This article was first published on Computer Vision News of March 2022.
Pier Giulianotti is a Full Professor and Chief of General Surgery at the University of Illinois in Chicago, the first center in the world to conduct robotic training for surgical residents. Pier speaks to us about this pioneering work and what the future holds for the field.
Professor Giulianotti, can you tell us about your work?
My work is mainly based on advancing techniques in minimally invasive surgery, including artificial intelligence and robotics. The idea is that we can perform operations better, minimizing complications and improving outcomes in terms of faster recovery and convalescence. It is an ongoing and never-ending process of improving science – a revolutionary step that opens up the field for unlimited possibilities.
What is the current status of minimally invasive surgery?
That is a very broad question. The penetration of minimally invasive surgery in different disciplines and specialties depends on the technical challenges of that specialty, but it is almost 100% in some indications. For example, the number of minimally invasive prostatectomies due to prostate cancer is probably more than 80% now. The concept is more difficult in other fields, such as major abdominal surgery or transplants, so the number of cases performed with a minimally invasive approach is much lower.
What makes some fields more suited to this kind of approach than others?
That is a good question. The prostate, for example, has a particular anatomical location deep into a narrow field into the pelvis. Robotics is the favored application here because the instruments do not need to move around much. For multi-quadrant surgery, which may require working inside all quadrants of the abdomen, instruments must have an extensive range of motion, which is more challenging for robotics.
Is this because tracking and navigation among the organs is a real challenge?
There is not yet AI-guided navigation. Tracking and navigation are so far based on human guidance. The human mind recognizes landmarks or anatomy and then addresses the direction of the instruments. In the future, the use of AI will mean we will be able to recognize anatomical landmarks and automatically manage the instruments in the proper location and at the appropriate angles of approach to the target anatomy, avoiding major collisions with anatomical structures.
“Instead of spending trillions of dollars on developing nuclear bombs, maybe we can spend it on improving the quality of our world to allow people to have a better quality of life, including better surgery and better outcomes!”
You have already performed thousands of robotic surgeries – what is the main breakthrough you have noticed since your first one?
It is probably in the range of 5,000 robotic surgeries now. Some of those were major operations; some were smaller. When I got started in August or September 2000 in Grosseto, Italy, the platform was a kind of prototype. We were struggling to make it function. It was like having a Formula One car still in development! If you have a good pilot, that can compensate for the state of the vehicle. I was a good pilot, so I could compensate for any problems in the surgery. It was in the infancy of the project. Now, the system is much more refined. It is much simpler than it was 20 years ago. It is easier to guide and perform even in a sophisticated operation.
What new developments in AI would make your work easier?
From a mechanical standpoint, the robot is very well refined, and I do not think we can achieve more sophistication in terms of mechanics right now, but we can achieve much more in terms of interaction with AI. The first step is elaborating virtual images to help the surgeon interpret a patient’s anatomy better and adopt the right strategy to reach the target and avoid collisions. Think of it like playing chess. The human mind can do very well, and there are probably some champions who could defeat the computer. Still, in general, the computer is much better at playing chess because it can perform millions of operations in a fraction of the time. It is the same for surgery. The computer can calculate in milliseconds the risk of collision and damaging important structures while you are navigating to reach your target. It can tell you, no, this is not the right direction, you have to change approach, or instead of coming from the left to reach a tumor in the middle of the liver, it is better you pass to the right or from the bottom, or the back. AI can do this better than the human mind.
Will you need real-time imaging and great surgical intelligence software to understand what is happening?
Absolutely. The next important development is to overlap and integrate virtual images into realtime surgery. The surgeon can decide to overlap or replace the standard images with the virtual images elaborated by AI. This could help them make critical decisions, such as how close they are to a tumor to ensure the operation is within safe margins while sparing healthy liver or parenchyma.
You founded the International School of Robotic Surgery in Chicago and are very active in the Clinical Robotic Surgery Association (CRSA). What can you tell us about those two organizations?
We have opened up a new lab at the school in Chicago called the Surgical Innovation Training Laboratory (SITL). It is a very modern facility with a lot of equipment and connected with supercomputing centers like the Argonne National Laboratory. We offer training courses and are working on research to apply updated software to improve imaging and navigation.
The CRSA was founded many years ago in Chicago and brings together robotic surgeons who all share the same vision that the future improvement of medicine is connected with the correct application of robotics and AI. They are committed to clinical research, developing the best techniques in multiple operations, and training and teaching younger generations to improve the application in the surgical ward.
That is fascinating! Do you have a final message for the surgical robotics community?
Keep going! Be optimistic that science is making continuous progress in this field. Our operations will be safer and more precise and minimize the suffering, pain, and negative consequences for our patients. We have to believe that. Humanity will define the priorities. Instead of spending trillions of dollars on developing nuclear bombs, maybe we can spend it on improving the quality of our world to allow people to have a better quality of life, including better surgery and better outcomes.
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