Dream Machine: Pediatric Robotic Surgery

August 15, 2020

Typically, we photograph every patient appearing in HealthU. Because this story was planned during the surge of COVID-19, that contact would have been too risky. Instead, our team took a creative approach and replaced photo shoots with illustrated portraits of patients.

In mid-April 2019, 12-year-old Blake Lewis told his mom, Angela, that he had a bad stomachache. She monitored him for a while, assuming it was just a bug, but eventually took him to K. Hovnanian Children’s Hospital at Jersey Shore University Medical Center when his pain worsened.

During a weeklong stay at the hospital, various tests showed that Blake had an infection in his intestines. He was treated with a restrictive diet and an enema to flush his system, then released, symptom-free.

However, the testing revealed something more ominous, something entirely unrelated to his infection. The CT scans showed a lesion on his spleen—the organ located in the uppermost area of the left side of the abdomen, just under the diaphragm, that helps fight certain bacteria and acts as a filter for blood as part of the immune system.

“If it hadn’t been for the stomachache, we would’ve never known it was there,” Angela says. “And we have no idea how it got there or how long it had been there, either. It could have been since birth or could have been a couple of years.”

The Waiting Game

Victoriya Staab, M.D., a pediatric surgeon and medical director of pediatric trauma at K. Hovnanian Children’s Hospital, was concerned about the finding and told Blake’s family that there were two options going forward: watchful waiting or surgery.

“It’s very rare to have a mass on the spleen, and rarer to find one in children,” Dr. Staab says. “So, of course, the million-dollar question was: Is this cancer?”

Blake’s parents—Angela and his dad, David May—opted for watchful waiting. The lesion on his spleen didn’t grow, but it didn’t go away either.

So during a multidisciplinary tumor board meeting, a team of physicians from various specialties, including pediatric hematologists/oncologists, pediatric surgeons, robotic surgery experts and radiologists, decided to recommend surgery to remove Blake’s lesion. “When they told us they wanted to remove the lesion, we were happy to hear it; we were so stressed out just waiting,” Angela says. “They explained everything in ways that we could understand and made us feel so safe and cared for.”

Blake’s medical team wanted to preserve as much of his spleen as possible, as removing the entire spleen is incredibly risky in children. Because the spleen acts as a filtration system, removing it could lead to an array of bacterial infections, some of which could be deadly.

They decided to remove only the lesion, and not the entire spleen, during a surgical procedure called a partial splenectomy. But the lesion was located on the upper portion of Blake’s spleen, making it difficult to reach during surgery.

The team also wanted to avoid a traditional open surgical procedure, which requires a larger incision, a lengthier recovery and a higher risk of complications. Dr. Staab consulted with Seth Kipnis, M.D., FACS, director of robotic surgery at Jersey Shore, to find out if it would be possible to perform a partial splenectomy using robotic surgical technology.

Uncharted Territory

The surgery wouldn’t be just any surgery. A robotic surgery on a pediatric patient had never been performed at K. Hovnanian Children’s Hospital. Still, Dr. Staab and Dr. Kipnis knew it was their best option. “Since Blake’s lesion was difficult to reach laparoscopically, the only way we could avoid a total splenectomy was to use the robot,” Dr. Kipnis says.

On September 20, 2019, Dr. Staab and Dr. Kipnis worked as co-surgeons during Blake’s two-hour procedure. Dr. Staab operated the intraoperative ultrasound, which is used to assess the size, margins and blood supply of the lesion during surgery; Dr. Kipnis operated using the robotic surgical system.

The da Vinci robotic surgical system that Dr. Kipnis used during Blake’s operation has four arms: one that holds a camera, and three that hold tiny surgical tools. While sitting at a control console equipped with a screen that displays real-time, high-definition video transmitted from the camera, Dr. Kipnis performed Blake’s surgery by maneuvering the robotic surgical system’s arms and inserting small surgical tools into four very small incisions in Blake’s abdomen.

“The robot allowed me to control everything and access all the hard-to-reach spaces,” Dr. Kipnis says. “I even recorded the surgery and plan to present it at a conference later this year because it’s just so rare.”

The lesion was successfully removed, Blake’s spleen remained intact, and tests later confirmed that the lesion was benign.

“Before the surgery, we did our best to downplay it for Blake so he wouldn’t get scared,” Angela says. “He was such a trooper and was mostly just fascinated by all the robot technology in the room.”

A Story to Tell

The day after his surgery, Blake was up and walking around the hospital. A few days later, he went home. The only downside was that he couldn’t participate in the sports he loves, like cross-country, play too hard at recess or even ride his bike for a few months while his body healed.

Then COVID-19 happened. Blake and his family began sheltering in place in March.

“I was a little afraid before the surgery that I might not wake up, but all the doctors and nurses made me feel better,” Blake says. “When it was over, I wasn’t hurting, I was really just fine. But now, I’m going crazy stuck at home!”

Soon enough, Blake will be back to his routine. He’ll have completely normal function, and zero side effects from his surgery. Plus, he’ll have an awesome story to tell his classmates.

“I wouldn’t want to do it again, but the robot was really cool,” Blake says.

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