When Pier Giulianotti was a medical student, he hated the sight of blood. In the mid-seventies, he travelled from his native Italy to Spain, on a fellowship, and watched a lung resection. “I nearly fainted,” he recalled recently. “I had to sit down in the corner.” The next day, he attended a plastic-surgery procedure. “Something more gentle,” he told himself. “This will be for me!” The patient had a burn scar on her face. First, the surgeons removed the damaged skin. “You’ve seen the movie ‘Terminator’?” Giulianotti said. “I was trembling on my legs, but I was trying to resist.” After the surgeons prepared a graft by slicing healthy skin from the woman’s thigh—“Swoosh swoosh swoosh, like cutting a piece of salami!”—he went woozy. Again he was led to the chair of shame. Giulianotti considered quitting medicine, but he loved helping patients. He got over his squeamishness and decided to specialize in surgery, but kept wondering if the practice could be refined. “I am Tuscan—anatomy is painting,” he said to himself. “Surely there is a more artistic way to interact with the human body.”
He finished his medical studies and did surgical residencies at the University of Pisa and the University of Milan, which are among Italy’s best medical faculties. In the mid-eighties, he became an expert in laparoscopic surgery, in which a doctor inserts a camera inside a small incision and then uses the video to guide surgical tools that have been inserted into the body through other incisions. Minimally invasive surgery speeds recovery and reduces the length of hospital stays. But he found that laparoscopic equipment was disorienting to use—among other problems, depending on the position of the probe inside the body, the image that the surgeon sees can be backward.
In 1999, Giulianotti remembers, he attended a conference in Germany, sponsored by Johnson & Johnson, where the company demonstrated a prototype of a robotic arm for use in performing surgery. The response was tepid—the surgeons present said that they just wanted better laparoscopic tools. Johnson & Johnson shelved the project, but Giulianotti was galvanized by the concept. “Ninety per cent of the surgeons said bullshit,” he said. “But I knew.”
On a recent morning in Chicago, Giulianotti, who looks a little like Arnold Schwarzenegger with white hair, put on a sterile gown and cap, covered his craggy face with a surgeon’s mask, and entered an operating room. Giulianotti is now a professor of surgery at the University of Illinois College of Medicine, where he runs a program in robotic-assisted surgery. At the age of sixty-six, he has now performed roughly three thousand procedures with the aid of a robot, and has helped train nearly two thousand surgeons in the art. Farid Gharagozloo, a professor at the University of Central Florida and a surgeon at the Global Robotics Institute, said of Giulianotti, “He single-handedly started the area of general surgery in robotics, and I don’t think that’s an overstatement. No matter what the field, there’s a certain panache and sort of genetic makeup that makes people the leaders—makes them do things that no one else wants—and Pier has that.” Gharagozloo said that, when he watched videos of Giulianotti’s surgeries, he was left “in awe.” Giulianotti was the first surgeon to perform more than a dozen robotic procedures, ranging from kidney transplants to lung resections. In the operating room, he relies on one robot: a multi-armed, one-and-a-half-million-dollar device named the da Vinci.
The patient, a woman in her twenties, lay etherized upon a table. She had a genetic endocrine condition that causes an enlarged thyroid, and recurring tumors on the pancreas and on the adrenal glands. After Giulianotti arrived in the operating room, the physician assistant and the chief resident made four tiny incisions, marked with red dots, on her stomach, and inserted narrow tubes, called cannulas, into the holes.
Giulianotti greeted the support team and took me over to a monitor, to look at a preoperative black-and-white scan of the patient’s innards. He pointed to a large tumor on the tail of the woman’s pancreas, a couple of centimetres from her spleen. It would be “very, very challenging,” he warned, to remove the tumor without damaging the spleen. The abdomen is as densely packed as an overstuffed suitcase. The spleen nearly touches the curvature of the stomach and a section of the colon. To operate successfully within such density, surgeons must have a pinpoint sense of their tools’ locations. Giulianotti’s clinical fellow, Michail Papamichail, who was observing the operation, explained, “If you miss the plane, one mistake leads to another, and soon you have to convert.” Converting is switching to conventional surgery. Giulianotti told me that he had once made a conversion after one of the da Vinci’s arms stopped moving. But he had never missed the plane.
Robotic surgery has several advantages. First is the ability to cut and suture in deeper, tighter quarters. Robots have thin rods instead of bulky hands, and—in contrast to conventional or laparoscopic surgery—the rods never tremble. The da Vinci has four arms: one holds a camera and the other three grasp instruments. Surgeons sit at a console and use joysticks and foot pedals to control which two of the three rods they are manipulating at any given moment. A user as skillful as Giulianotti creates the illusion of having three operative hands; surgeons who regularly use the da Vinci often report experiencing a heightened sense of control. Robotic instruments are more flexible than a human wrist and can rotate three hundred and sixty degrees. Laparoscopic tools, by comparison, have a limited range of motion and can be awkward to use: when the tip of a laparoscopic tool is deep inside a patient’s body, it can be hard to exert leverage precisely, and the tiniest movement of the surgeon’s hand can lead to a major mistake. Finally, whereas most laparoscopic probes show a two-dimensional image, the da Vinci’s robotic camera gives a full three-dimensional picture of the body—the surgeon looks at the footage through a stereoscopic viewer that is attached to the console.
Papamichail told me that, were I to see the procedure unfold solely by watching the console screen, it would look like “such an easy operation to perform.” He added, “But it is not. Otherwise, many people would do it. Pier makes it look easy because he moves so smoothly, accurately, and quickly.” Papamichail also said, “What really impresses me is his perception of the inside anatomy and how delicately he is moving the robotic instruments. For each operation, he strictly follows his preoperative plan. For whatever action he does during an operation, there is always a reason behind it.”
Despite the enthusiasm of such practitioners as Giulianotti, many members of the American surgical establishment remain skeptical of robotic surgery—in part because it is expensive (having a robot perform your kidney transplant can add several thousand dollars to your hospital bill) and in part because doctors often prefer to stick with methods they have already mastered. Some physicians view robotic surgery as a pretty technology in need of a problem. Marty Makary, a doctor who performs both laparoscopic and robotic surgery, and is also a health-policy expert at Johns Hopkins University, told me, “Because the robot has been so heavily marketed, it has become a ‘one hammer’ approach. I know of instances where there’s no real benefit, but surgeons insist on using it, in order to attract patients.” Since robotic surgery first came on the scene, twenty years ago, more than eighteen thousand studies of its efficacy have been conducted, and with many procedures, such as a pancreatectomy, the method is considered superior; with other procedures, it remains unclear whether a robotic approach produces meaningfully better outcomes than laparoscopic surgery.
Giulianotti, who performed robotic surgery on a cadaver in 1999, has never looked back. He recalled to me the first times he used a da Vinci for operations on living patients. (They were all gallbladder surgeries, because for an accomplished surgeon the procedure is difficult to mess up.) He described the experience in sensual terms: “I felt the small robotic hands of the robot were a prolongation of my own. If you are used to having flat vision, and you pass into 3-D, you feel you are immersed inside the human body. It was a fantastic journey—the interior of the anatomy, the shadow of little vessels and nerves. I immediately fell in love.” He told me about a bravura operation that he performed, in 2008, on an Italian woman who had a huge tumor on her liver. The patient was a Jehovah’s Witness, and therefore couldn’t be given blood. Giulianotti recalled telling himself, “Any mistake, and the patient will die on the operating table.” Because his da Vinci-assisted incisions were so precise, he said, he was able to remove the tumor with only three hundred cubic centimetres of blood loss—about half a pint. “That was a big turning point for me,” he recalled. “I thought this technique could be expanded—a lot.” (He has since operated on dozens of other Jehovah’s Witnesses.)
For the patient currently on the table, he felt that the advantages of robotic surgery were particularly clear. Given her condition, this was unlikely to be her last visit to an operating room, and he wanted her body to emerge as intact as possible. Typically, the operation would call for removing the patient’s spleen, but she was a young woman, and it was better to keep it. “The spleen has immunitary functions,” Giulianotti explained.
At 7:35 A.M., the circulating nurse gave the “time out”—the reading of the patient’s name and age, and the reason for the surgery. Then she turned on the carbon dioxide and the patient’s stomach expanded obscenely; the suitcase became a closet. Giulianotti approached the operating table. Rows of gleaming scalpels, forceps, and sponges were arrayed on a tray—an arrangement familiar to anyone who watches medical dramas. But, at the moment when a typical surgeon would extend his hand for a scalpel, Giulianotti went into a corner, where there was a gray console that reminded me of a hulking computer from the nineties. He slid off his hospital shoes—green Crocs—and placed his stockinged feet on the pedals and his hands on the joysticks. He sank his face deep into the stereoscopic viewer. A nurse rolled a cart with four praying-mantis-like arms toward the patient’s exposed belly and connected them to the cannulas. The machine whirred as it gently adjusted its height, calculating a position that would allow its arms to move optimally inside the woman’s abdomen. Giulianotti asked for forceps, a hook, and a grasper, and the nurses attached them to the robot’s appendages. At seven-thirty-seven, the da Vinci inserted the instruments into the woman’s body, and they instantly appeared on the monitor. It was time to begin cutting.
In the nineteen-nineties, the Defense Advanced Research Projects Agency, the military organization that first developed the Internet, attempted to design a robotic-surgery device. The goal was for a doctor to sit securely behind enemy lines and remotely repair soldiers’ wounds on the battlefield. The project, which was based at the Stanford Research Institute International, was abandoned: the bandwidth available at the time was insufficient to operate a sensitive instrument halfway across the world without a devastating time lag. Some innovations pioneered at Stanford did work well, though, such as a method that offered better visualization of wounds. In 1995, a California surgeon named Fred Moll licensed the technology, with two colleagues, for tens of millions of dollars, and launched a startup, Intuitive Surgical.
Moll knew that laparoscopy, for all its benefits, could exhaust and frustrate surgeons, who often had to spend several hours manipulating their tools through tiny holes. But, if scalpels and forceps were attached to a remote-controlled robot, surgeons could easily go as deep as they wanted, at any angle. Moll and his colleagues built a device and called it the da Vinci. (Leonardo, the protean genius, had made drawings of a humanlike robot.)
Initially, sales were slow. Hospitals were wary of the high costs of the device, and many surgeons found it alienating. David Cassak, the editor of the journal MedTech Strategist, explained to me, “These are guys who like to be up to their elbows in gore.” He added that, when the da Vinci was new, “many really didn’t want to entertain the idea there was some machine out there that could replace them.” Moll began promoting the da Vinci for heart-bypass surgery, a gruelling operation for which no minimally invasive procedure was generally available—the patient’s ribs had to be cracked open. This turned out to be a strategic mistake. According to the company, one problem the researchers faced was that a patient undergoing a bypass can’t survive for very long on a mechanical heart pump: surgeons must race the clock. The procedure was too stressful for use as an introduction to the da Vinci.
One day in 2000, a German urologist named Jochen Binder decided to use a da Vinci to remove a prostate gland. He was impressed with the freedom of movement and the 3-D view offered by the da Vinci, and felt that robotic appendages, with their accuracy and strength, were especially well suited to the narrow space where the gland is tucked away. In laparoscopic prostate surgery, suturing was almost impossible—it was, as a medical executive explained to me, “like two chopsticks trying to tie a knot.” The da Vinci completed the sutures with ease. Quickly, a majority of urologists adopted the robotic approach. Intuitive Surgical executives now like to joke, “We aimed for the heart and hit the prostate.” (Around this time, Moll left the company.)
The company, like any West Coast startup, was consumed with making its platform ubiquitous: if it could get enough of its machines into hospitals, it would be hard for anyone to get them out. The sales force worked to create excitement not just among surgeons but also among potential patients, tapping into the futuristic appeal of robots. Da Vinci simulators were set up in malls. In radio ads, hospitals that owned da Vincis boasted about having the latest technology, using talking points that Intuitive Surgical had provided for them.
Many surgeons clearly preferred using the da Vinci for certain procedures, but were they sending patients home sooner and in better shape? The Food and Drug Administration hadn’t forced Intuitive Surgical to offer proof. The agency divides medical-device applications into various categories. The manufacturer of a product that employs new technology is required to demonstrate that it works and is safe. In other cases, companies need only show that their devices are substantially similar to products already in the marketplace. The F.D.A. judged the da Vinci to be a variant of laparoscopic surgery, and cleared it for sale.
Intuitive Surgical, in its early push for profit, developed a reputation for some sloppy practices. The training that surgeons were offered on the da Vinci often lasted only a day. In 2013, the F.D.A. sent the company a warning letter, accusing it of failing to keep the agency informed about updates to the da Vinci’s operating instructions, on matters such as the proper cleaning of instruments. Two years later, the American College of Obstetricians and Gynecologists declared that “the rapid adoption of robotic technology for gynecologic surgery is not supported by high-quality patient outcomes, safety, or cost data.” At about the same time, shareholders began filing lawsuits alleging that, among other things, Intuitive Surgical had made false statements about the da Vinci’s capabilities. Two of the cases were eventually settled, for fifty-five million dollars. Other lawsuits were filed by patients who said they had been harmed during surgery involving a da Vinci. A urologist, who caused a tear in the rectal wall of an obese patient while performing robotic prostate surgery, claimed that the company hadn’t warned him that the operation was not suited to seriously overweight patients. (Intuitive denied this, but settled the case.) Documents filed in that lawsuit revealed that sales representatives at Intuitive Surgical had pressured doctors to increase the number of procedures they performed with the da Vinci, so that the company’s numbers would be more impressive.
In 2014, Intuitive Surgical paid for an ad that featured a photograph of Giulianotti and other white-coated employees at the University of Illinois medical center. “We believe in da Vinci Surgery because our patients benefit,” the copy said. A blogger criticized the school for endorsing a commercial product, and noted that one person in the picture was neither a doctor nor a nurse but an administrator. The company had not compensated the medical team for the endorsement, but over the years it has given two hundred thousand dollars to help fund annual conventions for the Clinical Robotic Surgery Association, of which Giulianotti is a founding member. Giulianotti pointed out that the money was not paid to him personally, and he does not regret the ad, explaining that its purpose was to advertise for patients. “I am totally independent,” he said.
Makary, of Johns Hopkins, told me that in recent years Intuitive Surgical has “cleaned up its act,” and, among other reforms, now provides more extensive training to doctors. But its mistakes have contributed to the surgical community’s skepticism about robotic surgery. Phil Phillips, a former deputy director at the F.D.A., who played a major role in clearing the robot for use, told me, “I think the da Vinci was probably a lightning rod because its manufacturer cast it as a revolutionary device.” Giulianotti told me that most general surgeons still oppose robotic procedures. “Ask any of the presidents of the American College of Surgeons,” he said. “They’re basically all against it.” (A spokesman for the group said that it has no official position on robotic surgery.)
Even though Intuitive Surgical is controversial in the medical community, it has had the robotics field to itself, and has an excellent business plan. Currently, there are nearly five thousand da Vincis around the world. Servicing one of the robots can cost up to two hundred thousand dollars a year. From the end of the month in which Intuitive Surgical first went public, in 2000, to the end of last month, the company’s stock price increased more than eight thousand per cent—almost twenty-six per cent, on average, per year. During the same period, the Nasdaq went up less than five per cent a year. Some analysts call Intuitive Surgical the “Apple of the med-tech sector.”
Once the da Vinci had inserted its 3-D camera inside the patient with a tumor on her pancreas, everyone turned their eyes to a flat-panel screen. Monitors had been installed around the operating room, as in a sports bar. The da Vinci’s three arms were loaded and ready to go: one held a grasper, the second held a hook, and the third held forceps. Giulianotti moved the grasper to lift the stomach wall and hold it immobile. He then used the forceps to push tissue out of the way as he hooked a ligament and severed it. If you were watching the patient—nobody was—you saw the arms of the robot steadily moving in and out through the tiny incisions in the woman’s body. On the screen, things looked more frenetic. The robotic arms seemed to prod and grab at the tissue like a pack of predatory animals, giving the disquieting impression that they were feasting on a carcass.
Medical residents watched from the perimeter. As a playlist of Bach partitas played in the background, Giulianotti kept up a running commentary, which was transmitted via a sound system. He pointed out anatomical landmarks—the liver, the transverse colon—and described how he was using each instrument.
The pleasure that he took in his work was evident. “Through the navigation with the robot, you will see beautiful images,” Giulianotti had promised me. “You are moving around like you are dancing, avoiding major blood vessels and organs.” Now, after making a deft cut, he told his audience, “Michelangelo said the art is already inside the marble block.” As Giulianotti made his way toward the pancreas, he occasionally paused to exult in how little blood had been lost: “Only fifty or sixty millilitres!” He added, “That’s less than a glass of wine.”
He asked a nurse to replace the forceps with a tool called a vessel sealer, a device that emits electromagnetic waves in order to cut off blood flow, usually within seconds. It also contains a blade, for cutting blood vessels. Once the sealer had been attached, he went back to work. He came to the tail of the pancreas, where it joins the spleen, and cut the colon away from the left kidney. The 3-D camera revealed that smoke was curling inside the patient’s closed abdomen.
At last, the tumor—yellow-red and bulging—was at the center of the console screen. Giulianotti did not like the look of it. It seemed “hypervascularized,” and he suspected that it was cancerous. To test this theory, an anesthesiologist injected a green dye that moved through the patient’s bloodstream. Giulianotti switched the camera probe to infrared mode and, using the foot pedals, activated a laser on the da Vinci. The tumor pulsed green. This meant that it was sucking up blood, which suggested that it might indeed be malignant.
Giulianotti stood up and announced that “this operation has become a cancer operation.” According to standard surgical protocol, the woman’s spleen would have to come out, after all, because of the risk of leaving cancerous lymph nodes behind. “Let’s complete the job,” he said. He went back to the console, and the robot began methodically cutting the blood vessels that bonded the stomach to the spleen.
Throughout the operation, the da Vinci displayed morsels of digital intelligence. Whenever Giulianotti wanted to cut something, the robot first measured the tissue’s impedance—or resistance to an electrical current—and, thus, the extent to which blood had been stanched. If the da Vinci judged that it was O.K. to proceed, it gave an encouraging beep. The robot had a stapler, but it would not use it if the tissue that it was supposed to tack down was too thick. (It reminded me of a remark that Moll, Intuitive Surgical’s co-founder, had made to the Times, in 2008. He said that a key function of robots in an operating room was to constrain bad surgeons: “Robots are good at going where they are supposed to, remembering where they are and stopping when required.”)
At eight-forty-five, the tumor paled, its blood supply having been cut off. Giulianotti cut loose a section of the pancreas near the tumor and then separated the spleen, and its suspect lymph nodes, from the stomach wall. If there had been no evidence of cancer, Giulianotti could have chopped up the tumor and brought it out through the existing tiny holes in the patient’s belly. But this was impossible where there was a risk of malignant cells spreading, so a nurse sent a specimen bag through the cannula. Giulianotti used his robotic grasper to put the loose organ and the tumor inside the bag.
The elegance that Giulianotti so prized had evaporated. He got up from his seat and went over to the operating table. The chief resident made a three-inch incision in the patient’s abdomen. Giulianotti put a laparoscopic camera through one of the cannulas and, while watching the screen, used forceps to push the bag toward the incision. He then squeezed the contents until they fit through the slit.
At 9:42 A.M., he pulled out the bag with the severed spleen and the tumor. The specimen emerged through the incision with a plop. Giulianotti looked up like a boy with mixed feelings about having caught a fish. “We lost more blood from this stupid maneuver than from the entire robotic operation,” he groused. But there was compensation. “We finished before the Bach partitas did,” he noted.
Afterward, Giulianotti and I went to a small room outside the O.R., where various physicians were typing into terminals. He said, “Some people—even my colleagues—when speaking about the robot they are saying, ‘Oh, it’s a better tool.’ No. It’s not a better tool! It’s a complete”—he searched for the end of the thought—“philosophical concept. We are for the first time in the history of humanity using a world that doesn’t exist—virtuality—to be able to change reality.”
Later that day, we went across the street, where the university is building a new robotic-surgery center. (The most generous private donor is a satisfied former patient of Giulianotti’s.) The new lab, which is set to open next year, will be underground, and when Giulianotti first saw the bunkerlike space he found it too gloomy. So he lifted the audacious concept behind I. M. Pei’s addition to the Louvre, and added skylights, in the shape of glass pyramids, to various courtyards. Giulianotti told me that he had originally come to Chicago for a one-year sabbatical but had grown to like the city. “It is one of only three American cities acceptable to Europeans,” he declared.
To get to the new lab, Giulianotti took me beneath the university’s neuropsychiatric institute, whizzing past an “Authorized Personnel Only” sign. He has the mind-set, common to many surgeons, that he can do pretty much whatever he wants. At one point, when a publicist from the hospital told him that she was obligated to be at his side whenever I was present, he refused, informing her that he didn’t live in the Soviet Union.
Arriving at the new lab space, most of which was still under construction, Giulianotti showed me where seminar rooms and training facilities would go. He was particularly eager to try out an operation on patients who suffered from gastric reflux; if the technique worked as well as he hoped, the patients might emerge fully cured—and could stop taking medication like Prilosec. He swore me to secrecy on the new procedure, saying, “If they knew that I’m working on this project they could kill me, because I’m touching a business of billions around the world.”
We walked over to another empty space. This was where he planned to build a remote “cockpit” for surgeries in which the patient was not in the same room. It was the original DARPA project, reborn. “I think with 5G coming we can do it,” Giulianotti said. He will have to work quickly: a Boston-area company called Vicarious Surgical, which is partly funded by Bill Gates, is also working on a robot that a surgeon will be able to operate from a remote distance.
Even though competitors like Vicarious Surgical are beginning to emerge, Intuitive Surgical retains an overwhelming market share, and, with five billion dollars in cash reserves, it can afford to invest heavily in R. & D. An important next step for the company will be upgrading the da Vinci. With its cautionary beeps, the robot is more than a tool, but it is hardly as autonomous as, say, a self-driving car. It marshals no personal data about the patient or the population that has the same conditions; it does not make assessments by weighing genetic information or by aggregating data from similar procedures. During an operation, a da Vinci offers a surgeon only rudimentary guidance. If its software were a chess program, all it would do is keep you from accidentally sacrificing your queen on the next move.
Giulianotti told me that a more advanced robot could have assessed the tumor he saw that morning better in situ than he could: “I’m pretty sure that the computer would be able to recognize—based on the pattern of blood flow and the tissue itself, and based on billions of people—what is the best decision: ‘You can save the spleen,’ or ‘It’s better to remove the spleen.’ ” Later, I learned that the patient’s tumor was not actually malignant; she could have kept her spleen.
A company called Digital Surgery is trying to smarten robots by feeding visual data sets of surgical procedures into artificial-intelligence algorithms. The company already markets an app that trains doctors through simulated surgery, and it is essentially applying the same technique to training robots. The company’s founder, a surgeon named Jean Nehme, told me, “We’re not anywhere near playing grand-master chess. But the computers are at the level of a medical-school student. Our algorithms recognize and understand where a surgeon is in a procedure.”
Fred Moll, the Intuitive Surgical co-founder, is eager to see robotic medical devices incorporate artificial intelligence, but he argues that there are some decisions a computer simply can’t make. He asked me to imagine a surgeon removing a tumor from a patient’s brain. Too much cutting could lead to a loss of function, such as aphasia; too little cutting could leave the patient open to a possibly fatal outcome. The patient, meanwhile, is awake on the operating table, providing the surgeon with second-by-second feedback. “You’re trying to make a judgment about how much should I take, and there’s patient interaction,” Moll said. “When do you stop? There’s a component that’s going to be hard to displace onto a robot.”
Intuitive Surgical tends to point to the F.D.A. as the reason that complex artificial intelligence hasn’t yet made it into the operating room. Last year, Myriam Curet, the company’s chief medical officer, spoke to the Robot Report, a Web site, and said, “I actually think the technology to create an autonomous robot will actually be easy to solve. . . . The problem will be the regulatory environment.” Consumer fears will also have to be overcome. Gary Guthart, the C.E.O. of Intuitive Surgical, reminded me that human pilots still take off and land commercial planes, even though they don’t have to do so. He said, “Flight-wise, I think most folks, while they accept that there’s a fair amount of automation, they want the pilot in there. They want Sully Sullenberger.”He was careful not to promise too much autonomy for the da Vinci too soon.“When the computer makes a recommendation, it better be right,” he said. For the moment, Intuitive Surgical seems focussed more on making humans as good as robots than on the reverse. Intuitive’s main automation goal, Curet explained, is to dampen the variability of a human surgeon’s performance—“ ‘My child was throwing up, so therefore I’m tired today, and therefore my hands are not as steady as they were yesterday.’ ”
Some of Intuitive’s key patents related to the da Vinci have expired or will do so soon, and later this month the company will get a glimpse of its first significant competitor: a surgical robot made by Medtronic, the medical-products behemoth. Its device is tentatively being called the Einstein. (Giulianotti noted, mockingly, “Da Vinci was a genius, and they need another genius, so—Einstein!”) According to an industry executive who has seen photographs of the device, it doesn’t seem very different from the da Vinci. “There are only so many ways to build a robot,” the executive told me. The Einstein poses a threat mainly because Medtronic can use its market power to sell the device along with other products. The University of Illinois, despite its long-standing relationship with Intuitive Surgical, recently signed a million-dollar deal to test Medtronic robots in the new underground lab.
Another threat comes from Johnson & Johnson, which now has a robotics division headed by none other than Fred Moll. This time, Moll says, his goal isn’t to produce a huge robot for an operating room; instead, he plans to manufacture a more portable multipurpose device that can be deployed throughout a hospital, assisting on everything from colonoscopies to heart surgeries.
Scott Huennekens, who until recently ran a joint venture between Google and Johnson & Johnson, spoke to me about how the practice of surgery might be transformed in the next few decades. Once robotic devices become commonplace and reliable, surgery will no longer have to take place at a hospital, which means that far more people will have access to it—especially those in remote or impoverished areas. There will be dozens of kinds of surgical robots, and many will tackle specific jobs, from suturing in the abdomen to setting a broken leg. The over-all surgical plan will be generated by a computer, crunching data from the patients’ tests and previous similar surgeries. An A.I. algorithm will recommend a treatment regimen. Humans will oversee but not perform the actual operating. The only person who will be nostalgic for today’s clumsy methods is the kind of surgeon who is driven by the visceral thrill of immersing his hands in flesh. A data-driven, robotic surgical protocol will not only be more democratic, Huennekens promised; it will “result in better outcomes, faster recoveries, and lower costs.”
I got a sense of how far we are from this vision when I watched Giulianotti remove a woman’s gallbladder, a few hours after he’d finished the operation on the pancreas. He had lunched, reluctantly, on some woeful pizza in the medical center’s student cafeteria. During the meal, he gave me some culinary advice: “Never eat at a so-called Italian restaurant where there is Caesar salad on the menu. What is this, Caesar salad?” Then he went up to the designated operating room, and waited impatiently for his turn at bat—some urologists were taking forever to complete a robotic prostatectomy.
By two-forty-five, he was back in scrubs. For this patient, he was using Intuitive Surgical’s newest model robot, the da Vinci S.P. (The initials stand for “Single Portal.”) The robot has a solitary appendage: a metal tube that contains within it four little arms ready to spring out, like the tools in a Swiss Army knife. The operating team attaches to the arms all the necessary devices, from hooks to forceps. The patient ends up with only one visible incision. Earlier this year, the University of Illinois at Chicago sent out a press release boasting that it owned the only S.P. in the city.
The university’s internal review board had approved the gallbladder procedure, even though the F.D.A. has not yet officially cleared it for the S.P. According to Giulianotti’s estimate, only about fifty such operations have been performed. When I walked into the operating room, the patient was inert; incisions had been made around her belly button, and a flap of skin rested on her stomach like a tube of toothpaste that had been flipped open.
Giulianotti went over to his corner. The operation was not demanding—he had done it about five hundred times with the old, four-portal da Vinci. The probe, which resembled a metal straw, slid smoothly past the liver; once it was inside the abdomen, four tiny, jointed arms emerged from the tube. One held the camera; a second, deploying a grasper, pulled back the neck of the gallbladder; the remaining two moved to clip and cut an artery that connects to the organ. Because the da Vinci S.P.’s purpose is to function in even narrower surgical fields than the standard model, it has special icons on the console that help the user keep track of where the three tools and the probe are at all times. If robotic surgery is dancing, the icons help keep you from stepping on your partner’s toes.
Giulianotti quickly ran into trouble. In order to create a device that could fit through one small incision, Intuitive Surgical had designed more delicate tools. Giulianotti’s grasper lost its grip on the gallbladder, and the organ flopped back down, blocking the camera’s view. Giulianotti froze. I could sense his frustration both in his taut shoulders and on the screen. As I watched the grasper repeatedly fail to hit its target, I understood how much of an interloper the surgical tools were in the slippery confines of the body, and how much harm they could do if the surgeon got even slightly discombobulated. The patient’s liver hovered, like a piñata, just millimetres away.
Eventually, Giulianotti retracted all the tools, so that he could see the larger area more clearly. The grasper successfully latched on to the gallbladder’s neck, and the rest of the operation went smoothly. Once the gallbladder was free, Giulianotti used the grasper to bring it near the surface; the assistant surgeon then used forceps to pull it out of the patient’s belly button.
“It was difficult,” Giulianotti told me, outside the operating room. “We are still working on the procedure, what we can do better.” He assured me, with a touch of wounded pride, that “with the multi-probe it would have been a piece of cake.” A staffer on the hospital’s internal review board asked him if there had been “any issues.” Giulianotti curtly reported that the beginning of the procedure had been a struggle. But, after he’d walked down the hall and thrown his used scrubs into a compactor, his enthusiasm resurfaced. Because the incision had been made in the belly button, he noted, “the patient will have no visible scar at all!” If a laparoscopic operation had been done with only one incision, he told me, it would have been much more risky. “And by the way,” he said, “she’s going home in two hours.” ♦
