Are Intuitive about to seriously update their imaging capabilities?

Since the launch of the DV5 and the continual march with ION and SP - I’ve been wondering not “If” but “when” Intuitive will upgrade their imaging capabilities.

Firefly - their NIR (near Infra Red) ICG imaging has been on the system for a long time. It's good and it works... But compared to many current systems out there - such as Storz Rubina - well it feels a little dated.

Are Intuitive about to upgrade their imaging capabilities?

Let's remember... Smart companies don’t add features when they “get them” they add the features when they “Need them.” Just saying.

Even smarter companies work on technology stacks that can span multiple product lines - Rigid endoscopes (Xi, DV5) - flexible Laparoscopes (SP) - Flexible endoscopy (ION) for GI? Ohh let me tease more on that system. GI Ion..... ohhhhhhhh

Let me dig into several amazing new modes that Intuitive has up its sleeve; and show you what I think are their upcoming capabilities in imaging: And what that could predict for their next robotic platform.

Oxygen Saturation (OSI)

One of the important things when dealing with tissue in surgery or endoscopy is understanding the quality of the blood supply and being able to actually quantify it. What you care about in blood supply (as a physiologist - yes that's me) is the ability of the blood to bring oxygen and nutrients to organs and tissue. The most important being oxygen. No oxygen means tissue dath pretty quickly. Tissue death leads to breakdown of tissue etc etc.

Seeing that blood flows (ICG) is quite good - but understanding the “quality” of the blood and the ability to bring oxygen to the tissue is better. Especially tissue edges beyond a staple line.

Intuitive now have a capability to measure and heat map oxygen saturation via their Schoelly OSI Camera. Yes - they have the capability - but great companies only deliver it to the customer when it is perfect, meaningful, accepted and needed.

Many of you may have forgotten their purchase of the Schoelly fiberoptic robotics business back in 2019. And the fact that they have a super close working relationship. Or maybe not. But that is why Intuitive will be using this technology out of Schoelly.

There are many companies working on this type of technology - Hypervision, Activ surgical and of course the imaging companies like Olympus and Storz. Different ways of assessing SaO2 but all with the purpose of better understanding tissue quality. This is not main stream yet - except for in a handful of sub specialties. But seeing beyond the human eye is the next frontier.

Hypervision

The ability to measure and quantify Oxygen saturation can be useful in a few areas. One is checking for blood supply prior to transecting an organ - to help to guide exactly where an organ should be divided to maintain maximum blood supply to the cut edge. "Place your stapler here."

But it also is super useful post anastomosis - to see if there are any ischaemic spots, or if there is poor oxygenation supply - for example to the cut edge of a staple line. Fix it before you leave the OR.

And very interestingly - this technology can be used in both rigid endoscopes and flexible endoscopes. So it is applicable to their regular 3D scopes - but also their SP and ION systems. (Well according to the tech specs.)

A study of evaluating specific tissue oxygen saturation values of gastrointestinal tumors by removing adherent substances in oxygen saturation imaging Keiichiro NishiharaKeisuke HoriTakaaki Saito[...]Tomonori Yano

Let me say why ION is important. Well - one of the most interesting uses of this technology is potentially in GI endoscopy - companies such as FujiFilm have this on their flexible scopes. I have a suspicion that all of this is part of a growing tech stack to ION being used in GI sooner or later. Or a variant of it. Reminder: Neoguide is the foundation of Ion.

White Light Imaging  (WLI)

Of course this is a standard in most imaging systems. And they have White Light today. It is used in both rigid and flexible endoscopy. And it needs to be a core of any imaging system. I’ll say no more on basic white light - it's a google away. And not super interesting (on its own.)

Except. The standard now in ICG (NIR) is to overlay that green image on top of white light imaging. That allows a surgeon to have better tissue awareness and operate with the ICG turned on... (easier) So I suspect to bring FireFly (I guess they might call it something like FireFly 2 ???)  up to modern capabilities, they should use the White Light Imaging with ICG overlays. Makes sense.

CMR Surgical LimeLite on Versius

So expect soon an upgrade of the DV5, SP for white light imaging. Potentially even a major bump in resolution quality. Today an Xi is around 1920 X 1080 pixels in HD (per eye)

Their new white Light system gets a bump to 3840 x 2160 which is the 4K imaging we all hear about to much. That is a significant White light boost of about 4X vs an Xi in terms of pixels.

If you think that the current DV5 console screen is up at 4K per eye - and then you add in this 4K white light imaging chain… that will be a class leading robotic system (IF I’ve got the numbers right from their tech sheets.)

Blue Light Imaging  (BLI)

Why stop at white light when you can have blue light? This is another new mode for Intuitive. It’s been out there for a while for companies like Olympus (Orbeye), Fujifilm etc.

It is a specific Blue laser Light source that transmits at about 410nm - which is absorbed by haemoglobin - and so highlights blood vessels really well. This is particularly used in mucosa - hmmmmmm endolumenal is popping up again… hmmmmm

Albert J. de Groof, Anne-Fré Swager, Roos E. Pouw, Bas L.A.M. Weusten, Erik J. Schoon, Raf Bisschops, Oliver Pech, Alexander Meining, Horst Neuhaus, Wouter L. Curvers, Jacques J.G.H.M. Bergman,

Blue-light imaging has an additional value to white-light endoscopy in visualization of early Barrett's neoplasia: an international multicenter cohort study,Gastrointestinal Endoscopy,Volume 89, Issue 4,2019,Pages 749-758,

By seeing subtle changes in the mucosa blood vessels - a user can start to detect lesions or suspected lesions. Changes in things like polyps etc can also bee seen with Blue Light Laser.. It has multiple clinical uses - but is predominantly used in endoscopy (flexible) GI.

It may have some use in Brochoscopy - but it is screaming to me that Intuitive is heading into GI endoscopy and very soon. Why add this capability - for low rectal lesions and trans oral with SP .... and that's it. I doubt it.

Blue Light imaging Bright (BLI - Bright)

So now take that Blue light imaging - add in a second blue light laser and mash that all together with white light. You get this effect known as Blue Light Bright imaging - or “Bright” mode. This enhanced imaging mode is used for earlier cancer detection and seeing differences in lesions. Again primarily in endoscopic GI imaging. I won't go too deep but this is a way to see well beyond the human eye. Not exclusive to GI use but ... well I've said it.

Nishikawa, Yoshiyuki & Ikeda, Yoshio & Murakami, Hidehiro & Hori, Shin-ichiro & Hino, Kaori & Sasaki, Chise & Nishikawa, Megumi. (2018). Classification of atrophic mucosal patterns on Blue LASER Imaging for endoscopic diagnosis of Helicobacter pylori-related gastritis: A retrospective, observational study. PLOS ONE. 13. e0193197. 10.1371/journal.pone.0193197.

If I was Olympus or FujiFilm - I would be terrified at this point. If Intuitive gets an ION GI robot with this kind of capabilities - it is going to turn that entire business on its head. And not just because “there’s another competitor” but they will crack robotic see n treat endoscopy. I have screamed this for a very long time that the next generation of robots are endolumenal GI robots. More in a minute.

Linked Colour imaging  (LCI)

LCI uses colour contrast enhancement combined with a laser to allow image processing that is particularly used in gastric mucosa. It is very good in wide lumens over large areas so that a gastric scope can see those precancerous and cancerous lesions better.

Umegaki, E.; Misawa, H.; Handa, O.; Matsumoto, H.; Shiotani, A. Linked Color Imaging for Stomach. Diagnostics 2023, 13, 467. https://doi.org/10.3390/diagnostics13030467

So will ION be just a lower GI play? Erm not by my guess work. This type of LCI is ideal for the gastric space.

I think we are about to see a super capable robotic imaging and therapeutic platform appear. And one that can be used in colonic endoscopy and upper GI endoscopy. I do beleive this will be a major new addition to the ION platform. BUT I am torn if this will be navigated any way close to that - or this will see it being driven by the DV5 console.

Imagine a sort of love child between ION and SP - that makes a long flexible delivery platform with 2 or 3 instruments in it.

You putting this all together yet?

So this amazingly powerful imaging stack - when will it get clearances? Sounds complex and could be a long time until FDA clears it… oh hang on… what if all of this was cleared in June 2024?

Hmmm —- oops. (yes go check... it's all public.)

Let me give you my spin on why this is so so so important.

Firstly - this is a possible bump to the Xi, SP, DV5 image chain beyond belief. If the da Vinci lap robots can now use the 4K imaging - white light ICG and oxygen saturation imaging. They have just taken a bold bold leap forwards. And it will help with their stapling platform more than I can explain in this post.

The question is - when in their upgrade cycle they will release this beast? Well probably when the shine of the DV5 dulls a little? - and it is time for an upgrade bump? A smart adult never gives the kids all the candy at once.

A smart company has all the goodies ready to go - waits until supply chain has reduced down the inventory on old units, and then does a carefully planned upgrade. That upgrade allows competitive advantage and maintains premium placement and pricing. It refreshes a platform and encourages loyalty, premium pricing, and upgrades. It also is a weapon in contracting and tenders. All the companies that just got white light ICG will already be one feature behind... again.

** Go back to my original video on the DV5 and I kept banging on about the “laser” warning triangles on the image outputs. This is not just ICG. (Near infra red.) - They have been planning a while the ability to use different laser modalities for OSI, BLI, BLI Bright, WLI, NIR etc.

I cannot be sure - but much of that capability may already be inside that tower - today - just not turned on. I mean they have had a long time to plan this - and the fact they got FDA for this image tech stack in 2024 means something to me.

Woahhhh. Oh hang on hang on hang on.  So are we seeing an utter master stroke in the tower game here. Like most - have I been side swiped by the “The lap tower” in my limited brain. WTF? Is this also an endoscopy suite tower????  Could this tower also be the heart of a flexible endoscopy / robotic GI tower.

Nahhh surely not. Would make no sense…. Unless…. Unless they plan to be moving the advanced endoscopy towards surgery? Hmmm more on this in another post ;) (I am a tease...)

What I will predict is that Xi, SP and DV5 will all eventually be on the same tower (and same console). And different versions Xi, SP will get access to some featured imaging, DV5 and SP (plus) - my invented name - will get access to more imaging modalities. Premium modalities. Or this could be the start of upgrade pricing system. Like the auto industry is doing. Features can be turned on and accessed "over the air" in a premium subscription model... Okay maybe too far. But technically it could be done - and the Xi just got an FDA clearance for some Over The Air configuration settings.

Well anyway, that’s how I’d do it for a product line segmentation…. Pricing segmentation … market segmentation….

Don't forget the power of AI

Now let us also not forget that besides the imaging capabilities in that tower; we have a massive amount of compute power. NVIDIA GPU compute power. 10,000 X according to Intuitive.

If you take all of these imaging modalities - and now slam a layer of AI on top - you will get an amazing effect. Imagine the AI looks at the oxygen saturation and helps navigate your stapler to the Goldilocks zone for transection. It sets up a "cut here" line on the screen.

Imagine post anastomosis - You drive an ION GI inside and look for possible low O2 areas on the staple line - that feedbacks to the stapling system…. It learns.

Imagine a GI ION (I'm making these names up as you can tell) flicking between imaging modes and the AI telling you exactly where a lesion or potential lesion is. It then helps the user to dissect the lesion from the bowel wall using a GI ION with twin instruments... Imagine. I feel a long flexible SP with a similar camera - just long n flexible and skinnier.

Imagine if that AI powered system also talks to the DV5 - and from the abdominal side there is an approach to do a very high precision resection at that point….Oh I’m fantasising a lot here - but imaging alone is not the future. These high end imaging systems with multimodal viewing will be combined with AI for better cancer detection - better margin. Detection - better stapling - better dissection etc etc. Guiding the user (surgeon? Endoscopist?) to the margins. (Oh and do not foget Endometriosis by the way... don't forget it...) Gary was apssionate about it... )

For me, It’s not an IF it’s a WHEN. And I do wonder if this entire stack will suddenly release with upgrades to the Xi, SP, DV5 and the possible co-release of their (specultaion) GI robotic platform? Do they do it when they bring all the bedside arms under one tower and console?

Is this the end of GI companies?

If and it is a big IF… Intuitive do release a GI robot (much like EndoQuest) and it has very powerful diagnostic capabilities linked to a robotic diagnostic (see Ion today) and amazing AI capabilities - where does that leave companies like Olympus and FujiFilm etc?

(okay I may be being dramatic here......)

I’m sure people are sitting in an office somewhere in Japan saying "It will never happen.” “Our installed base is too big.” “The costs will never work.” "Our customers are too loyal..."

For me, if these conversations are even remotely happening - they've already lost. They just don’t know it yet.

Of course the robotic companies are not just thinking about laparoscopy - “you fools….” Edge Medical from China has a lung robot. JNJ has one. Medtronic has a lung and GI business. Watch for more GI robots to come from startups and Chinese companies and big strategics. A next battleground is therapeutic endoscopy - concomitant (rendezvous) procedures and then the slippery slope to diagnostics.

Once the robot gets in - and it shows amazing value - manual systems are toast.

You will be able to do things with robotic scopes and AI and therapeutic platforms that have not been imagined yet by most people (see my other posts on where this all going.) Complex ESDs and EMRs will become routine by endoscopitsts (surgeons?) using assistive technologies that ":make it all easier to detect, diagnose and treat."

But it all starts with Imaging. You need to see first. And well Intuitive might be able to see better than most already.

These are just speculations and predictions by the author based on public available information. Filings and patents. They are specuklatove and for eduaction purposes only.