10 mistakes to avoid when commercialising a Soft Tissue Surgical Robot in the USA

As we see more and more FDA clearances for robots - I get asked. “What are the dangers of commercialising in the USA?” My eyes go wide. Dangers a plenty - but there are a few key mistakes you absolutely want to avoid, or this is going to be a short commercialisation ride. I’m talking here specifically about the soft tissue surgical robots that compete around The da Vinci space (or periphery to da Vinci.) However some of these things also apply to other areas of robotics so worth a read. Let’s begin in no particular order.

1) Relying on the sale forecasts you built the project on

Let’s all be honest for a second. If you were raising money as a startup, or you were competing internally for money at a strategic to “Take on the robotics market” - you gave a bit of bullshit. You puffed up the numbers for the overall market an growth - you certainly puffed up your own sales numbers - and worse… you had a super fast hockey stick of revenues with oodles of million dollar capital deals up front. Remember? Five or ten years ago it was all Unicorns and pixie dust when you sat around the spreadsheets. Smoking whatever you smoked. In group think you all sat there saying - “well it could be a bit higher… why not it’s an amazing product” - even though the product was a collection of bits in an R&D lab. But the vision of “better than da Vinci” - “Democratising surgery” - “Lower cost” and finally “allowing more procedures” sounded good in your heads and presentations. There was that one decanting voice saying “are you sure. I’m thinking those numbers are aggressive.” And you all sat there (unless that was you) saying “Coward. If you don’t believe the numbers get off the bus.”

As you went through revisions, the COGS came down at an amazing clip (of course as we hit volumes the cost crashes) and the revenues went up and up with revision after revision (have to make the IRR look better) (Have to be more attractive to investors). And a big % of your P&L model was all that lovely cash up front capital deals, and endless margin on servicing contracts and instruments. Yada Yada.

Everything works in excel - and every product works in powerpoint. But it’s 2026 and you’ve got FDA on a nixed product. Intuitive have moved ahead from the Si and early Xi data your thesis was built on. They are not the “hated” company you all schemed around. The market has way more competition for customers to evaluate. And investors and board members keep dusting off the old 2017 spreadsheets and PPTs and saying “Why are we so far behind on sales plan?” “Why are unit costs still so high?” Etc etc.

The biggest mistake you can do is to cling to those old sales projections. It’s just fantasy. Instead. You need to do a bottom up new USA P&L based on the stark reality of where you are. Where the market is. What your product really is. Where reality is. You need to be honest about what you can really sell, to who, when, and if you can take any capital up front. Get a blank spreadsheet and start again NOW. Get inputs from people that have sold your system in the real world - not new hires with wide eyes where anything is possible. Do a bottom up - where when - how much - how much capital. Apply real world volume costs. Apply real world support costs.

I can feel many of you wincing as you think “But if I do that we are toast. The numbers won’t work anymore."Better for the numbers to not work on a forecast than in the market - you can’t defy gravity. Be honest with investors, management and your teams. You can’t talk your way out of this. And sorry to say but if the numbers do not work - they do not work - you either need a better plan of get ready to pivot the entire thesis. It’s ten years later - things have changed. Stop clinging to the past thesis as it will kill you sooner or later.

2) Not including the urologists because “da Vinci owns that”

If I had a dollar (Euro or Pound) for every time I hear. We will avoid the urologists and let Intuitive have them; I’d have - well quite a bit. Having sold a few systems - (or rather my amazing team did) - I can tell you that the Urologist has a massive voice. Massive. They get asked “is it a valid system?” And they get asked “Can you use it for prostates?”

WHY? Because in many regions the urologist still has the most experience. The urologist does volumes. The urologists make profit on the robot. The urologists have to share the robot now. The urologist has power in the robotics decisions.If you can only do upper GI procedures - what can the Urologists say? “No idea haven’t used it clinically.” Or “Nope I can’t use it as it’s not cleared. So that one needs to stay out of our department.” Or “I’ve tried it. Look it’s not an Xi. It’s okay but I would not give up my Xi (DV5).”Any of that helps swing purchasing decisions and thoughts to “Well maybe if we just have one provider?” Or “If we need to upgrade next year we can’t upgrade to that system” or “So we need retraining of staff including more fit out of sterile services?” - and “And our super user Urologists can’t use it.  I know this is for the general surgery team - but what if we need to do cases - and the urologist just can’t jump on it?” — “add here all the excuses…”Better to stick with Intuitive. Sigh.And here I am talking about the mid tier high volume centres that can have two or max three robots in 2026, and cannot deal without sharing robots from a scheduling point of view. Not massive mega centres like Mayo etc that can have 15 robots and do research. I’m talking genuine business customers.

It’s not about being a better prostate machine - it’s about being capable to do prostates well and a viable option that doffs its cap to Urology.

3) Not getting enough critical mass of procedures

Continuing that theme. Robots work economically and efficiently when they are highly utilised. And most hit a breakeven when they hit three specialties. If you are launching with just one specialty (even multiple procedures) do not expect real business any time soon. Yes you can “place” systems in keen centres. Yes you can “give it away” but that is neither a business for you or a business for your customer. And US healthcare is a business first and foremost - especially for those paying for the robots and making the big corporate calls.

And if you do not get enough specialties on your slate you are not going to be able to tick enough boxes on requests for quotes. You will look anaemic against Intuitive. And intuitive sets the template for most quotes and tenders.

But more so - you will not be able to gain the mass of departmental support required to have senior management choose your system. Thoracics will complain “it’s not suitable.” ENT for TORS will say “Well it’s not approved.” General surgeons for nipple sparing mastectomy will say “That’s a long way off.” Cardiac… etc etc. Specialties are a massive moat. And every voice that says “it’s not for me and I’m not willing to wait” will go against the specialty with approval saying “But we will use it for now and keep it very busy.”  The balance of departmental voices will be against you.

4) Changing up your sales team too quickly

We haven’t hit the numbers? Must be the fault of the VP os sales that clearly don’t know how to sell. Go find me an ex-Intuitive robotics expert - hahahahahaha. Is all I say.

But on a serious note. Your lack of sales is all relative. TO WHAT?

Your insane plan you signed up to?

Compared to finances unfounded demands to make the P&L work?To how you think other competitors are doing?

Your under investment in marketing?

Your poor position of the product?

Your lack of features compared to what the market expects?

Your real pricing? Not what you hypothesised about.

Your lack of instruments?Your lack of clinical data?

Your lack of reference sites?Your lack of health economics data?

Your lack of digital ecosystem?

You misunderstanding of how long it takes to sell a system?

Your lack of understanding that you are not selling agains the Si you built your specs on?

Your lack of opinion leaders that think your system is better?

Your misunderstanding that your system is not as good as an Xi? The workhorse.

Your lack of any real Unique Selling Proposition?Your theory on why people will run to you was wrong?Your delusion that everyone hates Intuitive collapsed?

Your investor expectations that have zero clue of real world selling in robotics? How hard can it be?

No.  None of that. It’s just the shitty VP of sales that doesn’t know how to sell your wonder! Give me a fucking break.

The worst thing you can do is assume that - change out the team and think all of the above suddenly and magically get’s fixed by having a new face infant of the customer. I’m not saying you didn’t hire a duffer… but if early sales - low hanging fruit can’t be picked by a duffer. It ain’t the duffer!!!

Every person you change out will take 12 to 18 months to become effective - understand the nuances of your system - understand how you sit in the market - understand how to sell around the fact your system is just not that good - convince people why only having one procedure “is okay” etc etc etc etc.

18 months you lose - so act wisely !!

And this is a small market - and that churn resonates with investors - sales pros - customers - and competition! Think long and hard. Is it the person or the product or the positioning?

5) Launching without the full featured product and expecting to compete

You remember that old powerpoint with the product roadmap. You know the one where you had 4K white light ICG, wristed energy devices, full stack software that never bugged out, perfect architecture, wristed specialty devices a go-go, wristed stapling devices, a full range of instruments that worked (every time), a stable product that needed servicing every 6 months (oh the profit) and all those R&D promises of why this is so much better than a da Vinci. Remember?

And then you wake up on a Monday morning: More emails saying we lost a deal because we didn’t have stapling. We don’t have the spatula for TORS. Our needle holder just doesn’t grip. Our scissors life out after 20 minutes, we need an app, we need AI, where’s or IGC. We had three more software issues - the list goes on.

Without a full featured product (that at least meets the spec of an XI) means that only a few “pioneer” centres will be willing to put up with the lack of function. Development partner sites. Not mainstream business.

No issue to have an MVP (Minimal Viable Product) launched in the USA as long as you set sales expectations to MVP levels and certainties. You forget “beating” Intuitive. And you get all the bells and whistles on ASAP. I mean ASAP - not 2 or 3 years later. You will be dead. Don’t think “we can limp along with the MVP - it’s good enough.”

And if you are slightly off the beaten track of Intuitive with an “ASC robot that is different” you better be able to deliver on the promises that makes you different. If you improve “efficiency” for an ASC - your feature set better deliver that day 1. Not “you’ll have to just add 20 minutes to case for now until we get all the features cleared.” In the ASC world (see in a minute) you don’t have that luxury. If you save time or money or increase efficiency based on feature sets. Get them now. Don’t go wide and then disappoint again and again. News travels fast. Be successful in a few well targeted sites.

Don’t think that if you are up against da Vinci - “People will just tolerate the lack of features because they hate Intuitive. But they love us. They want to work with us.”

That’s simply delusional.

Be competitive or don’t compete.

Deliver your feature promise or don’t launch.

6) Having systems come back

I think this one hurts more than anyone knows.

If people have never used your system and say “looks shit” then you can brush that off as bias.

But if people have used your system in their clinical cases and say “it’s shit” and send it back. That’s hard feedback.

The issue is that it doesn’t need to be “shit” it just needs to disappoint in several ways.

“It works okay when it works - but stopping so often is a pain - I can’t use it”

“It doesn’t feel as good, as smooth, as polished.”

“It’s just not as good as my Xi - sorry.”

“The learning curve is too hard. Easier to get back on the Xi - I’m busy.”

“We looked for efficiency - we don’t save any staff - we didn’t work faster and we didn’t save money.”

“It just can’t do what I need it to do. Too much clash… too much faff.”“We actually don’t save money but have less features.”

“We’re now splitting data over two systems that can’t talk. We can’t monitor like we used to.”

“Sterile services had to start again and they are pretty upset running two systems”

Etc Etc.It doesn’t matter what the reason or excuse. When you put a system in - it better be only to hospital teams that are begging for something different. That go in eyes wide open and understand fully this will not be an Intuitive. Eyes wide open it’s a learning curve. Eyes wide open it’s disruption to their cases. Eyes wide open there will be problems. Agree to it all and still sign up. (Oh get all that in writing.)Because if not - and a system is slowly not used - never gets to regular usage - or just feels bad vs what you “sold them” -  then it is coming back.

Watch for “we will do some clinical studies” they present  a paper saying “It’s equivalent” and then never buy it. Or worse… say “you can take it back now. We’ll use the da Vinci.”

Any and all of that is a train wreck for your product. And everyone will know. I recently sat at a big dinner with some thought leaders. A few had tried a certain new system. And the three of them said “It’s okay but I’d never use it daily. Was happy to do a paid trail but it’s not a real product.”22 other surgeons heard that.

“So do you still have it?” - was asked across the table.

“No. We asked the company to take it back. But we are getting a DV5 instead.”

Utter and total devastation for the brand.

If any site is going to get your system early on - vet the site - vet the users - manage expectations so that thing never comes back. Hyper care the hell out of the site!!! There must be no reason they fall off the wagon. Trust me - 20 systems out and half come back after a year is a death sentence of the product.

7) Believing major “names” are business

There’s a weird effect that happens when major Hospital names are mentioned. People puff out their chest and say “we have a system in Mayo or UPMC or Cleveland Clinic.”I think if it is to say that reputable hospitals and clinicians are doing clinical trails for you - or just being honest about robotic education; and having one of each. That’s fine if it is seen that way.

But these hospitals have everyone’s robot - and not for business reasons. They are not regular customers - they are reference sites. Lighthouses.

“Obvious Steve - what’s your point?”

I see these presented time and time again in the regular business numbers. I see their usage extrapolated for trend lines. I see them “hidden away” in revenues (if there is any) but more so in “case numbers” that are mixed in with genuine customers.

There is no issue with a big name. Hell I encourage to have some big name users as lighthouses, training centres, teaching centres, clinical centres. But say them for what they are - money pits.

In the past I did an assessment of the profit per centre - and almost unanimously all the big name centres. When I did the real revenues vs real cost to the company -  they were a loss. Yet they were often presented as good business. If you build your business on loss leading centres - be ready for some home truths.

1st - they have no cash limits - that’s not real economics for your system

They use everyone’s system - how special are you to them?

If anyone digs in and sees a hospital with 1 competitor A, 1 competitor B, 1 competitor C and 12 da Vinci Xis and 3 DV5s - read the room.

And if they are paying for the da Vinci cases - and you are subsidising your cases… more fool you.

Let’s get honest - and make sure we keep lighthouse marketing / clinical sites out of the “real day to day” business numbers. If you want to delude yourself fast - just lump it all together and feel good and warm to the point you shut your company down.

8) Believing the meme “We hate Intuitive”

I still hear this again and again and again.

“You know - Hospital X told us that they are sick and tired of Intuitive. They can’t wait until there is competition. The minute we come out they are going to convert everything across to us. They hate them. I mean hate them.”

Really? Is that really what they say?

Or is it “da Vinci is too expensive and Intuitive is inflexible.” - maybe in the past that was a perception.

Or is it “We don’t like there just being one company. I don’t like monopolies.” - opinion.Or is it actually “If we have competition we can negotiate the price down” - hope. And assuming you are cheap.

Or is it “We could never get capital deals it was always $2 million up front” - erm 50% plus leasing deals now ????

Look towards OUS. The reality of the numbers of systems going in do not reflect all of this nonsense. Intuitive are still winning the vast majority of installs. Why? If everyone hates them. Surely they would have just collapsed by now OUS?

Because it is not true. It’s an old meme that won’t go away. Because it’s convenient hope.

At best, It’s a few people in a hospital venting (to you) and telling you what you want to hear.

Try this with them next time - “if you hate them that much will you buy my system at a premium? Let’s just sign the deal now without having tried the system.”

Or “Let’s send all the da Vinci systems back and buy four of ours. Right now. It’s not even a discussion right. You hate them,. Why would you not do this?”

No? But you said they “HATE” them. Ohhhhhhhhhh. Right……….It’s a sort of - well kind of a way to say things right…

Companies still have business cases built on Intuitive customers running away from Intuitive in droves to their wonderful “alternative.”

It’s a great investor story.

It’s a great soundbite to give to your board or strategic CEO.

You’re gonna get a rude awakening when you spend 18 months in that account “that hates Intuitive” and weirdly, they choose them “again.” Hmmm let that sink in.

This is not fantasy - it’s been happening OUS for YEARS.

Stop this crap. And even if it was true… do you want to build a business on customers that run from someone just to escape. No matter how bad your product is? How’s that gonna work out in the cold light of day?Or do you want honest discussions where a customer wants to run to you because they see a future partnership, and will take you in “warts and all” without ever bashing the competition.

Which business is more healthy in the long run?

Stop listening to this meme - build a solid business on your own merits.

9) Thinking you can run to the ASC too soon

It’s absolutely right that trying to displace Intuitive from the main US hospitals - large teaching centres - major regional hospitals is a hard fight. Especially as we are now at an average of 2 da Vinci systems per hospital.

The logic - and correct logic - is to go fight them in the ASC where they are at a bigger disadvantage. Not as many installed. Not financially always the best alternative to lap. Not always fitting the ASC flow…. Etc.

It is the right long term gameplay. 100% a good strategy.

BUT do not try this too soon in the USA.

ASCs are factories - with KPIs and profits that must be made. Margins are thin - OR time is an expensive resource. Staffing is a premium and often scarce - and sterilisation services are complex. Time is money.

The issue is - there is ZERO tolerance of disrupting their daily workflow to get up learning curves. The ASC is NOT the place to work out your thesis - perfect your technology - understand your USP - understand logistics. That is not the test bed site to do that. You will get your ass handed to you pretty fast.

If you go in with promises of efficiency - staff saving - staff utilisation - OR workflow - You better F’in deliver it day 1.

Go to the ASC - but only once your system in the USA reality has every kink worked out, and you can show the $s - prove the the economics. Say with confidence - to the second - the time savings. To the unit - the efficiency. Back it up and deliver it. You won’t get many bites at this if you slow them down - cost them money - cause disruption - have long learning curves - cancel patients - and just don’t deliver. They will kick you out fast. They are not doing this for glory… they are doing it for business.

Get all the kinks worked out in similar workflow environments in Europe or Asia. (Clinics - ASCs)

No? Then get to anything that resembles that environment. An OPD may be closer (not perfect) but get your shit together there.

No? Then run main blocks as best you can to emulate an ASC - way more forgiving - way more tolerant - way happier to generate data. Get the ducks lined up there. Build your promises on reality - and then execute in ASCs when you are 100% sure you’ve got it nailed.

Intuitive are not in many ASCs just because “Their system is big” it’s because maybe now after 25 years they have XiR - the economics starts to work - they know the procedures - they know the drill - the system has 99% up time - they have all the data - etc etc etc. Don’t make assumptions of “why” historically they were not in the ASC - because size of the system is not the whole story.

For sure get to the ASC - when your are ready.

10) Not understanding how long it takes

I’ll finish with this one. I talk to investors - board members - senior leaders and still scratch my head when someone that has never sold a robot tells me how long they think it takes - especially in the USA. They saw the DV5 launch and assumed to clearance to first purchase was the actual sales cycle. And that is their benchmark ?!?!??!?!?!!?

In general terms, they are often out by a factor of 4. Firstly - the hospital has to want a new system. You can’t just sell to someone because you have a number on a spreadsheet. They need to be in the market for one.

Next - the amount of contact points to see everyone and herd the cats is vast. C suite - estates - information officers - different robotics users - sterile services etc etc etc. 500 call interactions. Demos, evaluations, paperwork, requests for quotes, paperwork, specifications, labs, paperwork, legal documents and oh… paperwork.

In 2018 there were two systems in the USA to evaluate: the Xi and Asensus. And most people with a quick drive would say yeah or nay to Asensus. 2026 More choice means more evaluations - and often now “we want to try it clinically” is creeping in. We want a system on loan for 6 months… and then system B for six months ….. Time is dilating not compressing.

Then there’s now more trade-ins and XiR and complexity to contend with. Choices = time.

It is not a rep to surgeon sell - just forget that. This is a business to business complex enterprise level interaction that drags on. And now it’s in a more competitive environment with more on the market systems. AND lots of systems in the wings “just hold off until we are cleared you’re gonna love this…” delays.Be prepared for 18 to 24 months to get a deal. So don’t bust the chops of the VP of sales that they didn’t hit your hockey stick by selling 10 systems in the first 6 months.

And finally - getting a system sold is the easy part. Getting a program up and running - and hitting volumes where the system is not coming back is the hard part. The long part. It may be 12 months after install before they say - yep - we’ll continue with the contract: only then it becomes “real business”. It’s 12 months before they say “Nope sorry not sold as seen you blagged me.” Systems come back late.Timelines to volumes are long - and don’t match your hockey stick case predictions. Adopting a system is slow. And if they have a da Vinci to fall back on… “well this case needs to be done one the da Vinci. We’ll find the right Goldilocks case soon.”

Investors - “Why are you only selling 1/3 of the case volume? Fire the VP of sales.”

Chief Commercial Officer: “Erm because the system can still only do one specialty and we sold it to the Hospital based on the case volumes of three specialties QARA and R&D promised we’d have. But we still don’t have clearances - features - staplers - energy…”“No excuse fire the sales team it’s clearly their fault and they just don’t know how to sell without those features and specialties.”

These are just musings and thoughts of the author and for education purposes on.