32 THENEWYORKER,SEPTEMBER30, 2019
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, re-
luctantly, on some woeful pizza in
the medical center’s student cafeteria.
During the meal, he gave me some cu-
linary advice: “Never eat at a so-called
Italian restaurant where there is Caesar
salad on the menu. What is this, Cae-
sar salad?” Then he went up to the des-
ignated operating room, and waited im-
patiently for his turn at bat—some
urologists were taking forever to com-
plete 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 soli-
tary appendage: a metal tube that con-
tains within it four little arms ready
to spring out, like the tools in a Swiss
Army knife. The operating team at-
taches to the arms all the necessary de-
vices, from hooks to forceps. The patient
ends up with only one visible incision.
Earlier this year, the University of Illi-
nois 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 offi-
cially cleared it for the S.P. According
to Giulianotti’s estimate, only about
fifty such operations have been per-
formed. When I walked into the oper-
ating room, the patient was inert; inci-
sions 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 cor-
ner. The operation was not demand-
ing—he had done it about five hun-
dred 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 sec-
ond, deploying a grasper, pulled back the
neck of the gallbladder; the remainingtwo 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 stan-
dard 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 danc-
ing, the icons help keep you from step-
ping on your partner’s toes.
Giulianotti quickly ran into trouble.
In order to create a device that could
fit through one small incision, Intui-
tive Surgical had designed more deli-
cate tools. Giulianotti’s grasper lost its
grip on the gallbladder, and the organ
flopped back down, blocking the cam-
era’s view. Giulianotti froze. I could sense
his frustration both in his taut shoul-
ders and on the screen. As I watched
the grasper repeatedly fail to hit its tar-
get, I understood how much of an in-
terloper 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 success-
fully 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 in-
ternal review board asked him if there
had been “any issues.” Giulianotti curtly
reported that the beginning of the pro-
cedure 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 in-
cision had been made in the belly but-
ton, he noted, “the patient will have no
visible scar at all!” If a laparoscopic op-
eration 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.” 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 medi-
cal-products behemoth. Its device is
tentatively being called the Einstein.
(Giulianotti noted, mockingly, “Da Vinci
was a genius, and they need another ge-
nius, so—Einstein!”) According to an
industry executive who has seen pho-
tographs 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 de-
vice along with other products. The
University of Illinois, despite its long-
standing relationship with Intuitive Sur-
gical, recently signed a million-dollar
deal to test Medtronic robots in the new
underground lab.
Another threat comes from John-
son & Johnson, which now has a robot-
ics division headed by none other than
Fred Moll. This time, Moll says, his goal
isn’t to produce a huge robot for an op-
erating room; instead, he plans to man-
ufacture a more portable multipurpose
device that can be deployed throughout
a hospital, assisting on everything from
colonoscopies to heart surgeries.
Scott Huennekens, who until re-
cently ran a joint venture between Goo-
gle 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 hos-
pital, which means that far more peo-
ple will have access to it—especially
those in remote or impoverished areas.
There will be dozens of kinds of surgi-
cal robots, and many will tackle specific
jobs, from suturing in the abdomen to
setting a broken leg. The over-all sur-
gical plan will be generated by a com-
puter, crunching data from the patients’
tests and previous similar surgeries. An
A.I. algorithm will recommend a treat-
ment 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 proto-
col will not only be more democratic,