12 emerging health robotics areas that should have your attention

When we think about “health robots” and more so “surgical robots” depending if you look at the soft tissue robots or hard tissue robots - you will see the world as either Intuitive da Vinci multi arm, or Stryker Mako. Those two robots are responsible for about 98% of the world’s robotic surgical procedures in the past 20 years.

But health robotics is so much bigger and wider than that. In fact there are about 600 different health related robots and here are just a few of the categories they fall under…

But then when you take some of these categories and go deeper - in say just therapeutic and diagnostics you see a wealth of very interesting and emerging robots in healthcare.



And of course these can be sub divided and subdivided more and more.

For year, billions of dollars have flowed into either hard tissue robots like spine or knees. Or has flowed into system to take on the da Vinci Xi. And unfortunately returns, in some areas, have been sluggish; so many investors, and even industry folk are a little battle shy. They’ve seen that Intuitive is a hard nut to crack, and that Stryker and Globus have very entrenched installed bases.

But don’t be disheartened as there are some super interesting companies to work for and investment opportunities on the horizon in the field of health robotics.

What I’m seeing is a movement away from the “My robot can do anything and everything” to more and more specialised systems that go after single diseases, approaches or anatomies.

Why? Because in many respects it is easier to do. It allows laser focus (some puns there) and means the complexity of the robot can be less; as it is a purpose built robot for that anatomy or function. (I will do a full post on general vs specific robot applications.) But basically if I don’t have to do lips to toes - and focus on one anatomical area - or delivering one instrument, energy or therapy. I can massively reduce complexity and often cost.

So with that in mind - here’s an overview of 12 emerging areas in robotics that you should all be very excited about:

Single Port soft tissue

Odd one to start I know. As again led by da Vinci with the now very capable da Vinci SP. But it is still a tiny fraction of the installed base, and the procedures numbers of the big cousin the Xi / DV5. (The multi arm). So this means lots of opportunity still exists for other companies to grow in this segment. It is not saturated with Intuitive.

And make no mistake - with the resources Intuitive are flooding into this system - it is an area of growth for them - so an opportunity for others. An open area - expanding area - and less competitive - means it is a good area for companies in surgery to think about.

Microport’s Medbot has launched its version of a single port Toumai with very clever twin C boom design.

You have Vicarious Surgical coming along soon with an interesting approach with decoupled actuator arms - a swivel camera and unprecedented manoeuvrability and reach.

Shurui SP another Chinese robot, but different variant that has a capability to be split into multi-arm - and it has a very interesting console system. Read interesting as you want.

Edge Medical - a well known in the multiport arena for it’s tele surgical Intuitive clone has a highly capable Single Port - most likely also tele surgical.

Then you have a smart move by Harbin Sagebot with their single port that is aimed at just transoral. A clever approach that is being very anatomically focused so they can tune their system for excellence in that application. 
You should also include in here Virtuoso Surgical with their bladder single port robot, Momentis surgical with the ANOVO system. And slightly tangential (see my other full blog review) Virtual Incision (I’ll include it here.) All taking very different approaches to reducing the number of surgical incisions.

All of these systems will help to make this a growing and interesting segment. And as I predict - all companies with a multiport will need an SP (or be paired with one) and all SP companies will need a multiport. Because the spectrum of which procedure fits which system will blur as capabilities of the single ports increase.

That will also start to come heavily into contracting - as bed side units start to work with cross platform towers and consoles - it’s going to start to be a compelling ecosystem to lock hospitals in and lock competitors out. Get our console and tower - select the bedside system you want to work with it for that case.

Endolumenal GI

Led by Endoquest Robotics - this is the flexible GI robotic scope (delivery platform) with robotic capabilities. Already now in humans and performing ESD (endoscopic submuscosal dissection) these systems are about to revolutionise endolumenal surgery and endoscopy beyonds the limits of the mouth and Anal canal.

They are about to voyage deeper, and start to catch diseases before they become full blown cancers. Reducing large excisions to precision excisions.

They will soon get more capabilities and be looking at lower GI and upper GI work - staring to take some of the procedures away from surgery. It will take a while but it will come.

Look for the addition of specialised tools for energy delivery (including PFA) Plus Field Ablation for metabolic diseases, localised drug therapies, and transmural technologies.

(Of course there are other Endolumenal systems already in use like ION and Monarch - but there is space in GI until JNJ or Intuitive decide to launch something.) So the time to get in is now.

Until then there are interesting companies like INEN from France, Harbin Sagebot flexible robot, Neptune medical with their Triton Surgical Robot. Plus there is Agillis robotics from China looking at EMR and ESD. Out of Singapore we have Endomaster for GI.

And there’s a couple of stealth programs out there that I just cannot talk about.

Challenges are control of long flexible instruments - cloning of instruments - cleaning of channels - and getting the life of instruments high enough to allow a cost per case that will be close or even fit into current reimbursements.

This will be a critical type of robot as technically it could be moved trans mural for the long since (2008) anticipated NOTES revolution. But it could also be transabdominal (tricky and 100 reasons why not to do this as a pure Endolumenal platform per se, but as a base platform with an SP adaptor?)

And do not forget that Intuitive took on NeoGuide as the core platform of ION and that was always a GI based system. So they will be heading this way sooner or later.

Watch this space.

EndoCardiac Valve

Cardiac is having a revival. And Intuitive (see my other posts) are positioning themselves back into Cardiac. And why not… you have SSI and Mantra that are poking the cardiac bear. But besides the trans thoracic MAS cardiac procedures… of big interest is Capstan Medical that is delivering Valves on a robot. And delivering them from inside the heart.

Is there anything more cool than saying we deliver a mitral valve and deploy it via our endo cardiac robot. If investors are not throwing their money into this game changer they are sleeping. If the big valve companies have not woken up to this… then wake up. This in combination with some cool robotic cardiac imaging - direct visual and non visual (not all for today) is about to revolutionise this space. Steerability - stability - precision - repositioning - all at your robotic fingertips. Ohh that is exciting.

And no… they are not the only ones - there are a few coming.

EndoVascular Stroke

If there was ever a massive problem in healthcare; it is fast access to Stroke Thrombectomy. For me, one of the the most exciting opportunities, to move the dial in healthcare, is better and faster stroke thrombectomy. I won’t do this now but will do a big post on this. It deserves it.

But look to companies like X-cath, Remedy Robotics, Microbot Medical, Nanoflex robotics and even Robocath. All innovating to allow robotic catheter guidance via robotic controls. 

Broader players in this space are Stereotaxis and Siemens Healthineers with Corindus. Bigger companies that are using different robotic techniques magnetic vs direct drive - to steer catheter tips.

All at various stages and all looking at driving robots via different methods - into the brain.

And then some like X-cath are trying to do that remotely via tele manipulation.

Their goal is to be able to have experts 6 hours away by road - be virtually present in minutes to treat the stroke at distance. And remember “Time is Brain!”

If Investors, and we as a healthcare community, are not behind that…. What are we thinking?

Vascular access robots

Maybe less “dramatic” but probably way more massive is accessing blood vessels for blood draws or even as complex as central catheter placement .

Obvius Robotics. Has a neat hand held guided robot for CVC placement - super cool idea to make CVC placement standardise - quicker and simpler.
But then go to the community blood draws with Vitestro - automated blood draw robot. Put in your arm - let it puncture the veins - draw the blood. All robotically controlled using ultrasound guidance. Very cool.

Just think of how many blood draws are done per year globally? How many CVCs are placed… you get it?

Autonomous Ultrasound imaging

One of the most difficult things is being able to get good and repeatable and reproducible ultrasound images - especially for complex procedures like cardiac. Through combinations of AI image analysis and robotic movement (and storing these movements and recording the paths of movement) Ultrasound is about to undergo a revolution. Especially in some very specialist areas first.

There are multiple companies working on different approaches for how they want to be able to apply robotics in Ultrasound. It seems the access to good ultrasound will become a bottle neck for many healthcare systems in the near future. There just won't be enough skilled clinicians that can deliver the ultrasound diagnostic to the level needed. This use in advanced ultrasound procedures with robotics at the centre could help to unblock that issue. Either by direct robotic autonomy, guided assistance or remote tel operated ultrasound. Watch this space.

Prostate focused robotics

We are seeing more and more focused approaches to either a disease state or an organ. Why? It is easier to concentrate on one thing and make a simplifies robot that does that one thing well.

Procept with the Aquablation and Hydros system is a great example of where a robot can be applied to perform a pre planned BPH (benign prostate hyperplasia) procedure.

This is done because manual HOLEP treatment is tough, and user dependent. By applying a different approach - using hydrodissection of the tissues along a guided robotic path Precept have brought robotics to the prostate. And they are looking at moving beyond benign procedures to cancer.

Remember I said that HOLEP is tough? Well HOLEP (Holmium Laser Enucleation Prostate) is still considered a gold standard. But it really is difficult and user dependent. So step in Andromeda Surgical which is taking autonomous robotics and applying it to the HOLEP procedure for BPH.

You also have companies like EDAP - TMS with Focal One highly focused ultrasound to approach prostate cancer ablation. And a few others out there.

A da Vinci does a prostate removal well… but also do 100 other procedures. Where as these robots are focused into the anatomy and procedure. Different philosophy and different approach. But Could replace the need for an Intuitive in Prostate eventually. (Well for a lot of cases.)

Non invasive procedure robotics

Lot’s of different energy modalities from radiation to focused ultrasound are being mounted onto robotic delivery arms. All use different tissue effects via percutaneous delivery (or needle placement in slightly more invasive procedures like Epione, or Interventional Systems). But big news at the minute is the application of pre planned targeting of tumours by focused usltraound. This energy modality causes a strong non thermal cavitation effect that literally implodes the cells and destroys all protein fragments - absolutely destroying the cancer cells via implosion. Called histotripsy and pioneered by robotics company Histosonics. This is making big waves as it attacks liver tumours and has several ongoing trails for other areas. Big promise for small tumours.

It is a smart use of image navigation - live ultrasound planning and robotic arm movement to give precise energy delivery.

Dental robotics

With only four players so far - and only one tackling veneers - this is a wide open space. In part because much of dentistry is patient self pay - or out of pocket. Other is insurance. Dental offices and DSO’s (dental service organisations) are looking for premium procedures with higher profits. And well - dental robots are a key to unlocking the patient demand that is out there, but many dentist do not have the skills to do the procedures.

This unlock will make advanced, high end treatments available to more lower skilled dentists - so more patients can get access to these premium treatments. This is a big untapped market and growing as influencers show off their designer smiles. As aligners treat the tooth orientation - the robots can then fix the rest of the issue. And people really want this. And interestingly, this is one of the markets that is able to more easily pioneer autonomy. The fixed teeth make tracking and planning easier than softy tissues. In fact an Autonomous trajectory dental veneers robot - Lupin Dental is already doing clinical and commercial cases.

Next Generation Spine robotics

Spine robots have been around a while. But LEM surgical is leading the way in a new generation of spine robots. Today they are navigation aids that for the most part allow guided pedicle screw drilling. Often not enough added value to justify the increased set up and costs. But it is a growing category led by Globus. However the next generation of spine robots intend to go further - much further. Twin arms and advanced imaging intends to give spine stabilisation and that will allow for automated drilling - and screw placement.

This is where the robot will not just hold a guide. The robot will drill the hole and place the screw. Plus as algorithms get better the idea is to manage the soft tissues associated with spine procedures. And make intricate bone cuts and removal of old disc material. Look for an upcoming change in the hard tissue robotics space. They are about to break out of being just fancy robotic navigation guides to active procedural participants.

Open Microsurgery robotics

Precision - motion scaling - tremor filtration are all renowned traits of da Vinci. But when you take that to a next level and apply it to an open surgery robot you end up with MMI (Medical Micro Instruments) - the Italian born robot that focuses on microsurgery.

The kind of fine anastomosis these robots deal with are so small it’s hard to fathom. The sutures used are finer than a human hair - a lot finer. By hand it is for the few - and results vary with difficulty of cases. Bring in the robotic microscope - and the robot and put the surgeon comfortable in a chair with huge magnification - massive motion scaling (allows big hand movements to make very small robot movements) - remove all the hand tremor and you get a level of precision that is a game changer.

So far we have MMI leading the pack - including with FDA clearance. But hot on their heals is MUSA3 from Microsure and Galen robotics (slightly different but microsurgery). Even companies like Sony have shown a deft demonstrator prototype - which shows there is interest in this space. An area Intuitive does not play in today - so relative blue ocean. It is a fast growing category.

Ocular robotics

In a similar vein - or not vein but eye…. Systems using microscopes - robotics and software. Different systems for different approaches to surgery on the eye - in the eye. From cataract to retinal surgery - you have companies like Preceyes, ForSight robotics, Axsis Project out of Cambridge UK, OptoRobotics (still early) - but this is another area Intuitive does not play in.

It is another massive area where the capabilities of a robot can bring immense value - as again scaling, tremor control, precision are all needed in these delicate microsurgery procedures. Plus with such a small working area and volume robots can work in these confined spaces.

Already a lot of robots in this space - but still early enough to be exciting for investors and health professionals alike.

Summary

What I hope to show with this short list is an exciting world of therapeutic and diagnostic robotics that don’t play where Intuitive plays today. What we will see is the “robotisation” across many areas of healthcare. With that we get smart devices with tons of data being thrown off. This brings dual advantages.

It allows more surgeons - dentists - care givers to treat more complex patients without patients always having to go to “centres of excellence.” Often called democratisation (sorry don’t like the word.) What I prefer to think about is different ways that robots can be in the middle of complexity and allow a broader group of healthcare providers to get immediate access to - know how and skills to be able to use the robot and the data and the “integrated know how” to be able to bring the treatments to the patients. Rather than the patients having to go to the experts (as today).

Of course 50% of good clinical practice is good clinical decision making. But also here as the best minds - the best skills get codified into systems (robotic or digital information systems) the best practice information can be disseminate faster (real time) and the robots can help to implement those decisions into real world actions.

With that said - the march to robots and digital systems (and I must mention AI of course) will continue and accelerate. In all facets of health delivery (from pill dispensing robots to cleaning robots to linen folding robots etc etc all the way up to da Vinci 5). It is an exciting time to be in healthcare where we may see the fastest adoption of new tech ever seen. I encourage all of us to support these new robots, these new areas - innovate and invest in them. And don’t just think da Vinci and Mako when we think robots.

These are just opinions of the author for education purposes only.