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Conjoined twins, a rare anomaly in which same-sex fetuses are partially or completely joined, present unique challenges in diagnosis and management. This article reports the first successful operative separation of pyopagus conjoint twins in Pakistan, an achievement in a low-resource setting. The female twins, diagnosed prenatally, underwent a planned cesarean section at 37 weeks. The initial physical examination revealed an 18 cm conjoined area with a shared anal opening. Postnatal monitoring in the neonatal intensive care unit detected abdominal distension, leading to pelvicdivided colostomies. A multidisciplinary team, including gynaecologists, anesthesiologists, pediatric medicine specialists, neurosurgeons, and pediatric surgeons, collaborated on the operative procedure of the six-month-olds. The process involved bone removal, dural incision, and anorectoplasty. Postoperatively, one twin experienced cerebrospinal fluid leakage, which was managed conservatively. The twins were discharged after a week with a one-month follow-up.