THENEWYORKER,SEPTEMBER30, 2019 27
The patient, a woman in her twen
ties, lay etherized upon a table. She had
a genetic endocrine condition that causes
an enlarged thyroid, and recurring tu
mors on the pancreas and on the adre
nal glands. After Giulianotti arrived in
the operating room, the physician as
sistant 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 blackandwhite 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 chal
lenging,” he warned, to remove the tumor
without damaging the spleen. The ab
domen is as densely packed as an over
stuffed suitcase. The spleen nearly touches
the curvature of the stomach and a sec
tion of the colon. To operate success
fully within such density, surgeons must
have a pinpoint sense of their tools’ lo
cations. Giulianotti’s clinical fellow, Mi
chail 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. Giu
lianotti 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.
R
obotic surgery has several advan
tages. First is the ability to cut and
suture in deeper, tighter quarters. Ro
bots 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 con
sole 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 in
struments are more flexible than a human
wrist and can rotate three hundred and
sixty degrees. Laparoscopic tools, by com
parison, 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 move
ment of the surgeon’s hand can lead to
a major mistake. Finally, whereas most
laparoscopic probes show a twodimen
sional image, the da Vinci’s robotic cam
era gives a full threedimensional pic
ture 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 per
form.” He added, “But it is not. Other
wise, many people would do it. Pier
makes it look easy because he moves so
smoothly, accurately, and quickly.” Pa
pamichail also said, “What really im
presses me is his perception of the in
side 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 al
ways a reason behind it.”
Despite the enthusiasm of such prac
titioners 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 technol
ogy in need of a problem. Marty Ma
kary, a doctor who performs both lapa
roscopic and robotic surgery, and is also
a healthpolicy expert at Johns Hopkins
University, told me, “Because the robot
has been so heavily marketed, it has be
come 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 sur
gery first came on the scene, twenty years
ago, more than eighteen thousand stud
ies of its efficacy have been conducted,
and with many procedures, such as a
pancreatectomy, the method is consid
ered superior; with other procedures, it
remains unclear whether a robotic ap
proach 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 gall
bladder surgeries, because for an accom
plished surgeon the procedure is diffi
cult 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 3D, you feel you are immersed in
side 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 per
formed, 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. Giu
lianotti 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 centi
metres 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 Je
hovah’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 in
tact 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 op
erating 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
