Pygopagus conjoined twins represent 6-9 % of all the conjoined twins. They are joined at the sacral area with sharing of the terminus of the spine, gastrointestinal system, genitourinary system, and spinal cord to a variable extent. Reported worldwide incidence is estimated from 1 in 50,000 to 1 in 100,000 births with a higher incidence of 1 in 14000 to 1 in 25000 births in Asia and Africa.We share a reportedly first-ever case done in Pakistan of symmetrical Pygopagus twins presenting our challenges and treatment strategies for separation done in collaboration with pediatric surgeons and anesthesiologists playing a vital role by managing twins on two anesthesia machines simultaneously. The neurosurgery team was responsible for the careful separation of the fused sacrum and shared cauda equina rootlets. To summarize, the dysplastic sacrum was separated, fused cauda equina rootlets and filum terminale bisected and neural tube reconstruction of both twins was done augmented by fibrin glue. Layered closure of tissues done in reverse fashion. At present, both twins are healthy and living their independent lives without any neurological deficits.

To be updated.