.:: ENDOSURGERY ::.

AN INTERVIEW WITH PROF. P. C. GIULIANOTTI

Grosseto (Italiy)
Wednesday, June 25th, 2008

E.O.O. In 2003 I went to a Spanish Congress in Valladolid and I had the opportunity to listen at your conference about Pancreatic Robotic Surgery. I became really impressed by the possibilities of the technique and I started to fight to get the equipment, which was very difficult due to the characteristics of Spanish Public Health System. In spite of this, we got it in 2006. Now we have only two tears of robotic experience, and we are in a very nice moment cause we are showing that procedures may be performed. From your vast experience, as a pioneer in the world, do you think robotic approach is going to spread? My personal perception is there is an important part of the surgical community thinking something like “I do not need the robot cause I am an outstanding laparoscopist”. What do you think about this?

P.C.G. Yes, but I think they are going to lose the battle. The future will be robotics. I`ll try to explain why, there are two main reasons: one is the most evident to everybody but maybe it’s not the strongest, the most evident is that the ability of movement of the electronically controlled instruments is incomparable with the standard tools of laparoscopy and it is not true that a good surgeon is able to do the same things. It’s not true. I think I am a good laparoscopic surgeon but I am unable to do a 5-0 suturing of a bile duct to the Roux-en-Y loop or a 6-0 suturing… That’s not true. I am unable to remove an aneurism of the renal artery and immediately to perform a perfect reconstruction… This is unfeasible by laparoscopy. This is very clear. Everybody, even a naïve person, can understand that an endowrist electronically controlled instrument is able to achieve better movements that straight laparoscopic tools. But this is not the most important reason. There is another less evident but, in the long run, it will be more and more important. Robotic surgery is the beginning of a revolution that we can call “virtuality”. What does it mean? This means that the surgeon is not touching tissues, he’s just manipulating an image. So, we can consider the operation as a two-branches process: one branch is the acquisition of the image and the other branch is the mechanical movement response, the mechanical answer of the instrument. And the human mind is in between these two branches. All these two branches, acquisition of the image and mechanical response of the tools, are computer controlled processes. That means they are implementable with all the improvements of informatics. Let’s think about the acquisition of the images: our ability to view at an organ is limited by the capability of our eyes to see some radiofrequency rays and we are able to see some details but not going into that. Now think about the possibilities of ultrasound or scan: ultrasounds are able to detect vessels and to draw them even in the depth of an organ. So the computer can create something that doesn’t exist and implement the virtuality. For example, we could work on some images depicting the vessels on the organ, or looking at the infrared emission of a tumor… so, the possibility of development of this acquisition of images process is enormous, because it is computer controlled. And think about the efferent branch: this is a mechanical answer that is also computer controlled. So, we can transmit this control through continents or we can miniaturize the instruments, or we could use some radioguided detachable instruments… yes, because all this process is computer controlled. So, which will be the role of the human mind in this process? Just control. Just the decision making part. The human mind will be in between this computer controlled process, being able to decide: “I want to do this…”, “go ahead…”, or “please, face the artery…”. The computer will say: “Are you sure that you want to cut the hepatic artery?” and you will say “Yes” or “No”. Maybe in the future even some parts of the operation will be automatic. So, the computer will choose by itself the easiest way to dissect the tissue and may be the human mind will be just to control a pilot to decide to perform any part of the operation particularly difficult, while the majority of the operation is done by the computer.
Behind the door there is a great revolution that many people is underevaluating. This revolution is virtuality. Surgery is becoming a part of a computer process, of a mathematical scientific process, and this revolution is connected to virtuality. Robotic techniques are just the first steps. In the long term this will be the most important part, not the ability of the instruments.

E.O.O. Why did you decide to get into robotic surgery and which were the most important drawbacks at the beginning?

P.C.G. That’s a long story… I was already developing minimally invasive surgery, because I understood that the winning concept of modern surgery is the reduction of the consequences of the big trauma of surgery. Sometimes we have innatural consequences of the approach, of the access for surgery, and this was a very charming and interesting idea. But, at the same time, I realized that the standard laparoscopic equipments were very rough, very primitive tools and I disliked many laparoscopic procedures at the beginning by the fact that they were unable to reproduce the sophisticated techniques of the open surgery.
Robotic approach requires, at least at the beginning, a lot of work, you have to think in advance about your operation, you have to know very well the mechanisms of working of the machine and the lab is absolutely important and to perform some preliminary works on the cadavers on the lab. That’s why I had to fight for having this lab from the beginning, cause I think when you are dealing with new technology, even to take advantage of the best qualities of the new technology, you need to do even some experimental part of the job. The lab is absolutely fundamental.

E.O.O. You are a very complete surgeon. From the beginning of robotic surgery in Europe, you and your team are present in the literature with most of the different surgical techniques performed by robotic approach. Taking this experience into account, which is the surgical procedure that in your opinion may benefit more of robotic surgery?

P.C.G. Let me make a general premise, and after that I will say which I consider, at the moment, the most benefited procedure by robotics. After some years of experience, I think that we could divide the operations that can be done by robotics in three big groups: Procedures that are unchanged, that I consider that the benefits of using robotics, at the moment at least with the actual technology, out of didactical issues (may be important in a program to keep some simple procedures just for training)… I think that doing a gallbladder doesn’t make a big difference using robotics or not, even if the quality of image is so high and even if you are going to have never an injury or a lesion. I mean, in the long run, even these minor procedures may be benefited by robotic surgery: there are interesting developments of “solo-surgery” that, for the short-age personnel may be interesting options for hospitals and private institutions. So, these are simple procedures that you can do by yourself without any kind of assistant using 4th arm or may be 5th arm of the robot. Then, at the moment some procedures are not clearly modified by using robotics: Nissen and gallbladder are examples of this. There is a group at the other extreme, in my opinion, they are procedures feasible only with robotics, in minimally invasive fashion. If you don’t have the robot available, simply you cannot do that. For example, a tubal reconstruction for stricture to achieve fertility by doing an intracorporeal 10-0 reconstruction by laparoscopy is unfeasible, removing an aneurism from a visceral artery, like renal artery or splenic artery and immediately to reconstruct by an end-to-end 5-0 or 6-0… these procedures are unfeasible by laparoscopy and to do them you need to go back to open surgery. In between these two extremes (procedures not modified and procedures feasible only with robotics) there is a big group of procedures that in my opinion are improved by robotics. They are feasible by laparoscopy: a Whipple is feasible by laparoscopy. I can do it. But using robotics you have an extra-quality. So, this group of procedures is improved in some steps by robotics.
Going back to the original question, which procedure is mostly clinically benefited by robotics, I would say many examples but, in my opinion, the spleen preserving distal pancreatectomy is one of the clearest examples. By laparoscopy, some parts of the procedures may not be feasible because you have to dissect all the branches to the pancreas from the splenic vessels. Of course you can tie or section the splenic artery, or the splenic vein, but it takes the risk of having a splenic infarction. Not only short gastric vessels are able to preserve the spleen. You see, with robotics, in 91-100 % of cases you can preserve the spleen. This is a big benefit. And this patient can be discharged after a couple of days from the hospital. There is a problem of minor leakage from the pancreas, but only one out to ten patients may come back with some collection, you have to follow the patient but 90% of patients are able to recover without problems.

E.O.O. What do you think about NOTES?

P.C.G. NOTES is very interesting. I believe… they are consistent with the philosophy that I love. The surgery with minimal trauma of access in the body… NOTES is in the same way. But let me say that the instruments of NOTES at the moment are very rough, so the possibility to do clinical surgery, some relevant task on patients at the moment is not true. There is a lot of faked operations, that are mixed of laparoscopy and NOTES…
NOTES will have a future, but resting on robots. So, you will be working at the console on some flexible probe and through this probe you will have microinstruments coming out and able, controlled by the console, to do all the sophisticated movements needed to perform an actual surgery.

E.O.O. Do you think you and me are going to see that?

P.C.G. I already tested some prototype in California… This is not a future on the long term, this is behind the corner. I already tried a prototype… it was a gallbladder on an experimental animal.

E.O.O. If robotics is going to generalize, which are the requirements do you consider a surgeon must have to become a robotic surgeon? Do you think there are surgeons in better conditions to access this technology?

P.C.G. There is a lot of concern about training since the beginning of laparoscopy, a lot of concern about young surgeons not knowing open surgery… Many surgeons not doing any open cholecystectomy are able to perform nice laparoscopies. So, I think it is an overemphasized problem. Anyway, I think the optimal situation is a specific organ driven knowledge of the pathology you want to do, of course, if you want to do hepatectomy, you need to know all the techniques of open surgery, have an experience in hepatectomy and, after that, basic laparoscopy because basic laparoscopy teaches you of all the basic problems that there are: fogging on the camera, suction of bleeding in a proper way, getting adequate exposure in the laparoscopic environment. So, organ specific knowledge of the surgery you want to do, and basic knowledge of laparoscopy because you need to know all the tricks specific of laparoscopy, and after that you can start directly with the robotic surgery. Just to learn basic console work it takes a couple of days, if you are enough confident after a couple of days you can start with basic work like cholecystectomy or Nissen. The learning curve of the Nissen, I think, is about twenty cases, thirty cases, after 20 – 30 cases you are perfectly able to go more far…

E.O.O. There are some surgeons trying to transmit the idea that you don’t need to have knowledge of laparoscopy to start with robotic surgery. They are trying to show that the most important advantage of robotics is you don’t need to know about laparoscopy. I don’t agree with this, what do you think about?

P.C.G. It’s not true. It may be true for some kind of specialty surgeons, like urologists, because they are always doing the same kind of job (as prostate), same kind of field and they can just learn the basics of laparoscopy while they are doing and learning robotics, but for surgeons, I think knowing laparoscopy is a basic requirement because, as I told you before, there are common problems, sometimes they are simple problems that you can overcome, you can fix… but you need to know how. If you have some fog in the videocamera, if you have some bleeding and you have to react fast… you need to know how to use clips, how to use stitches… so, it’s a complex. If you want to do a sophisticated surgery you need to know laparoscopy.

E.O.O. About the issue of the assistant in the table, and the team, do you think it is important to do a team work when using robotics? Is it more important at the beginning?

P.C.G. This is a very important point. The role of the team is fundamental. It is fundamental at the beginning because you cannot deal with all the problems by the console. You may have mechanical difficulties, collision of arms, changing instruments… you need to have a very good team knowing exactly how the system is working. Concerning the role of the assistant, I think it depends on the kind of surgery. If it is a simple surgery, we can think in the future about expanding the capabilities of the robot and working alone. There is some kind of “solo surgery” for simple procedures. But for the complex procedures you need to have a good surgeon working with you, because sometimes even the role of assistant may be difficult: getting good exposure, placing stitches in difficult places, to know how to suck selectively, how to make the bleeding spot more visible… So, for complex procedures, the assistant role, in a very sophisticated one, is more demanding than in laparoscopy because you are limited by the occupancy of the machine in the surgical field and the communication… so you have to rely on effective help. I know some surgeons who have failed to develop a successful robotic program where those that didn’t believe in work. They thought they could sit at the consol and do the surgery immediately. That’s a very stupid approach. And they failed… For developing a successful program you have to develop another philosophy involving personally and professionally.

E.O.O. We sincerely acknowledge Prof. Giulianotti his kindness and attention, and we are sure his opinions and comments will be of outstanding interest for all our laparoscopic and robotic readers.