The 2001 separation of conjoined twins Ganga and Jamuna Shrestha in Singapore remains one of the most ambitious and technically challenging feats in modern surgical history. Lasting an unprecedented 103 hours, the operation not only set a world record for duration but also redefined the limits of multidisciplinary collaboration, the use of emerging technologies, and surgical risk management.
Yet in a recent Sermo poll, only 36% of physicians correctly identified it as the longest complex multidisciplinary surgery ever recorded—64% did not. This knowledge gap underscores why revisiting the case matters: it offers rare, enduring lessons in the evolution of complex procedures, the integration of virtual and 3D technologies in surgical planning, and the delicate balance between surgical ambition and patient safety.
This article examines every facet of the Shrestha twins’ separation—from the initial clinical scenario and the formidable technical and ethical hurdles, to the cutting‑edge planning, intraoperative innovations, and the broader implications for the future of surgery.
Initial medical condition of Ganga and Jamuna Shrestha
Born in Kathmandu, Nepal, on March 17, 2000, Ganga and Jamuna Shrestha were joined at the top of the head—a rare form of craniopagus twinning seen in roughly 1 in 2.5 million live births. This condition, affecting about 2% of conjoined twins, often involves shared cranial vaults, blood vessels, and brain tissue, making separation among the most complex and high‑risk procedures in surgery.
Imaging revealed they shared large portions of skull and a common venous drainage system, but no significant neural tissue, making separation possible in theory. The challenge lay in dividing intertwined blood vessels and bone without causing fatal bleeding or severe neurological damage.
Their first year was marked by recurrent infections at the conjoined site, delayed development, and restricted mobility. As their personalities and abilities began to diverge, concerns grew over their long‑term neurocognitive outcomes if left unseparated—underscoring both the urgency and complexity of the planned operation.
Historical context: the 103‑Hour surgical marathon
At the turn of the millennium, multi‑day surgeries were rare, and successful craniopagus separations even rarer—survival rates hovered below 20%, with most survivors facing severe disabilities. Against this backdrop, the 2001 Singapore case broke precedent, lasting an unprecedented 103 hours over four continuous days. The twins were just 1 year and 17 days old when the operation began on April 6, 2001, at Singapore General Hospital.
The effort demanded extraordinary coordination. Led by neurosurgeon Dr. Keith Goh and plastic surgeon Dr. Chumpon Chantharakulpongsa, more than 20 senior consultants and 100 medical staff worked in rotating shifts. Preparations spanned over six months, involving advanced simulations, full‑team rehearsals, and the creation of custom surgical instruments.
Dr. Ben Carson—the renowned American pediatric neurosurgeon known for pioneering craniopagus twin separations—served as an advisor to the Singapore surgical team during the extensive preparation for the 2001 separation of Ganga and Jamuna Shrestha.
While he was not in the operating room performing the 103‑hour procedure, Carson’s expertise in similar cases was sought during the six‑month planning phase, where he provided guidance on surgical strategy and the use of advanced imaging and virtual reality modeling
The scale and ambition of the effort drew global attention—not only as a display of surgical heroism but as a test of the limits of medical science. Outlets such as the BBC and South China Morning Post documented the procedure in detail, offering rare insight into the immense logistical and ethical challenges faced by the team.
Surgical challenges
The separation required navigating shared skull structures and a complex venous drainage system without damaging critical brain tissue. The extended surgery duration compounded the risks, demanding meticulous planning to prevent fatigue, maintain sterility, and manage anesthesia over four continuous days. Every stage carried the potential for catastrophic complications, from uncontrolled bleeding to abrupt neurological collapse.
Technological assistance
The team pioneered the use of virtual reality (VR) and advanced computer simulation to model the twins’ cranial anatomy—cutting‑edge technology in 2001. High‑resolution MRI, CT, and angiographic scans were merged into a 3D reconstruction, allowing surgeons to “walk through” the procedure, identify anatomical bottlenecks, and plan precise bone cuts and vessel separations.
VR rehearsals improved precision, enhanced team coordination, and enabled patient‑specific reconstruction strategies. Alongside VR, fused 3D imaging provided detailed anatomical maps that guided surgical decisions. While 3D printing was still emerging, this case laid the groundwork for its widespread adoption—now used to practice bone separation, simulate vessel handling, and pre‑fit custom implants.
The outcome of the longest surgery ever
Both twins survived the separation and were discharged just five days later. Post‑surgery, each underwent extensive cranial vault reconstruction using biological tissue flaps and synthetic materials such as polymethyl methacrylate and titanium mesh, modeled from preoperative imaging for rapid fitting. Months of staged tissue expansion before surgery ensured adequate scalp coverage.
Sadly, Ganga passed away in 2008 from pneumonia and meningitis. Jamuna, however, remains healthy—her survival a testament to the surgical team’s precision, planning, and endurance. The case continues to influence modern approaches to complex craniofacial and neurosurgical procedures worldwide.
What kinds of surgeries take the longest to perform?
While the Shrestha twins’ 103‑hour separation stands as an extreme outlier, several other procedures are known for their prolonged duration. Surgical length is influenced by multiple factors: the complexity of the anatomy involved, the patient’s overall condition, the need for meticulous dissection or reconstruction, and the integration of advanced technologies that, while improving precision, can extend operative time.
In a recent Sermo poll, 60% of physicians said the longest surgery they had personally participated in or witnessed lasted under 6 to 12 hours, 24% reported 12–48 hours, and 7% had been involved in procedures exceeding 48 hours. The biggest challenge in these ultra‑long cases, according to 73% of respondents, is managing surgeon stamina—coordinating multiple surgical teams and shifts while avoiding fatigue‑related errors.
Community experiences echo these findings. A GP in Spain noted that “staff rotation, subspecialization, improved hemodynamic monitoring and anesthetic drugs, and technological advances make long surgeries less dangerous today—though cardiac surgery remains one of the most important.” An internal medicine physician in the USA recalled a liver transplant during medical school, calling the surgeons and anesthesiologists “rock stars.” A pathologist in the USA described transplant procedures lasting nearly a full day, adding, “I hope the surgeons have good stamina and the ability to work while hungry, thirsty, and tired.”
Other specialties shared equally demanding cases. A general surgeon in Colombia recounted a 12‑hour microvascular flap for head and neck surgery, emphasizing the emotional intelligence and team coordination required. A GP in Colombia remembered assisting in a 12‑hour pediatric brain aneurysm repair, quoting a neurosurgery professor who called the successful closure “orgasmic” for the sheer satisfaction of saving a life after hours of intense focus.
Surgeries that take the longest
While most operations—even complex ones—are measured in hours, some push far beyond the limits of endurance, technology, and logistics.
These surgical marathons are rare not only because of their extreme duration, but because they demand flawless coordination, advanced planning, and the ability to sustain precision under relentless pressure. From multi‑day neurosurgical separations to intricate multi‑organ transplants, these types of surgeries are redefining what is surgically possible.
Emergency exploratory laparotomies
Emergency exploratory laparotomies can stretch for many hours when surgeons must identify and repair multiple traumatic injuries in unstable patients. The urgency of these cases often means working without the benefit of full preoperative planning, adding to their unpredictability.
Cytoreductive surgeries – 4 to 10 hours
Cytoreductive surgeries often performed for advanced abdominal cancers, are inherently time‑consuming because they require the removal of all visible tumor deposits from multiple organs and peritoneal surfaces. When paired with HIPEC (hyperthermic intraperitoneal chemotherapy), the operation extends further, as heated chemotherapy is circulated within the abdominal cavity to target microscopic disease.
Liver transplants – 5 to 8 hours
Liver transplants are another marathon procedure, demanding precise removal of the diseased organ, preparation of the donor liver, and meticulous reconnection of blood vessels and bile ducts. Complex vascular anatomy or prior abdominal surgeries can add hours to the process.
Whipple procedures – 6 to 7 hours
Similarly, Whipple procedures (pancreaticoduodenectomies) for pancreatic or periampullary cancers require careful dissection around major blood vessels and reconstruction of the digestive tract, making them among the most technically demanding abdominal surgeries.
Complex spinal deformity corrections – 8 hours
In orthopedics and neurosurgery, complex spinal deformity corrections—particularly those involving multi‑level instrumentation and fusion—can last well into double‑digit hours. These cases require constant attention to spinal cord monitoring, precise alignment, and hardware placement.
Multi-stage neurosurgeries – 10 to 15 hours
Finally, multi‑stage neurosurgeries, such as those for large skull base tumors or intricate vascular malformations, may be performed over consecutive days or in prolonged single sessions. These operations demand extreme precision to avoid neurological injury, often with intraoperative imaging and navigation systems guiding each move.
What drives the duration and success of ultra‑long surgeries
When asked which type of surgery takes the longest, over 40% of physicians on Sermo pointed to multi‑organ transplants, which combine the complexity of multiple reconstructions with the logistical demands of organ preservation and implantation.
Nearly a third of poll respondents credited better anesthesia management and monitoring as the single biggest factor enabling the success of ultra‑long surgeries today compared to decades ago. And when a procedure is expected to last more than 24 hours, nearly half said the ideal approach depends on the patient’s condition and surgical goals—underscoring the individualized decision‑making that defines modern surgical practice.
Across all these examples, the common threads are surgical complexity, the need for multidisciplinary expertise, and the delicate balance between thoroughness and patient safety. Advances in imaging, robotics, and perioperative care have improved outcomes, but in many cases, they have also redefined what is surgically possible—sometimes at the cost of longer time in the operating room.
How to prepare for a long surgery as a physician
Ultra‑long surgeries test not only technical skill but also physical stamina, mental focus, and team coordination. Preparation begins well before the first incision and involves both personal readiness and collective planning. Surgeons and anesthesiologists who approach these cases strategically are better equipped to maintain precision and avoid fatigue‑related errors.
Key preparation strategies include:
- Prioritize sleep – Ensure adequate rest in the days before surgery to sustain focus and decision‑making.
- Eat well and stay hydrated – Maintain steady energy levels and avoid dehydration during prolonged standing.
- Wear compression stockings – Reduce the risk of venous pooling and leg fatigue.
- Focus on good posture – Prevent musculoskeletal strain over long hours.
- Take strategic breaks – Rotate out when possible to recover without disrupting workflow.
- Thoroughly review the case – Understand the surgical plan, potential complications, and contingency steps.
- Anticipate patient needs – Prepare for intraoperative and postoperative requirements in advance.
- Communicate with the patient – Build trust and set expectations for complex, high‑risk procedures.
- Coordinate with the surgical team – Align roles, timing, and handover protocols to ensure seamless execution.
Real‑world accounts from physicians highlight how these strategies play out in practice. One vascular surgeon on Sermo described a 10‑hour intestinal resection where the team rotated staff for breaks, monitored anesthesia and positioning to prevent complications, cycled in fresh instruments, and maintained strict infection control while planning for postoperative ICU care.
Another physician, an otolaryngologist, reflected on a 12‑hour case where the greatest challenge was not technical skill, but sustaining concentration: “Long surgeries test not only surgical skills but also discipline, resilience, and the ability to manage one’s own physical and mental resources.”
Technology—such as advanced imaging, navigation systems, and real‑time monitoring—enhances precision and safety. Effective collaboration among subspecialists ensures smooth transitions during multi‑team operations. Finally, managing both physical and mental fatigue through structured breaks, ergonomic awareness, and mutual support is essential to sustaining performance in the operating room.
Beyond the longest surgery: learning together on Sermo
The 2001 separation of Ganga and Jamuna Shrestha remains a defining moment in surgical history—103 hours of precision, endurance, and innovation that pushed the limits of what medicine could achieve. From pioneering VR planning to seamless multidisciplinary coordination, the case continues to influence how complex, high‑risk surgeries are approached today.
Across specialties, ultra‑long operations—from multi‑organ transplants to intricate neurosurgical reconstructions—demand the same core ingredients: meticulous preparation, advanced technology, skilled teamwork, and strategies to combat fatigue. Modern advances in anesthesia, imaging, and perioperative care have expanded what’s possible, but success still hinges on the discipline and resilience of the surgical team.
On Sermo, physicians share these lessons in real time, offering candid accounts of their toughest cases, the challenges they faced, and the solutions that worked. Communities like Sermo have become vital contemporary spaces where physicians debrief, learn from, and critique complex surgical cases. These peer‑to‑peer insights turn extraordinary surgical experiences into practical knowledge that can improve outcomes worldwide.
Join the discussion. Share your experience. Learn from colleagues who’ve been there. Your story could be the one that helps another physician save a life.
