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asymmetrical conjoined twin has a member , the host ( auto - site ) , which is near normal .
the host bears the parasite , which is incomplete , smaller , and fully dependent on it for growth .
this form of conjoined twins is referred to as heteropagus and when attached to the epigastrium of the auto - site , is called epigastric heteropagus .
we report a novel approach for the repair of omphalocele using the gluteal skin flap available from the parasite .
a 2-day - old male was referred to us as a case of conjoined twins .
the baby was a full - term normal vaginal delivery , first in birth order , born out of non - consanguineous marriage .
the mother was 25 years old , not registered for antenatal care and with no antenatal ultrasound scans done . on examination , there was an incomplete parasitic twin attached to the epigastrium of the auto - site with an omphalocele above .
the parasitic twin had well - developed lower limbs , a penis with urethra , which was blind beyond its root , a poorly developed scrotum without testes and an anal dimple without an anal opening [ figure 1 ] .
the auto - site had an omphalocele , the contents of which were liver and intestine .
2d - echocardiography ( 2d - echo ) revealed multiple cardiac anomalies ( atrial septum defect [ asd ] , ventricular septum defect [ vsd ] , patent ductus arteriosus [ pda ] , overriding of aorta , and peripheral pulmonic stenosis ) .
ultrasonography with doppler showed the parasitic twin being supplied by a single vascular pedicle arising from the epigastric region .
operative management consisted of the removal of the parasitic twin and covering the omphalocele with the gluteal skin flap secured from the parasitic twin .
the gluteal skin flap was based on the cutaneous branches of the superficial epigastric vessels of the auto - site and superior gluteal perforating artery of the parasite . during removal of the parasitic twin , a large section of skin and fat ( flap )
was raised by making an incision parallel to the iliac crest [ figures 2a and b ] .
the fat on the superolateral aspect of the flap was dissected down to the level of the deep fascia covering thr gluteus maximus muscle .
this flap was then used to cover the omphalocele of auto - site [ figure 3 ] .
( a ) gluteal flap marked from the parasitic twin , ( b ) gluteal flap marked from the parasitic twin post - operative outcome post - operative course was uneventful , except for infection along the edges of the skin flaps , which was managed conservatively . patient is asymptomatic after 6 months of follow - up .
conjoined twins , is a rare congenital anomaly , seen in 1 in 50,000 - 100,000 live births .
asymmetrical conjoined twins refers to unequal and asymmetrical twinning , in which the dependent component ( parasite ) is smaller and attached to any portion of body of the dominant component ( auto - site ) or even within the body as a fetus - in - fetu .
epigastric heteropagus conjoined twins , a condition in which a parasitic twin is attached to the epigastrium of the auto - site , is extremely rare and only 44 cases have been previously reported in the world literature .
embryologically , epigastric heteropagus results from ischemic atrophy of one fetus at an early stage of gestation and selective atrophy of the cranial part of the parasite .
; the parasite has duplication of the pelvis and pelvic organs , such as the complete urinary tract , external and internal genitalia .
investigative work - up , apart from routine , consists of contrast enhanced computerized tomography ( cect ) , barium meal follow through , 2d - echo , and angiography .
barium meal follow through is useful to evaluate any connection between the auto - site and the parasitic intestine .
common cardiac anomalies are pda , vsd , and asd . in the literature , management of asymmetrical conjoined twins with omphalocele
the various surgical procedures described in the literature for management of epigastric heteropagus with omphalocele are : 
 excision of the parasite in the neonatal period and conservative management of the omphalocele ( using local applicants such as tincture benzoin , mercurochrome).surgical excision of the parasite and primary omphalocele repair that is a reduction of omphalocele contents and repair of the abdominal wall defect.surgical excision of the parasite in the neonatal period and delayed omphalocele repair using mesh ( ethicon vypro ii ) . after extensive search in the literature
, we have not found any report in which use of a flap has been made for repair of omphalocele , in case of epigastric heteropagus . 
 
excision of the parasite in the neonatal period and conservative management of the omphalocele ( using local applicants such as tincture benzoin , mercurochrome ) . surgical excision of the parasite and primary omphalocele repair that is a reduction of omphalocele contents and repair of the abdominal wall defect . surgical excision of the parasite in the neonatal period and delayed omphalocele repair using mesh ( ethicon vypro ii ) . after extensive search in the literature
, we have not found any report in which use of a flap has been made for repair of omphalocele , in case of epigastric heteropagus .
we report the 45 case of epigastric heteropagus twins and a novel surgical approach for the repair of omphalocele of the host by covering the omphalocele with gluteal skin flap secured from the parasitic twin .
epigastric heteropagus is an extremely rare congenital anomaly , in which there is asymmetrical conjoined twinning , with the parasitic twin attached to the epigastrium . 
 a 2-day - old male , with epigastric heteropagus and omphalocele , was operated in our institution . 
 after excision of the parasitic twin , omphalocele was covered with a gluteal skin flap available from the parasitic twin . 
 post - operative course was uneventful , except for infection along the edges of the skin flaps , which was managed conservatively . 
 only 44 cases of epigastric heteropagus twins have been reported previously in world literature . 
 we present a novel surgical approach for the repair of the omphalocele in a case of epigastric heteropagus twins , probably the 45th case to be reported in the world literature .