FEATURE STORY — July/August 2008

The Beethoven of Surgery

Many consider Dr. Pier Cristoforo Giulianotti to be the world’s preeminent specialist in robotic surgery.  So why did he decide to leave Grosetto, Italy, and come to UIC?

By Sandra A. Swanson

It’s 7:30 on a brisk January morning, and in room 14 on UIC’s surgical floor, an operation is underway—one that reflects the future of surgery here, and around the world.

Upon entering, the first thing you notice is a light-grey, 5-1/2-foot-tall, 1,200-pound machine in the center of the room. Its official name is the da Vinci Surgical System. Here in the operating room, it’s simply called “the robot.” Presently, it looms above the patient, who is covered head-to-toe with a cobalt blue sheet, save for her exposed abdomen.

The robot’s four linebacker-sized arms dip, bend and sway, in an erratic dance that seems out of step with the soundtrack of the OR (the patient monitor’s steady beep, blended with faint strains of classical music). Attached to the end of each arm is a metal rod—about the diameter of a pencil and nearly twice as long—which partially disappears inside the patient’s belly.

 To the casual observer, it’s an uneasy sight. The robot’s sheer hulking mass doesn’t say “minimally invasive surgery” so much as “I can pulverize asphalt.” Equally disconcerting, as a half-dozen doctors and nurses circulate around the room, is the question of who’s in control here.

The answer sits along one of the OR’s pale-blue-tiled walls, about five feet behind the patient, eclipsed by the robot’s girth while orchestrating its every move. His name is Dr. Pier Cristoforo Giulianotti, considered by many to be the world’s preeminent specialist in robotic surgery. In the fall of 2007, he left his position in a small Italian town, 5,000 miles away, to help cement UIC’s status as a pioneer in robotic surgery. “He is the Beethoven of surgery,” says Dr. Enrico Benedetti, RES ’93, head of UIC’s surgery department. “A surgeon like him comes along once in a lifetime.”

HOW SURGEONS CHAT WITH ROBOTS

On this particular morning, Giulianotti is performing a hepatectomy, eliminating a cancerous growth by removing the left lobe of the patient’s liver. For the next two hours, he remains seated at the “surgeon console,” a gray-hued unit that could be mistaken for some sort of utilitarian, virtual-reality arcade game. His elbows rest on a black padded ledge, while each hand maneuvers a small, joystick-like metal bar. With precise, subtle movements, his fingers tell the robot how to perform a carefully choreographed dance of cutting, cauterizing, suturing. His feet play a role, too; the console has five pedals that control the camera’s focus, among other things.

A fiber-optic cable links his console with the robot, sending instructions to its arms and their detachable surgical instruments. The robot, in turn, sends vital information back to the surgeon—courtesy of its dual camera lenses that probe the patient’s abdomen. Throughout the operation, Giulianotti rests his forehead against a binocular viewer while the two cameras deliver a different image to each eye. The result: Although the OR’s medical staff has a good view of the operation via flat screen monitors (the robotic cameras provide up to 28-times magnification), Giulianotti has the best seat in the house. His viewer provides 3-D vision, intimately acquainting him with this patient’s liver, spleen and abdominal wall.

When the operation is complete, the patient will have several incisions measured in millimeters rather than the three-to-six-inch incisions that would have resulted without the robot’s assistance.

Small incisions certainly aren’t a new concept in the OR. Laparoscopy has achieved this since the 1990s. Several plastic tubes (called ports) are inserted in the patient, through which the surgeon inserts long instrument rods with different attachments (robotic surgery also uses the port system). One key attachment is the laparoscope, which emits light and has a small video camera, so surgeons can peer inside a patient.

Like robotic surgery, laparoscopy is a minimally invasive approach, and that means less trauma to the patient. But it also has notable shortcomings. “It is a very primitive way to operate,” says Giulianotti. For example, surgeons must stand for hours, with arms and shoulders strained, and the long instrument rods they hold have a limited range of motion. By comparison, robotic instruments have wrist-like joints at their tips with a 360-degree range of motion, which surgeons operate while sitting in relative comfort.

DISCOVERING THE DIGITAL REVOLUTION

When Giulianotti first witnessed a demonstration of the da Vinci robot in 1999, he was hooked. It was a fine Italian pairing: the robot’s namesake, Leonardo da Vinci, and Giulianotti both grew up near Tuscany (the robot itself is designed by Sunnyvale, Calif.-based Intuitive Surgical). Like da Vinci, Giulianotti also shares a passion for both art and science. His conversations are peppered with references to philosophy and classical music. When comparing Italian cities with Chicago, he muses that while both have beauty, the former is like a Botticelli painting and the latter resembles work from futurist painter Giacomo Balla.

On his sparsely populated office desk sits a copy of an Italian-American English dictionary. It’s one reminder that, less than a year ago, Giulianotti primarily spoke his native language in the operating rooms of Misericordia Hospital in Grosetto, Italy.

His attraction to medicine began in high school. “I felt it was the renaissance compromise between the humanistic aspect of life, and the scientific,” says the 54-year-old head of UIC’s division of minimally invasive, general and robotic surgery. “You can’t completely define surgery as a science—there is a portion of art. Sometimes you can do an operation in a way that another person is unable to do, like sculpturing,” says Giulianotti, tapping an imaginary marble chunk with an invisible chisel.

Robotic surgery has shifted that balance somewhat. “Compared to many years ago, the scientific portion is increasing more and more,” he says. That’s because robotic surgery’s obvious patient benefits—such as performing intricate surgeries in small cavities, with minimal blood loss—may not even be its most compelling aspect. For Giulianotti, the real revolution is digital.

With the advent of robotic surgery, the details of procedures could suddenly be translated into bits and bytes. The da Vinci system’s computer processes the surgeon’s manipulation of the robot, as well as the images captured by cameras during surgery, says Giulianotti. “For the first time, the [surgical] procedure itself is measurable.”

His eyes widen as he lists the possible applications. After analyzing thousands of procedures, the computer could warn surgeons if they are about to make a mistake. Or the computer could help simulate surgery. Currently, if Giulianotti has a particularly challenging case, he visualizes the procedure for several days in advance. The robot could create a sophisticated virtual surgery experience based on real procedures in the OR, benefiting both new and veteran surgeons.

ROAD TO ROBOTVILLE

Many parents would be thrilled to have a child who pursues medicine as a career, but Giulianotti’s father was not one of them—not initially, anyway. As high school graduation neared, Giulianotti expressed his desire to become a doctor. “I had a big fight with my father,” he says. “He was an officer in the army, and wanted me to continue the tradition of the family, in a military career.” His father offered a compromise: train to be an army officer and a doctor at the same time.
To Giulianotti, this was unacceptable. “I thought medicine should be a full dedication of the life, not being half soldier, half doctor,” he explains.

At that point, his father refused to provide financial support for his education. Ultimately, that wasn’t a problem for Giulianotti. He was accepted by one of Europe’s most prestigious colleges, Ecole Normale in Pisa, where tuition is free but admissions are few. “They take no more than five or six students per year from Italy,” says Giulianotti, who notes his father was the first person to congratulate him.

While the UIC team was there, other prominent surgeons from Italy, France and Japan also arrived to observe Giulianotti.

He went on to earn his medical degree at Pisa University, where he served his residency in general surgery, and also served as a professor for nearly two decades.

In 1998, he joined Misericordia Hospital in Grosetto, Italy, as head of surgery. The hospital didn’t have the da Vinci robot before Giulianotti arrived, but that soon changed after he lobbied local government and financiers—no small feat, considering the investment required (currently, a da Vinci system costs about $1.5 million).

Giulianotti delivered a substantial return on that investment. Patients from Florence and other large cities began flocking to Misericordia because of his expertise, says Benedetti. When the two men first met in 2003 at a UIC medical conference, “he was already the doctor of the rich and famous,” including Italy’s health minister, Benedetti notes.
 
Giulianotti and Benedetti developed a fast friendship. But the idea of the Italian surgeon ever moving to Chicago was “beyond [UIC’s] wildest dreams,” says Benedetti.

In the world of robotic surgery, Giulianotti was a bit of a rock star. Benedetti got a hint of that when he traveled to Misericordia in 2005 with a few other UIC staff members to learn from Giulianotti’s robotic technique. “What we found, in this remote place, was a registry of his guests. There were three books filled with signatures of the who’s who in surgery,” recalls Benedetti. While the UIC team was there, other prominent surgeons from Italy, France and Japan also arrived to observe Giulianotti. “That was standard,” he says. “That OR was always crowded with people coming from all over the world to watch the professor.”

What made this even more extraordinary was the surgeon’s location—not in a major Italian metropolis, but in Grosetto. “Pier Giulianotti is the ultimate underdog,” says Benedetti. “It would be the same thing as a general surgeon in Joliet becoming the most famous robotic surgeon on earth. Except maybe Joliet is a little bigger.”

After three days of observing the underdog, Benedetti and his colleagues had an epiphany. “We knew we were watching the best surgeon alive in the world,” he says. “We had never seen anything like this … and we are not an unsophisticated crowd.”

PATIENT’S EXPERIENCE WITH THE ROBOT

During that visit, Benedetti marveled as Giulianotti performed a pancreaticoduodenectomy. The procedure’s other name, much easier on the tongue, is the Whipple (named after the American surgeon who refined it). Considered to be the most complex abdominal operation a surgeon can perform, the Whipple involves removing the gall bladder, part of the stomach, and the head of the pancreas, and attaching the pancreas and bile duct to part of the small intestine.

In 2003, Giulianotti became the first surgeon in the world to perform the Whipple procedure robotically. Even today, few surgeons are able to achieve this, notes Benedetti.

So when patient William Schaban found himself in a UIC hospital room last September, he had at least one thing in his favor: impeccable timing. If his duodenal ulcer (then potentially cancerous) had been discovered months earlier, his Whipple procedure probably would not have been performed robotically—and certainly not by Giulianotti, who was still based at a hospital 5,000 miles away in early 2007.

Schaban jokes that his first impression of Giulianotti was his height (both men are 6’2”). “He exuded confidence—I was very comfortable with him right off the bat,” says the St. Charles resident, sitting in a UIC doctor’s office with his wife, Emily, after one of his weekly check-ups. Ten weeks after his Whipple procedure, Schaban still has a surgical drain in his abdomen. What he doesn’t have is a long scar, thanks to the robot’s minute incisions. After seeing his belly, post-Whipple, Schaban was surprised: “There were no bandages; they just glued everything shut.”

When he first learned about the Whipple’s delicate, seven-hour procedure, it was “a little scary,” Schaban admits. Still, he was pleased to hear there was an 80 percent chance the procedure would be done robotically.

His wife shared that sentiment. “I felt good about the way they were going to go in, because years ago, I had gall-bladder surgery, and they really cut me from way up here all the way down,” says Emily, using her finger to draw a line through her torso, stem to stern. “They went through nerves and muscle—I’m still numb by the incision.” Emily’s reaction when she saw her husband’s incisions? “Jealous!” she says, laughing.

It took only one week for UIC to discharge William after his Whipple procedure. “They told me I could drive right away, but to use common sense … like, don’t lift 50-pound bales of hay,” he says.
 
Asked to share his state-of-mind the morning of his surgery, William leans in, confessionally: “To be honest, this is the first operation that I’ve ever had.” At age 69, that truly is impeccable timing; if you must go under the knife, why not wait seven decades for a dramatic improvement in medical technology? “So I was kind of looking forward to it, as an adventure,” says William. “I was concerned that it was a delicate operation, and that things could go wrong, but I had every confidence that it would go right.”

DR. GIULIANOTTI COMES TO TOWN

Before Giulianotti arrived in Chicago and performed William’s procedure, UIC already had a well-established robotic surgery program. The Medical Center obtained a da Vinci system in September 2000, just two months after it was approved by the FDA, and UIC surgeons were the first in Illinois to perform a robotic procedure.

That momentum was threatened in the summer of 2006, when the surgeon who led UIC’s robotic program accepted a position in California. Benedetti, then interim head of surgery, immediately called his friend Giulianotti. He knew it wouldn’t be easy to lure the surgeon away from Misericordia. Several other universities had already tried, including a U.S. Ivy League institution, says Benedetti.

So why did he choose UIC? “I was attracted by the idea of cooperating with Dr. Benedetti,” says Giulianotti. “Because in my opinion, he is a marvelous transplant surgeon, and he shares with me the idea that the surgery of the future will be robotic and minimally invasive.”

That’s not a universally shared vision, apparently. One might think the patient population would have some resistance to robotic surgery—after all, they’re the ones getting poked and prodded. Instead, it’s members of the surgical community who typically oppose robotics, even at prestigious universities, says Giulianotti.

At UIC, he knew that wouldn’t be a problem. “Dr. Benedetti would be able to create the right environment for the best results,” says Giulianotti.

His new position in Chicago also would give him the chance to be published in peer-reviewed medical journals. Says Benedetti: “That’s what will really place your name in the history of medicine.” Giulianotti plans to publish several articles this year, including one that links robotic surgery’s low rate of transfusions with cancer patients’ improved chances of full recovery.

Giulianotti and Benedetti share a strong desire for a robotic-surgery clinical program at UIC. In late January, the medical center acquired a second da Vinci system for training and research. “The fact that we have a guy like Pier means that we have an ideal situation to promote faculty who are already competent in a certain field to become good robotic surgeons,” says Benedetti. “UIC will have a tremendous advantage … My firm belief is that 10 years from now, a lot of procedures now done with open [surgery] will be done robotically.”

The recent trend in prostate surgery supports his theory. Each year, U.S. hospitals perform about 70,000 prostatectomy cases. In 2003, about 400 were done robotically; three years later, that number skyrocketed to more than 40,000.

Giulianotti isn’t particularly interested in prostatectomies, though. He wants UIC’s program to focus on three major areas: liver, pancreas and lung. “They are the most difficult [operations to perform], and the ones in which minimally invasive surgery is really very rare,” he says.

At age 44, Giulianotti began learning robotic surgery techniques, and he’s taught dozens of other surgeons during the past decade. “For me, it was the beginning of a passion,” he says of his first da Vinci encounter. Not all surgeons are such apt pupils. Giulianotti observes that younger students tend to do better with the robot. “Older, established surgeons, they don’t like to be questioned, put into criticism,” he says. “I think it’s a matter of psychology, not the age itself, that is the limiting factor.”

Ironically, older surgeons may be shunning the very thing that could boost their career longevity. As they age, even the best surgeons experience increased hand tremors; the robot’s instruments neutralize the effects of shaky fingers. It also significantly reduces the physical effort required for, say, a 10-hour procedure.

Yet for all its advances, robotic surgery doesn’t solve every problem in the OR today. The da Vinci is the only robotic system currently available in the United States, and it’s a costly piece of equipment. Its size is a bit unwieldy, too. The robot isn’t sterile (although its removable instruments are), so the entire unit must remain covered by clear plastic sheets at all times. It’s expensive to maintain and operate, and takes time to set up—which means that some procedures, such as removing tissue samples from a lung, are done more easily using laparoscopy. What’s more, most of the robot’s instruments aren’t small enough to be used effectively in pediatrics.

Giulianotti has high hopes for the future, though. He can only identify one limitation on robotic surgery’s potential improvements: “The ability to think, to imagine.”