green and purple groups and continue operating until completion.

What are the significant risks associated with this surgery? The risks are significant for this type of procedure. Because we are dealing with two abdominal and chest cavities and several vital organs, our main concerns will be bleeding, infection and blood pressure changes. We will also monitor for any heart issues given that their hearts will be in a new position. Closing their abdomens will also be a significant challenge.

Tell me about James and Amanda, the parents of the twins. They are remarkable people. I am amazed by the strength that they have demonstrated throughout this overwhelming process.  They have been eager and willing to learn everything that has been presented to them.

How does it feel that they are entrusting you with their babies? It is always an honor and one that I do not take lightly, when a parent entrusts me with their most prized possession.

What does this surgery mean for you as a pediatric surgeon? The opportunity to separate conjoined twins is an exceptional privilege most pediatric surgeons never get. It is only because we are standing on the shoulders of giants who have trained us, and incredible leaders who have laid the groundwork for this extraordinary institution that we are able to fulfill our Promise.

What does this mean for Cook Children’s? In 105 years, Cook Children’s has never been presented with the opportunity to care for conjoined twins. This will forever be a part of our history, and it is a great honor to all of us that Amanda and James have entrusted us to provide care to AmieLynn and JamieLynn.

What do you anticipate the recovery will look like? The road to recovery will start off slowly. First, we want the large incisions to start healing and for their intestines to start working so that we may feed them. After feeds are started, we will have them work with both dieticians and speech therapists. As time progresses, the twins will likely need physical therapy to address musculoskeletal abnormalities. Other than that, the healthcare team will address any and all issues as they arise. Overall, we are hopeful for a smooth and successful recovery.

What do you think their prognoses will be after surgery? Given their anatomy, I am optimistic that they will recover well and lead happy and healthy lives.

How do you think you will feel once the surgery takes place? Proud of leading a great team to a successful twin separation and humbled by the family who entrusted us. We are a team that has worked countless hours individually, in small departmental groups, multidisciplinary, and now it is time to put all of those pieces together for an operation that will be monumental for all of us here at Cook Children’s Medical Center.

Lastly, I will forever be grateful. Grateful for AmieLynn, JamieLynn, Amanda, James, all of my friends, family and colleagues for supporting and encouraging me throughout this journey. 

Getting to know Dr. Iglesias

Dr. Iglesias is married with two kids. Practicing medicine runs in the family as his wife is a neonatologist, his son will graduate from medical school in June and his daughter is a nurse resident in the NICU at Cook Children’s. “I love having her there.”

Dr. Iglesias started scuba diving during college. His passion was passed onto his son and, together, they earned their master diver certifications. Once or twice a year, they explore new destinations together.

"I moved to Fort Worth and began my career as a Pediatric Surgeon at Cook Children's in 2001 after completing my training at St. Jude & Le Bonheur Children's in Memphis, TN. My wife and two children have loved growing with the city and the medical center ever since. I attended medical school at the University of Texas Southwestern and did my residency training there also, including Parkland and Dallas Children's hospitals. My clinical interests have included minimally invasive surgery, and I was fortunate to be able to expand the technology and procedures during my time at Cook Children's. Other clinical interests include pectus and chest wall deformities, tumors, vascular malformations, and congenital anomalies. Currently, I'm the Medical Director of Pediatric Surgery (since 2014) and previously was Associate Medical Director as well as the Chief of Surgery.

Outside of surgery, I enjoy spending time and traveling with my family. Photography, scuba diving, skiing and performance driving are among my favorite hobbies. My son and I are Master Divers who enjoy exploring new destinations while my daughter and I enjoy perfecting our photography skills with one another."