10 reasons your soft tissue surgical robot is failing or will fail
- Steve Bell
- 2 days ago
- 14 min read
Updated: 23 hours ago
I was asked by a few people to explain why some of the soft tissue surgical robots are not gaining the traction that they all thought back in the day. And why still (now over 6 years after competition popped up) we still see a major dominance by Intuitive. Why hasn't the competition got more traction.
Here’s a list of 10 reasons the robot is failing, might be failing or will fail after launch. This list is in no order; and not aimed at any one robot or company. And, for clarification, I’m talking about head on with the space of da Vinci - not unique robots like Procept, or Histosonics etc. I’m talking soft tissue lap robots. I'll pick why other robot type struggle in another post.
And yes this is just my opinion so if you disagree then disagree - I want us to discuss this stuff.
The basic design is wrong
With so many companies making direct copies of the architecture of da Vinci - you kind of know that something in the Xi boom format is inherently right. 20 million procedures across all specialties means that Intuitive have worked something out. (and yes I know 20 million is also X and Si and S)
But that still doesn’t mean that the actual underlying design of the embedded software - mechanics - drive is still right. Many have got it right and many have got it wrong. If any company is still copying the Si / X architecture - then watch out. That is probably why people that have used the Xi format think your system is not up to it. The side boom is old school - old news and a generation out of date.
In other formats like modular, or single port, or bed mounted - there is a very subtle line between “cool theory... and doesn’t deliver.” There are several robots out there, and in development, that have the wrong basic design. In whole or in part. And it just makes the entire thing “not work well enough.” to be competitive.
You end up either trying to train your way around the defects, or worse, have the users make so many changes to what they're used to it becomes unworkable. And that is also for the nursing staff, sterile services teams and not just the surgeon and bedside assistant.
I see so many systems that are just awkward enough that people never get into the full rhythm of use - so the robotic program fails.
The issue you have is that the current champion is the right format! And unless you can deliver something better (see USP) or something so radically different it is worth the learning pain… you are going to struggle.
Everything works in powerpoint. Everything works in a controlled lab. Everything can be forced to work in a controlled trial. Real world… you better have a real world capable design.
You don’t have enough money
Simple one. You need 500 million to 1 Billion of post launch investments. (Get the F out of here Steve - I hear you cry.) If you want to go hard at Intuitive you need big boots. I mean big boots. Anyone can deploy ten to twenty robots and sort of cover it. But now go make some money. Oh no hang on... make real profit. Remember this is now in a world where you as "the competitor" are rarely selling your capital up front. So you have it all on the back end of a seven year robotics program. So every deployment becomes a black hole money pit unless you get to 200 plus procedures. But even then it takes three years to hit break even.
You need big big big money. End of story. Because you need to sustain a massive operation until you can reach that break even. And that is a decade for the company to reach profit.
You need enough working capital to get systems made, trained, deployed and supported. Then you need even more to sustain a level of R&D to ensure you get features to compete with the rapidly advancing market . Then you need cash to do the regulatory approvals, and clinical work needed to get enough procedure types to reach critical mass. This is all massive massive cash. And eventually you must go direct… Why? Because your lever of “we are cheaper” will get destroyed by levels of distributors and sub agents.
You need cash!
You have no uniqueness
Me too systems will work technically. But so what? Is this just about being cheaper? Because if it is then you are on a pathway to “win by price... lose by price”. So you need to have a uniqueness -a Unique Selling Proposition.
Telesurgery - Unique ! Able to go to emerging markets - Unique !
Autonomy - Unique !
Open Console because ….. Unique !
Modular carts that allow …. Unique !
But saying you are unique is totally different to actually being unique. I still see so much B.S. self justification going on (for both on the market, and in-development systems.)
Find a genuine unique differentiator and lean into it - but be able to back it up.
If you say “We eliminate staff” - prove it.
If you say “We allow more types of procedures” - prove it.
If you say “We make workflow better” - prove it.
If you say “We are massively reducing the cost of surgery” - prove it.
Once proven - then lean in. But have something unique that no other competitor has (not just da Vinci) be that system - company - people - pricing model… I don’t care. It just must be “Unique” and users must say “WOW!” And you must be able to prove it not just say it.
You didn’t deliver the massive cost savings
For the past 10 years I’ve heard how system after system will reduce the cost of robotics and “finally democratise it.” Wrong.
You can absolutely show cost savings in some markets compared to say how you heard a distributor sold Xi in another market. “We are less than $1 Million and the Xi is $2.8 million average.”
Oh my F’in chuff. If I hear that one more time !!!!!
You are either comparing 2012 pricing with a dual console - training backpack - X number of cases thrown in etc etc to your basic system. OR you are looking at pricing from 2014 through some middle eastern distributor that is that is "selling" with on costs and on costs when the only option was “da Vinci or nothing.” And they knew the customer for years and it's all part of a bundle deal.
Not only is that missing the reality of most modern lease deals - most countries being direct - most offers being $1.2 M for an Xi - or $600K to $900K for an X (go read the tenders). But now you have XiR that can be placed at almost zero cost, or put in at $300K to $600K if they are valued into the deal.
Most other competitive systems are going in at $1M plus just for the hardware - single console.
Then the instruments - No you are not crashing the costs of cases - I’ve seen five tenders this year - and other RFQs - and no one is smashing the cost. Your volumes are too small to be cheap on instriuments. Period.
You do have to make some profit at some point ya know.
YES there are some countries where local dynamics / direct sales / local manufacturing allow cost advantages vs imported high duty on systems combined withj additional local distribution layers. But that model does not hold up once you get to Europe - or LatAm or the USA from your country and the reverse applies.
The issue with all this “We will drop the cost” is that in the minds of the users - the buyers - they are expecting a 50% reduction on ownership lifetime costs vs da Vinci. Less than 30% and the cost of switching is not worth it. Trust me I have all the maths on this. I have seen the primary data from the purchasers.
So when you have had customers “waiting” for this ”massive” cost saving and you go in on parity - or you are actually more expensive than an offering by Intuitive. You then wonder why the customers are so deluded. So pissed off.
Or worse. You drop in the prices to “loss lead” to just gain some traction and that deal hammers your P&L - sinking into black hole after black hole. And you have now set the level of your pricing below “cost of running the program” not just the cost COGS.
Unit costs on the program - unit cost on the program - unit cost on the program.
You get it yet?
And once you deliver a system that is not quite as good as an Xi - with less features - and not quite the same support - for a 5% saving or parity. Don't wonder why the users have a poor experience and value model in their minds. Final note: "We are cheaper always reads - we are inferior."
Your reliability is too low
The bench mark is 98% plus up time. And the expectation is “It never ever ever crashes in a case.”
Two very very different metrics that get confused - badly.
If your system stops in a case - you are in the shit. Even if it causes no patient harm - the user tolerance for this is almost zero. Once is a grumble. twice is a major complaint. Third time is a returned system.
If your system takes 15 minutes to boot down - undock - reboot and get going again…. Woahhhhhhhhh.
You cannot have case conversions to lap - in 2026 that is just a 100% zero tolerance no no.
So if you are having “case stops” or “Case delays” - you are doomed. But it’s worse.
If you cannot get (within 24hrs) a system back up and running you are toast. The expectation is to not be telling patients “Sorry your case is cancelled because the engineer can’t get here until next week.”
OR “Sorry we will be opening you tomorrow as the part is four days away on the wrong side of the customs line.”
There are certain standards - times - repairs - engineer times etc that are a must. If you cannot get that system back up and running in 24 hours - a) you’re in the wrong business. b) you just discovered why that country was not serviced by Intuitive yet.
It’s not only about “can we sell a robot” it is “can we support a program and ensure that level of uptime” - two things that are being very much confused today. And I see the consequences of systems coming back on a regular basis.
Your service back up is not good enough
This rolls from the last point. You have to have qualified engineers for all aspects of service install to back up. Many of the emerging companies do not have enough engineers for something called hyper care. They have sold for “too little” and can’t make the $$ numbers work for 1:1 field service engineering in the early days. Miss this at your peril.
They then scatter systems all over the planet and have 2 or 3 centralised engineers that are five days from a service repair.
Parts are on the wrong side of the customs line. Your FRUs (field replaceable units) are just wrong.... again to try and be frugal.
You don’t have the telemetry systems to do preventative maintenance. That service you sold for $100K per year - because that’s what you heard - that 10% of the deal value… Yada yada. Sounded like lovely free cash.
But then you can’t back it up and the customer is right royally pissed off with you. And you eat the $100K fast.
Those systems are coming back. The $100K sets a very very very strict bar for service back up. Deliver it.
You don’t have enough features to compete
In 2026 the robot is not the “main thing.” It is the table stakes of what should work. All robots must deliver smooth movements - tremor filtration - scaling - imaging - fully wristed instruments. You don’t get any point for the basics.
Inside your company - that fact you managed to get the system to work end -to -end is not a big flex anymore. In fact a basic system with basic imaging and instruments is now relegated to the expectations of systems of 2004.
Users are no longer just wowed that you move your hands and the robot follows… they expect feature sets.
Full lines of instruments that work every time. Imaging with ICG at a minimum… but that bar is about to go off the charts.
They expect advanced energy (and a straight ultrasonic barely cuts the grade.) You need fully wristed - advanced energy systems.
Stapling - yes you need it. End of story. Not a negotiable.
A complex and rich data ecosystem with AI based analytics and feedback - is now basic.
"But Why? Not everyone uses them? You don’t need a stapler for a prostate?"
Oh dear….
It’s not just about the actual use - it’s about tick boxes on RFQs and Tenders. If Intuitive users at the RUG (robotic user group) set the spec - then they will set up all these tick boxes. And yes when only Intuitive has that feature you can argue it off the list…. But when three others have a stapler - or ICG - or advanced energy.
You are basically screwed!
You don’t have enough procedures to compete
Likewise - Intuitive sets the benchmark now for what procedures the system can, and should do. And every RFQ, Tender and RUG will write down the list.
Can’t do TORS? (trans oral robotic surgery) - sorry can’t buy it.
Can’t do Thoracic? - well we need that.
Can’t do nipple sparing mastectomy? Cardiac? Etc etc etc - then you are just giving one more reason to choose the tried and tested full feature, full procedural, reliable champion.
And it is not about “reality” it is about the fact you need to get all departments to agree to a robotics program, a robot “they can all use.” And every department that has a “no vote” against your system is another hurdle you have to justify to dstaty in the race.
Of course some hospitals will buy your system. But the pond you are fishing in is getting smaller. And remember back in 2016 when you made that “blue ocean” excel sheet about all the procedures you could do - all the systems you will be selling post launch…
That ocean is now a small mill pond.
THAT is why you can’t hit your numbers. THAT is why it is harder to close a deal than you imagined. THAT is why the funnel you had is 100:1 for deal closing not the predicted 10:1.
You’re making up your story
Internal think goes back to the original hypothesis that got the robot projected in the first place - over a decade ago. A group sat down and made a strong story of why Intuitive are shit, everyone hates them, they sell at $2.8 million and that is why the robot is used only once or twice a week. They sat and said “people are desperate for choice and the minute we come in on our white charger they will throw business at us.”
Those stories got bolder and bolder. And as your robot took shape the bullshit got deeper.
“We will take twenty minutes off docking”
“We will have a better imaging system.”
“No one wants booms, they are desperate for bed mounted or cart mounted or ceiling mounted”
“We will make th most economical robot ever and instruments will be made for $50 and sold for $1000 and we will still be cheaper but with away more profit.”
“Intuitive never trained anyone - they just let them go and we instead will be the masters of education and people will flock to us.”
“Our brand is so strong the minute we have a robot - of course nostalgia will kick in - they’ve just been waiting for us to have a da Vinci killer… they are depserate for us to have a robot with our end effectors.”
I could go on but it makes me want to cry.
Roll forwards a decade and we come to launch of a nixed system with half the procedures or less - a third of the functionality. Costs have spiralled - Intuitive have moved on and you are no longer benchmarking against the S system you had as a test system. The feature sets and reliability of a da Vinci are off the chart...and low and behold - all those customers that “just hated them” continue to buy - even in the face of 30 competitors. ??? Ehhhh ??? That can’t be right.
Oh and their NPS (net promoter score) is off the chart. Oh and they now do a high % of leases? Oh and there are more economical systems like the XiR that are better than our system and 40% cheaper.
Oh Shit.
BUT - let’s not adapt and realise the thesis is wrong - let’s just internally trot out the old memes. Let’s externally act like it is still true. Let’s pretend our system is better. I mean we have lots of low hanging fruit we can get - friends and family - and that will sustain us until the customers wake up and smell the coffee.
I still see multiple companies executing on a playbook they invented a decade ago… and wondering why they are struggling. Change the playbook!
Your training and implementation suck
Making the robot is 10% of this game... if that. So even if your robot is good - there is a bigger part to the reason for success. Besides having an actually competent salesforce that know how to close one of the most difficult deals in MedTech (another day) - selling a robot is the easy part.
Getting robotic program up to 200 cases per year in multiple specialties is way harder. I still see today that companies are not doing the training and case support needed. Now some are - and are doing it well. So hats off to them.
But there’s others that think “well they know how to use da Vinci... how hard is it to use our system?”
In an effort to be “frugal” and match their selling prices they dream of... they are not doing the surgeon training - bedside training - nurse team training - sterile services training on a regular bases. So those teams “fall off."
Then they think they can get away with a 5 to 10 case “case support” - and that is a recipe for disaster. The further your system is away from the design concept of an Xi - the harder this gets. If your system is vastly different - then strap in for a 12 to 18 month case support extravaganza. If not… you will not see cases get to the numbers that make your system viable.
Sales is like a leaky bucket because of churn. The churn cycle of a robot is often 12 months plus. That is the time for a customer to decide - “this isn’t working.”
If systems come back it is an utter disaster for reputation (news travels very fast) - P&L - rebooking big sales is a killer - and resources. It’s an 18 month sell for a robot plus 12 months of heavy support - and the plan is to recoup costs over 7 years. In 12 months if the wheels fall off - you are in a world of robotic hurt.
Too many companies are not getting their robot from “excited curiosity” to “Boring daily use.”
They are not understanding the need to get regular usage to be able to say at month 12 - this is a keeper.
Bonus: Buyers don’t know who you are and are worried you will be gone soon
Final bonus for those that bothered to read this far. The surgeon is rarely the “buyer”. This is a B2B institutional purchase with a major change of service or expansion of service.There can be up to 50 people making the purchasing decision for a robotics program. And you only need a few to say “but who is this company?” Or to to say “Have you seen their balance sheet? Are they even going to be here in five years?” Or “Chinese - do we really trust that?” Most companies are not doing enough high level brand and trust building. You are up against Intuitive, Medtronic and soon to be JNJ. Trusted megabrands! “Too big to fail”We are talking about $5 million lifetime deployment of capital for a hospital, reputation and trust. This is not them having a go with a new pair of gloves.
Far too my companies are again being “frugal” and not spending the $$ on marketing to reach the brand awareness and getting to the purchasing teams. It is tough to get people top trust you. And when you deliver your system the purchasing team hears of any users issues....
They will accelerate the return of your system. They were nervous enough signing it off when the surgeons campaigned for it. Now the surgeons are all bleating and giving the reasons that “can’t use it” - they are validating the skittishness of the purchasing teams. "Send it back before the 2 year time frame," becomes the mantra. Miss out trust brand marketing at your peril. Oh... and Chinese companies - get 100% of the Chinese writing off anything for Europe and USA. Bonus tip.
Not all companies have all ten of these (11 if you were counting) . But you only need one or two for people to default back to buying the tried and tested da Vinci. I throw these out there every so often as I get more blog readers and many of those are now struggling. When I started saying this a few years ago - few people had the real world experience. Now… it’s real. And for a few - it’s about to get real in the next 12 months.
Good luck !
These are just musing of the author for educational purposes only .
