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8 misconceptions about soft tissue surgical robotics

I have heard over the years every single bizarrity about surgical robotics. Urban myths - memes - tropes and just down right propaganda. Here I've put together some of my favourite bits of nonsense. Do Enjoy....


(And please do support my blog with a subscription)


We are only 5% penetrated into robotic procedures

I think this one annoys me more than any other. This shows an utter and total lack of any understanding of surgery by any measure.

So if people are saying that 2.2 Million procedures (as done in 2023) is only 5% of procedures - that means there are 44 million procedures procedures that can be done with a robot.


I think Intuitive knows a little bit about the robotics market. And by their own admission they say that there are 7 million procedures in line of sight and about 22 million possible world wide procedures their robot could attack.

So where did the other 22 million procedures go?


Let me cut this cake another way. There are 313 million surgical procedures done each year - 6% in poor countries (according to a study from Vanderbilt.) Of that, about 13 million laparoscopy surgeries are performed. So on this one alone - if we are just looking at conversion of Straight stick Lap to robotic (back out the 2 million lap robotic cases) it means that we have about 11 million lap procedures that could convert. So quick math... 2.2 million out of 13 million = 17%


That is looking pretty "Line of sight" of the 7 million Intuitive look at. Because a lot of those lap procedures are just never being done with a robot (basic diagnostics being one example and a lot of those 11 million) - let me come back to "The ones you could convert" later as it is important.


Okay so let's say there are some open procedures that could come across to Lap through robotic. Intuitive is estimating on top of the 7 million (applicable) lap procedures there are another 15 million procedures that "could" come across. This is open procedures - and procedures where they don't have clearance or don't have geographical cover.

So if we use that we are 2.2 million into the 22 million possible (line of site) procedures - we are at 10% (if you could convert all of them) - and that is a big uphill conversion by the way.


So the actual real numbers are - we are about 32% converted of all lap procedures (ie 32% of all lap procedures that are applicable / possible are converted today.)


And we are at worst 10% of all possible procedures (with good wind) that could be done realistically with a robot. In all specialties - all regulatory clearances and all geographies.


However you want to slice the cake - it ain't 5% so let's stop this nonsense.

The reason companies want to state this misinformation is that it looks "great for growth" that "we haven't even started" and "there's lots of room."


Yes - but fact is 32% of all lap procedures (the low hanging fruit) is already converted to Intuitive. And that "easy"market has still got 68% to go after. It's still VERY BIG. So no need to hype it up so much. It's just annoying. Even if you say - "We are just 32% converted on the super obvious lap procedures that will come across." That is still impressive.


People don't like intuitive - they are begging for any alternative

I've heard this from so many places - from within hospital systems, from analysts and from companies. I imagine that this is a historic view caused by some individuals, with individual behaviours, back when Intuitive was a monopoly (I speculate here where this myth comes from).

I can imagine that many people were frustrated by the fact there was no alternative - the pricing was the pricing, and the terms were the terms on things like training. Intuitive had the market locked up - yes.


I can also imagine that a few individuals maybe didn't follow the company guidelines on behaviour.


But if you still believe today that people will "Buy your robot just because they don't like Intuitive" - then you are dreaming. (especially if your robot is inferior!)

It is by far still the number 1 chosen robot - year in and year out. Intuitive has an immensely impressive NPS (net promoter score) which rates customer satisfaction. It is higher than nearly every other company in medtech.


Think about it - People don't buy 13 of your systems if they hate you.

People don't celebrate with cakes and show how much they value the system if they hate the company.

Teams don't fly around the world to attend their events (surgeons, administrators, nurses) - to be with a company they hate.

Yes some people might not like them - but it's probably a lower ratio than the people that don't like other companies.


Any company out there today - marketing a surgical robot - or alternative - that thinks they will gain significant market share based on people not wanting to work with Intuitive are... well delusional.


And even if people don't get along so well with say... a rogue distributor... or the odd regional manger. I guarantee you that if they choose the daVinci - they love the daVinci.

And the hope that "They'll convert from their daVinci because they just don't like Intuitive..." is insanity.


My advice - make your company the best it can be... make your product the best I can be... make your offering the best it can be. That is how you will win customers. You always want customers to run to you... not run away from another company.


We are coming in with a cheap robot - we will reduce the cost of surgery

If there's one thing I will say - again and again. There is no such thing as a "cheap" robot. Not a fully functioning main frame that is totally capable.


You may have alternatives that do other things - like assist laparoscopy - but you are not then comparing Apples with Apples. In main frame robots there is a base cost to having console, tower, bedside units. Period.


The myth that Intuitive is the highest priced and most expensive robot is just not true. And this is for several reasons:

Firstly in multiple tenders across Europe - go to the freely available Government websites and freedom of information - and go and look at the bids and pricing. Most mainframes are quoting at or around the same price for capital and in most cases recently - the new competition is quoting way above an Xi. I've seen Xi bidding on government tenders at $900K, with competitors at $1.2million. Lots of 'em - go check the details are out there.


Second - if you think that... you are thinking just Xi pricing - because an X can drop to $500K or around that mark. Good luck competing on price down there and still making a profit.


But it's all irrelevant. 48% of systems by Intuitive were leased last quarter. There is not a battle anymore on the "Price of capital"- just go read my blog on Intuitive moving to a service model.


You may then say - "Ah well if we all place the capital it comes down to the cost per procedure. And we can provide 'Cheap' instruments and cheap cost per case." Really?

I imagine that in your "give it away phase" to gain market share that will be possible.

But no other company on the planet has hit more than 10 lives on their wristed instruments - and Intuitive is tuning at 20 on some of their instruments. That immediately is a 50% cost reduction per instrument use per case. It's just numbers.

If you again look at the bids and tenders out there - the "cost per case" is almost identical across companies - Service bids are almost identical at 10% of the proposed capital value (included in a lease now in most cases.)


It all seemed like a good idea to "Go after cost" when you were designing your robot a decade ago, as that was a complaint of the market. Of course it was.

But roll to today and company teams realise "Oh it's expensive to run a robot company" and those dreams of crushing costs don't translate into real bids. Now of course price comes down as competition enters - but it will not be the new entrants that have the flexibility to drop the price. Not if they have any hope of ever getting to profit.


There are no "cheap" - fully functioning robots - so stop saying it.


We will finally democratise soft tissue surgical robotics

I just do not get this at all. This is the most nebulous and fluffy statement a company can make. It is a "good cause soundbite" wrapped up in a glib statement.

What is it supposed to mean? It means that instead of only a few elite surgeons and institutions doing a few elite cases on a robot. We will put this into the hands of everybody - and make all surgeons and hospitals equal through our technology and pricing. We will be the first to allow anyone, anywhere to get access to a robot.


Erm... so you think Intuitive don't want everyone to have a robot and have everyone doing robot cases? You think their plan is to ration this as purely an elite sport?

Wow. Interesting.


Marketing teams need to up their game - or get out into the field. Robots are not for the elite. Robots are in general hospitals, clinics, and lower acuity centres. Not just the Mayo clinic and such likes.


Everyone is trying to sell as many robots to as many people that can afford them - see value in them - and do good with them - period. Everyone. Stop trying to sound like some benevolent charity - these are businesses - that must make profit. You make profit by increasing revenues and dropping costs. You increase revenues by widening your installed base - increasing utilisation and keeping price up as best market will allow.

Everyone is trying to "Democratise robotic surgery" - because that's called business growth.


There are countries, healthcare systems, and procedures where a main frame robot will work -- and there are countries, healthcare systems, procedures where it just won't. No one is trying to "stop" anyone in those places it can work from doing it. The entire industry is moving to placed capital and pay as you go. That eliminates the biggest single barrier - up front capital spend.


So what are you doing to finally democratise robotic surgery?

"Well our digital ecosystem and data will level the playing field."


YES - but that is not about democratising access to robotic surgery - it is about raising outcomes in surgery. Two very different things. If smart robots with guided systems - interventions - checklists etc etc etc can be put into the hands of more users - the idea is that "with robotic assistance" you can narrow the skill gap and raise the floor.

But if you have anywhere on your website that "We are going to democratise robotic surgery..." then the comments section is open below - have at it - convince me of how you and your company will actually do that (and that no one else is running that same play.)


Robots so far have just been dumb. In the future they'll be smart

No.

Robots have never been simple and have just moved instruments. To even say that is utterly disingenuous to the hard working engineers in multiple companies. It shows nothing more than a total lack of understanding of what current surgical soft tissue robots are capable of.

For over a decade, robots have been using their on board computers to do so much. From automated instrument actions, to tremor control, to smart dynamics of arms, to emergency stops in clash, to stapler sensing at 1000X per second, to kinematic feedback, to telemetry feedback - and so much more.


Yes they will get smarter - but compared to "no" computer in the middle - there is an abyss. You can perhaps say that until the last 5 years that data was not fed back in meaningful ways to help. But now with the connected apps, video analytics, scene recognition and so much more that the robots do. To say "They have been dumb so far, and we will change that." - hmmmm.

Again more marketing teams that should go spend some time in the field - go attend some surgical cases, and just stop these broad brush statements that are actually incorrect.


Robots only do on average 2.5 surgeries per week

There were about 8500* active soft tissue robots doing surgery by the end of 2023. 1000 plus of those only came online during 2023 so will be doing less as they ramp up.

(*probably less if we could understand trade-ins better - but let's role with 8500.)


But take that ramp up out of the equation - and just do simple straight line math -

2.3 Million procedures (Intuitive and others) in 2023 done by 8500 Robots = 258 cases average per year.

Or 5 per week at 52 weeks a year (so working every day)

But we know average working across the world is 47 weeks so that means 5.5 per week.


And that includes all of the ramping up systems. If you try to back those out you get to about 6 per week average. AVERAGE.

That curve has a massively long tail... and a big chunk of those centres are doing about 400 cases a year - so near 9 cases per week. And in some elite centre they are doing six or more cases a day.


If this is what you have been building your internal presentations on - to either justify "it' not that urgent to get into robotics as they are a gimmick that no one uses." or "It will be easy to capture market share because our robot will move procedures everywhere to 5 per day - we change the dynamics."

More delusions. It firstly say you have zero idea how hard it is to implement a robot and get consistent case numbers up to 5 cases per week.

It says that you do not under what the real constraints are to robotic case volume. And I'm not giving you that secret today. You'll need to sign up to my exclusive content to get that Gem. (Hint Hint).

It also assumes your new robot will work out of the gate and have no issues - and will be applicable to all cases and cleared to do all cases in all specialties. Whole lot to unpack there about what you can and can't do with your robot.


Bottom line - if this number is any where in your internal marketing decks to justify "why you will win." You are in for a very big surprise.


To date robots are just prostate robots / urology robots

This grates on me. I get it from so many places - that the daVinci is just a prostate robot and "we will come in and cover general surgeons and gynaecologists and thoracic surgeons."


One graph :



Intuitive world wide robotic  procedure trend
Intuitive world wide robotic procedure trend

If you can't read this... then let me help. Da Vinci is primarily a general surgery robot. It is accelerating in all areas with general surgery growing like crazy. In 2023 it was over 1 million general surgery procedures.


End of graph.


You can't move robots from room to room

Yes you can.

Not every room is equipped to take every robot. Not every room can take the weight, have the right electrical circuits that are isolated, have ease of access.

But technically nearly every robot can be moved from room to room.

You may claim - "some are easier to move" but the urban myth that "Technically the robot is blocked in the robotic OR" is not correct. It is an institutional decision for logistics reasons.


If your robot is easier to move - claim that. But to say "Others can't move" is just bad information.


We will convert open surgeons to robotic surgeons

Final one for today.

This is such a nuanced argument and when said in this way it makes my blood boil.


Back in the day - urologists were not majorly laparoscopic practitioners. The prostate procedure with straight stick lap was just so difficult - most did it open. Same for renal work and bladder removal and conduit reconstruction. This is back 20 years ago when lap was just a decade in.


So back in the 2000s it was fair to say there were "Open surgeons" for urology. And they made the leap (skipping laparoscopy) to robotics. (History).


That is no longer true. I believe there is almost not a single surgeon left in the specialties that robots care about that cannot in one form or another do some kind of laparoscopic (or thorascopic) surgery.

Instead there are some that chose to do open, cases such as mega colons, because they are not suitable for laparoscopy. Giant incarcerated ventral hernia - C-Sections....

Then there is a group that are less skilled in laparoscopy that chose to do certain cases open. They are NOT OPEN SURGEONS. They are surgeons doing OPEN CASES. Big difference.

Then there are expert laparoscopists, that for a small % of their cases, choose to do them open for technical reasons and challenges.


The robot is proven to convert open procedures to laparoscopic due to the technical help of the robot. That is the statement that is defensible.



Open laparoscopic and soft tissue surgical robotics cases
Open laparoscopic and soft tissue surgical robotics cases

But the data is clear - it is a conversion of both open procedures and straight stick lap to robotic.

So please stop talking about open surgeons and instead talk about open procedures when we discuss soft tissue surgical robots.


So that's my pet peeves for today. Do comment some of yours !!



These are opinions of the author for education purposes only and all names and trademarks and illustrative graphs are property of the rightful owners.












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Gość
05 mar

Dear Steven while your correctly addressing several misconceptions about soft tissue surgical robotics I would like to mention a few things.

Forgivable but you calculate the average number of surgeries per robot by dividing the total number of procedures in 2023 by the number of active robots? However, this assumes a linear growth rate for the number of surgeries performed by robots, which might not be accurate.

I understand but generalization of surgeon preferences suggesting that there are no surgeons left who exclusively perform open surgeries, implying that all surgeons are proficient in laparoscopy to some extent. While laparoscopic skills are becoming increasingly common among surgeons, there may still be specialists who predominantly perform open surgeries due to various reasons,…


Polub
Steve Bell
Steve Bell
05 mar
Odpowiada osobie:

Hi there. I did try to say that factually the goth is not linear for all robots (and that 2023 with 1000 robots wild be way less then ). I wanted to simplify - to show that even with that factor we are stilling the 2X plus penetration of robotics in procedures "that count". Sorry if that didn't get across. On the open surgeons -= I thought I'd said that most surgeons can do some form of laparoscopic so to call them "open surgeons" is a misnomer - it is surgeons that choose to do open procedures. Subtle but different - and that means we 100% agree. Tremor control is an inherent nature of all main fames (I was talking main frames)…


Polub
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