A blogger criticized the school for en-
dorsing a commercial product, and noted
that one person in the picture was neither
a doctor nor a nurse but an administra-
tor. The company had not compensated
the medical team for the endorsement,
but over the years it has given two hun-
dred thousand dollars to help fund an-
nual conventions for the Clinical Ro-
botic Surgery Association, of which
Giulianotti is a founding member. Giu-
lianotti pointed out that the money was
not paid to him personally, and he does
not regret the ad, explaining that its pur-
pose 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 clear-
ing 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 op-
pose 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 con-
troversial 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 thou-
sand 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 in-
creased more than eight thousand per
cent—almost twenty-six per cent, on av-
erage, per year. During the same period,
the Nasdaq went up less than five per cent
a year. Some analysts call Intuitive Sur-
gical the “Apple of the med-tech sector.”
O
nce 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. Mon-
itors had been installed around the op-
erating room, as in a sports bar. The
da Vinci’s three arms were loaded and
ready to go: one held a grasper, the sec-
ond held a hook, and the third held for-
ceps. Giulianotti moved the grasper to
lift the stomach wall and hold it immo-
bile. He then used the forceps to push
tissue out of the way as he hooked a lig-
ament and severed it. If you were watch-
ing 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 parti-
tas 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, “Michelan-
gelo said the art is already inside the
marble block.” As Giulianotti made his
way toward the pancreas, he occasion-
ally paused to exult in how little blood
had been lost: “Only fifty or sixty mil-
lilitres!” He added, “That’s less than a
glass of wine.”
He asked a nurse to replace the for-
ceps 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 cam-
era revealed that smoke was curling in-
side the patient’s closed abdomen.
At last, the tumor—yellow-red and
bulging—was at the center of the con-
sole 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, acti-
vated 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 stan-
dard surgical protocol, the woman’s
spleen would have to come out, after
“I don’t need a club or a spear, now that I’ve mastered sarcasm.”
