1147 World-First Immersive Surgical Planning Using Augmented Reality for the Separation of Vertical Craniopagus Twins: A Case Series

INTRODUCTION: The separation of vertical craniopagus twins remains among the most intricate and high-risk surgical challenges. Such procedures demand comprehensive anatomical knowledge, detailed strategic planning, and seamless multidisciplinary teamwork. Augmented Reality (AR) technology presents transformative capabilities for surgical preparation and intraoperative navigation by offering immersive, patient-specific, three-dimensional visualization. METHODS: Two complex surgical cases were addressed: partial craniopagus twins were successfully separated during a single 18-hour operation, whereas the complete vertical craniopagus twins required a staged approach involving four sequential surgeries over four months. Preoperative multimodal imaging (CT and MRI) was processed through the simXAR platform, creating detailed 3D holographic models. These AR models facilitated immersive surgical rehearsal, enabling precise planning for critical phases such as incision placement, osteotomies, vascular separation, reconstruction procedures, and custom implant creation. Markerless AR tracking ensured continuous, accurate real-time referencing during surgery without disrupting workflow. RESULTS: AR rehearsals significantly enhanced team synchronization, confidence, and precision. Incremental AR visualizations during staged surgeries refined anatomical insights and implant accuracy, notably achieving precise implant placement without intraoperative modification. All four children were discharged neurologically intact. CONCLUSIONS: This landmark series highlights the significant benefits of AR technology, notably the simXAR platform, in complex craniopagus twin separations. Immersive AR rehearsal substantially improved procedural safety, efficiency, and surgical accuracy, setting new standards for pediatric neurosurgical interventions.