Tracheostomy for definitive airway management in conjoined twins is a challenge for the surgeon, anesthesiologist, and support staff. A carefully choreographed multidisciplinary approach is required. A literature search finds few reports on tracheostomy in conjoined twins. We report our experience with tracheostomy with 5.5-month-old conjoined omphalopagus twins who were attached facing each other. Initial planning led to a careful rehearsal of infant positioning focused on optimizing anterior cervical exposure. A postoperative tracheostomy care plan was also addressed. Each twin was assigned his own anesthetic team and equipment early in his life to provide consistent care for the anticipated multiple surgical procedures throughout his hospital stay. Issues addressed in this report include transportation, intubation, intraoperative airway management, the mechanical ventilatory pattern of two individuals sharing a common diaphragm, and the pharmaceutical management of two children with partially shared vascular supply.