THE SURGICAL ROBOTICS RACE IS ON! WHO WILL EMERGE SUCCESSFUL & HOW?

The soft tissue surgical robotics race is in full swing with the established incumbent, Intuitive Surgical, clearly dominating the space.? With numerous emerging surgical robotics companies, both strategics and startups alike, vying for a share of the market, how will the soft tissue surgical robotics space look in 5-10 years?? Will there be a company that will displace, disrupt, or surmount Intuitive's commanding lead?? This effort, I believe, will be an unfortunate Sisyphean endeavor for most of the surgical robotics companies currently looking to penetrate the market.? That being said, is there room for competitors in the soft tissue surgical robotics market?? Absolutely.? As a surgeon who performs surgical robotics and who has had a seat at the table during discussions about surgical robotics with hospital administrators and value analysis committees, who have become the ultimate arbiters of the decision-making process to purchase, I have a few insights that I hope are helpful. ?These opinions are all my own and are my own humble thoughts.

For a company to succeed in this arena of competition, there must be a crystal clear and distinct financial and clinical value proposition, that distinguishes an emerging competitor from the exquisite offerings of Intuitive Surgical.? An emerging company that wants to truly compete in this space will need to coalesce assets and capabilities that create a lower cost and clinically differentiated soft tissue surgical robotics platform.? A company that tries to go head-to-head with Intuitive Surgical with a similar form factor as the DaVinci platform is dead in the water, plain and simple.?

At the core of emerging platforms, competitors need to bring something to the market that is differentiated, has a smaller physical footprint, serves a different target market, costs less, and preserves or improves upon existing operating room workflows. ?The last thing an emerging surgical robotics company should do is design a platform without a clear understanding of an operating room workflow.? Unfortunately, I think there are a few companies who may have already committed this misstep.? Of course, there will need to be integration of a robust digital ecosystem with data collection to provide clinical and operational insights, a rich visualization system, excellent instrumentation, and the ability to layer in AI and machine learning.? These additional items are essential in the contemporary competitive environment, but these need to be secondary to the core drivers of value.? A massive form factor system that can barely fit in an operating room, costs millions of dollars, and creates a bloated workflow will be doomed even if it has the best digital ecosystem, visualization, and instrumentation that has ever been created.?

Will hospitals willingly absorb the switching costs to wholly transition from their tried and trusted DaVinci systems to an emerging platform that is similar in form factor and cost?? No way!? This would require additional high capital expenditures in an environment where capital is scarce, making a shift to new consumables and navigating new supply chain logistics, ensuring proper training on a new system for surgeons and staff, integration of a new system into the brick-and-mortar infrastructure, IT compliance and digital integration of a new system, and the list goes on. ?Hospitals that are DaVinci natives will most likely remain DaVinci veterans, but there may be room for other competitors to edge their way in.

If hospitals retain their DaVinci systems, as they should, how many other soft tissue surgical robotics platforms would they and their surgeons be willing to bring on board?? ?In my humble opinion, either none, or maybe one other system?? I believe it would only be feasible for a hospital to have two soft tissue surgical robotics systems maximum for traditional minimally invasive cases.? Think about a scenario where Intuitive’s DaVinci system is leveraged for more complex minimally invasive cases such as complex surgical oncology cases, and a company like Moon Surgical’s Maestro platform is utilized for the more routine minimally invasive cases such as cholecystectomy and appendectomy.? Regardless of platform, if a hospital and surgeons are going to consider utilization of multiple platforms, the value proposition and clinical use cases for each will need to be distinctly different.? Hospitals may consider a third platform if an endoluminal robotics system such as EndoQuest gains traction and can demonstrate value or a fourth platform if there is a single port system that emerges as the dominant player.? However, to have the capital and the bandwidth to integrate multiple systems into a single hospital or health system will be the exception, not the rule.? Likely, this would only be replicated in a few of the biggest academic centers in the nation, at least for the foreseeable future.? ??

Certainly, I cannot see a case where hospitals would willingly acquire numerous soft tissue platforms such as Intiuitive’s DaVinci Xi, J&J’s Ottava, CMR Surgical’s Versius, Moon Surgical’s Maestro, Distalmotion’s Dexter, Asensus’s Senhance, Virtual Incision’s miniRAS, and Vicarious Surgical’s system.? That would be sheer lunacy to try and keep up with all of this from a financial, staffing, training, and logistics perspective. ?It is not going to happen and not all of these companies will be successful.? Hospitals and surgeons will choose one or two of these systems maximum and the decision matrix will be heavily weighted toward cost, cost, and cost.?

With all of this in mind, how can emerging competitors shine from a form factor perspective?? Choosing the correct form factor will be imperative.? While I have not had direct contact with all of these systems, I will offer some opinions here.? I see the form factor of Hugo, Dexter, Senhance, and Versius with multiple independent bedside carts that support independent robotic arms being too voluminous and cumbersome.? From what I can see the size of these systems, with multiple independent bedside components, takes up too much space, limits access to the operating table and patient, and greatly increases the work-flow burden to position two, three, or four independent carts and arms at the bedside?? Single port systems certainly have clinical value when an operation is focused in a small area or a single quadrant such as prostatectomy for example, however, single port systems are typically limited in their capacity outside of a focused anatomic region.?

I am sure there will be heated debates regarding open console versus closed console systems and which one of these is superior.? In my opinion, systems with an open console, or systems that keep the surgeon at the bedside, are better in that they allow superior situational awareness for the surgeon.? This enhanced situational awareness secondarily, I believe, provides superior patient safety which at the end of the day is the most important factor of all. ?A closed console away from the operating table really does limit situational awareness and I can speak to this firsthand. ?The closer the surgeon can stay to the patient the better, and this minimizes scrubbing in and out of cases multiple times which prolongs operations, anesthetic exposure, and sterile PPE use.?

Lastly, in what type of healthcare settings can emerging competitors readily compete?? With changing centers of care, the next big frontier will be an expansion of ambulatory surgery centers as these facilities are decoupled from traditional hospitals.? Companies with emerging surgical robotics technologies should aggressively pursue optimizing their platforms to seamlessly integrate into this segment of the market.? Platforms that can be rapidly turned over with minimal consumables, can easily be moved from room to room, and can agnostically integrate with existing conventional laparoscopic technologies and products will be well positioned to succeed.? Traditional brick and mortar hospitals that are new to acquisition of robotics platforms, and are not already entrenched with Intuitive Surgical, may be wooed by newer emerging competitors if the value proposition fits and affordability is there.? Think of smaller rural community hospitals or critical access hospitals that may not yet have existing robotics capabilities.? This is an underserved segment of the market that would be well suited to benefit from the right robotics platform.?

Needless to say, the soft tissue surgical robotics race is a fascinating one to watch.? Intuitive is not going anywhere any time soon, but there may be room in the market for a few emerging competitors to begin gaining incremental traction.? Will it be easy?? No.? Is it doable with the right strategic vision and sound tactical decision making.? Yes.? Nothing lasts forever and the emerging competitors who can continue to build momentum in this hypercompetitive environment may just have what it takes to gain some market share if they can embrace and leverage these critical areas for success.