When Pier Giu­lianotti was a medi­cal student, he hated the sight of blood. In the mid-seventies, he travelled from his native Italy to Spain, on a fellowship, and watched a lung resection. “I nearly fainted,” he recalled recently. “I had to sit down in the corner.” The next day, he attended a plastic-surgery procedure. “Something more gentle,” he told himself. “This will be for me!” The patient had a burn scar on her face. First, the surgeons removed the ­damaged skin. “You’ve seen the movie ‘Terminator’?” Giu­lianotti said. “I was trembling on my legs, but I was trying to resist.” After the surgeons prepared a graft by slicing healthy skin from the woman’s thigh—“Swoosh swoosh swoosh, like cutting a piece of salami!”—he went woozy. Again he was led to the chair of shame. Giu­lianotti considered quitting medicine, but he loved helping patients. He got over his squeamishness and decided to specialize in surgery, but kept wondering if the practice could be refined. “I am Tuscan—anatomy is painting,” he said to himself. “Surely there is a more artistic way to interact with the human body.”

He finished his medical studies and did surgical residencies at the University of Pisa and the University of Milan, which are among Italy’s best medical faculties. In the mid-eighties, he became an expert in laparoscopic surgery, in which a doctor inserts a camera inside a small incision and then uses the video to guide surgical tools that have been inserted into the body through other incisions. Minimally invasive surgery speeds recovery and reduces the length of hospital stays. But he found that laparoscopic equipment was disorienting to use—among other problems, depending on the position of the probe inside the body, the image that the surgeon sees can be backward.

In 1999, Giu­lianotti remembers, he attended a conference in Germany, sponsored by Johnson & Johnson, where the company demonstrated a prototype of a robotic arm for use in performing surgery. The response was tepid—the surgeons present said that they just wanted better laparoscopic tools. Johnson & Johnson shelved the project, but Giu­lianotti was galvanized by the concept. “Ninety per cent of the surgeons said bullshit,” he said. “But I knew.”

On a recent morning in Chicago, Giu­lianotti, who looks a little like Arnold Schwarzenegger with white hair, put on a sterile gown and cap, covered his craggy face with a surgeon’s mask, and entered an operating room. Giu­lianotti is now a professor of surgery at the University of Illinois College of Medicine, where he runs a program in robotic-assisted surgery. At the age of sixty-six, he has now performed roughly three thousand procedures with the aid of a robot, and has helped train nearly two thousand surgeons in the art. Farid Gharagozloo, a professor at the University of Central Florida and a surgeon at the Global Robotics Institute, said of Giu­lianotti, “He single-handedly started the area of general surgery in robotics, and I don’t think that’s an overstatement. No matter what the field, there’s a certain panache and sort of genetic makeup that makes people the leaders—makes them do things that no one else wants—and Pier has that.” Gharagozloo said that, when he watched videos of Giu­lianotti’s surgeries, he was left “in awe.” Giu­lianotti was the first surgeon to perform more than a dozen robotic procedures, ranging from kidney transplants to lung resections. In the operating room, he relies on one robot: a multi-armed, one-and-a half-­million-dollar device named the da Vinci.

The patient, a woman in her twenties, lay etherized upon a table. She had a genetic endocrine condition that causes an enlarged thyroid, and recurring tumors on the pancreas and on the adrenal glands. After Giu­lianotti arrived in the operating room, the physician assistant 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 black-and-white 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 challenging,” he warned, to remove the tumor without damaging the spleen. The abdomen is as densely packed as an overstuffed suitcase. The spleen nearly touches the curvature of the stomach and a section of the colon. To operate successfully within such density, surgeons must have a pinpoint sense of their tools’ locations. Giu­lianotti’s clinical fellow, Michail 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. Giu­lianotti 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.

Robotic surgery has several advantages. First is the ability to cut and suture in deeper, tighter quarters. Robots 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 console 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 instruments are more flexible than a human wrist and can rotate three hundred and sixty degrees. Laparoscopic tools, by comparison, 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 movement of the surgeon’s hand can lead to a major mistake. Finally, whereas most laparoscopic probes show a two-dimensional image, the da Vinci’s robotic camera gives a full three-dimensional picture 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 perform.” He added, “But it is not. Otherwise, many people would do it. Pier makes it look easy because he moves so smoothly, accurately, and quickly.” Papamichail also said, “What really impresses me is his perception of the inside 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 always a reason behind it.”

Despite the enthusiasm of such practitioners 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 technol­ogy in need of a problem. Marty Makary, a doctor who performs both lapa­roscopic and robotic surgery, and is also a health-policy expert at Johns Hopkins University, told me, “Because the robot has been so heavily marketed, it has become 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 surgery first came on the scene, twenty years ago, more than eighteen thousand studies of its efficacy have been conducted, and with many procedures, such as a pancreatectomy, the method is consid­ered superior; with other procedures, it remains unclear whether a robotic approach produces meaningfully better outcomes than laparoscopic surgery.