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It’s all in the wrists: Using robotic surgery to cure a life-long condition

Dr. Casey Seideman gives Nathan Garcia, 13, a high-five after Nathan completed a task using the da Vinci Surgical System training unit, May 26, 2017. Seideman used the surgical system to remove Nathan's urachal cyst. (OHSU/Kristyna Wentz-Graff)

“Are you good at video games?” asked 13-year-old Nathan Garcia when he heard the news.

“Yes,” replied Casey Seideman, M.D., confidently.

Five years ago, Nathan got sick, and for nearly a month, he ran a high fever. His digestive issues were extreme and his white blood cell count was high. Despite these severe symptoms, there was no diagnosis.

“The doctors we saw in our hometown thought something was wrong with his digestive system, but we couldn’t be sure and his symptoms kept getting worse,” said Nathan’s mother, Holly Garcia. This meant a nearly five-hour road trip north to OHSU Doernbecher Children’s Hospital in Portland, Oregon.

Nathan underwent multiple diagnostic procedures, including an endoscopy, or the insertion of a thin, flexible camera able to take images of his digestive tract. Eager to learn the test results and embark on a treatment path, the Garcias hit another brick wall. The images looked perfect. Nothing was wrong with Nathan’s digestive system.

Nine months later, Nathan’s symptoms subsided without explanation, but only for a short time. This pattern would continue for the next few years, increasing the level of confusion and frustration for the Garcia family.

“He was able to stay active with school and sports,” Holly said of her son, a star athlete and honor roll student. “He acted tough, but we could tell he was in pain. Some days, he wasn’t able to walk. That was hard for all of us to see.”

Then, in January 2017, just like Bowser in the legendary video game Super Mario Bros., the symptoms were back with a vengeance. After a late-night trip to the emergency room in Medford, Oregon, and a last-minute ultrasound of his abdomen, doctors found a large cyst.

“Our ER doctor came to us with a heavy heart expecting to deliver bad news,” Holly recalled. “Instead, we were ecstatic. After so many years, we finally had an answer.”

The exact diagnosis? A urachal cyst that had been present in Nathan’s abdomen since birth. While in the womb, a fetus’ bladder is attached to the allantois, or a cord that connects to the umbilical cord and expels urine. Typically, the allantois shrinks as a fetus develops, creating a urachal remnant that eventually disappears. In Nathan’s case, the remnant stayed intact and became infected regularly over the course of his 13 years.

Cheryl Rice, R.N., prepares the da Vinci robot for Nathan's surgery, April 7, 2017. (OHSU/Kristyna Wentz-Graff)

With this finding, the Garcia’s were immediately connected with Seideman, an assistant professor of urology at OHSU Doernbecher, OHSU School of Medicine. She managed Nathan’s care plan remotely until the family made their way back to Portland for surgery. Seideman performed the procedure, with a little help from a robot.

While a traditional open surgery would require a prolonged recovery time and leave extensive scarring across the entire abdomen, a robotic-assisted procedure – which requires only three small incisions -  limits scarring and length of stay.

“As an otherwise healthy teenager, Nathan was the perfect candidate for robotic surgery,” said Seideman, one of a handful of pediatric urology surgeons across the region able to offer such a procedure. “It is thrilling to know that we’ll not only be able to cure Nathan of his condition, but that we’ll do it with limited scarring and a shorter recovery time.”

Casey Seideman, M.D. operates roughly 30 paces from where Nathan lies on the operating table, using the da Vinci Surgical System, April 7, 2017. (OHSU/Kristyna Wentz-Graff)

On operation day, after manually making the incisions in Nathan’s abdomen, Seideman walked to the north corner of the operating room and took a seat at a da Vinci surgical system, roughly 30 paces from Nathan’s operating table. As two robotic arms and a tiny camera called a laparoscope were placed inside the incisions, Seideman lowered her eyes to the system’s console, lightly gripped the handles, and, as if she were playing an interactive video game, skillfully began to guide the robot’s arms as they carefully removed Nathan’s cyst. Four hours later, the procedure was complete and Nathan was in recovery, his family by his side.

“I thought it was kind of cool,” said Nathan recalling the moment Seideman suggested a robotic procedure. “I was a little nervous, but was excited about not having to be here [in the hospital] for a long time after the surgery.” Within hours of completing surgery, Nathan was up and walking around his hospital room with limited pain. After just one night’s stay at OHSU Doernbecher, he was on his way home.

This past spring, the Garcia family returned to OHSU so Nathan could test his skills with a robotic simulator, akin to the technology Seideman used in the operating room. Nathan jumped right in, easily completing virtual tasks intended for surgical resident training.

“He’s definitely got a career in robotic surgery,” Seideman joked.

With no signs of abdominal pain since the surgery, the Garcias are finally able to breathe a sigh of relief.

“Nathan recently reminded me that I’ll never again have to ask him if he is feeling the pain,” Holly said with tears in her eyes. “It’s a blessing.”

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