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I’ve got 3 da Vinci soft tissue surgical robots: why would I buy your robot?

Three da Vincis and no other robots
Three da Vincis and no other robots

I’m writing this post coming from a starting point of a hospital that has three da Vinci Xis (or more) already in their hospital. But remember, there are an elite 10% that have up to ten and beyond. But hey, let me go with just three for today’s thought experiment.

That hospital often has dedicated ORs where the robot sleeps at night and works in the day. So the systems are in the main block and busy. Forget this nonsense you keep hearing competitors say “Well our robot was designed to be busy. The issue today is that da Vincis sit in the corner not working… we will democratise surgery and get more cases done. Our robot will be the busy one.”

Those statements are ignorant crap. (Sorry I often say what I’m thinking by mistake.) Those statements are not factual… The busiest robots by far… by far are the da Vincis. That old meme of they do one prostate a week and sit idle all day is just old school propaganda from 2010.

2.2 million cases last year on just about 1000 active systems = 220 per system average.

And NO do not give me “Well a couple do a lot of cases, but most of them do only a few. And with our robot we can keep it busy all day…”

Utter tosh.

The other robots with the best record are doing about 1.2 surgeries per week - or 60 cases per year. And that is a few super users and a horrible inactive tail - I bet.

So this utter garbage story of “da Vincis are not used and our robot will open that up…” is fantasy.

(Ohh I’ve had a lot of coffee today. Grrrr.)

I’ve already invested into this: Time and money.

(I am not talking Moon Surgical, MIRA or other systems here that are not multi arm surgical robots - I’ll come to that in a later post. Get your head around a system trying to be bought to compete head to head with a da Vinci.)

Now if I’m running three da Vinci’s, I will probably have multiple specialties and multi teams in those specialties that are running cases on those systems.

So from a human capital point of view I have already had (let’s say) eight surgical teams go away, get training on the Xi. They have spent maybe a total of 24 days across the teams - 4 people per team - so about 100 human days of invested time in online training, residential training, system training.

Plus I’ve had 8 teams go through a significant learning curve to get to proficiency with the robot. Room set up, system set up, peri-operative efficiency, post operative tear down and care of the system and accessories efficiency.

Now that is very disruptive for teams - especially with a staffing crisis in many countries. So you only want to do that once.

And the competition rocks up with their new robot (I’m gonna say a head to head mainframe) and…

If it is a da Vinci clone or close enough (Toumai, Kangduo, Revo-I) then maybe that transference of skills would be faster. Maybe less training… but it’s still a pain.

But if you are a Hugo, an Ottava, a Versius - then that is a total redo. That means a complete new training paradigm. Base set ups, console use etc etc.

So here’s the logic: We are happy with da Vinci (could be cheaper per case) but the teams are up and running - the system is bullet proof and the team is super proficient and fast.

(If I hear again the utter BS that docking takes too long, and our robot will speed up docking… oh dear. Don’t get me started.)

So the teams can come in the morning - apply vast tribal knowledge on da Vinci - bang through cases efficiently - they are up the learning curve - and the system works. (Not all other systems and instruments are reliable yet.)

And you… want me… to start them from zero again. So they drop efficiency for three to six months… they disrupt the case loads again as they get up that learning curve…  again! They need to go away and be trained… again! And they need OR support again for the first cases - maybe five to ten with proctors again and maybe thirty cases to get back up to where they happily are today.

Erm… why?

“Because we democratise surgery. We will increase your throughput. We will dramatically reduce costs.” - Cough cough cough.

Now remember all three da Vincis are totally interchangeable - so every DV operating room can schedule DV cases for all 8 of those surgical teams in any day - any order - any way.

And if my robot number 4 that I want to add is a da Vinci  - I just bolt on capacity for any of those 8 teams - and I just improve OR availability, and tomorrow, capacity can go up in robotic procedures - no effort - no change - no retraining. Simple. And we are getting another robot because we need capacity.

Alternatively… I get another robot and disrupt my entire ecosystem. Maybe only one team initially can start on that system - so now I have to think about scheduling - and there is a chance that it won’t be used every day  with limited teams available to use it (as it’s just one team trained) so I have an asset that cannot be sweated like another da Vinci could. It can’t really help with capacity straight away.

Plus the surgeons and OR team are going to have to do the mental dance (even if it is pretty easy) and jump between two systems if scheduling doesn’t work.

Why would I as a hospital do any of that?

I already have their da Vinci ecosystem in house

Surgical robots are not Tyvek wrapped off the shelf products that you just order, stick on the shelf, and the surgeon uses. Then disposes of. Like a trocar or a stapler.

A surgical robot is a “program” and that means an ecosystem that has to happen around it to make it work as a program.

That includes many things - but let’s pick a few critical ones that people overlook.

You cannot underestimate the cleaning and reprocessing of the instruments. These are not simple dunk - flush and wash. Every manufacturer of robotic instruments has their own protocol - and every sterile department needs to learn that, have specific cycles for automatic washers, or specific manual wash steps. It takes time and education. To train them - and a tribal knowledge in a sterilisation department gets built up over years. They learn to be efficient. They learn in-team training. It just becomes part of their regular day.

So again - in trots Medtronic or JNJ into a multi system da Vinci account and their offer is this. Okay sterile department - time to get retrained again. Time to get all your staff (that knows how to do da Vinci) and start them from scratch on a second system. So now you have two types of instruments to manage - two protocols - two sets of instruments in trays and packages to deal with - and each day you’ll get some da Vinci and some Hugo instruments. The benefit to you is… well nothing… it’s just way more time, effort, complexity, risk of confusion etc.

Think of shelf space and stock management. Today I have a set of instruments, scopes, accessories and drapes - trocars and small ancillaries from just one supplier on one central shelf. Which in itself it is pretty complex. And they rock up and say - I’d like a whole new storage area and I want you to duplicate what you have for da Vinci so that you can use my robot - because nothing - nothing - nothing is interchangeable. So Please just create more work for yourself - more shelf space needed - more complexity, all for the the pleasure of having my robot in your hospital.

“Ahh… Steve but what if this is an ASC and they don’t have that already set up…” Good point - but much of the above applies irrespective of site of care - because if the ASC is hospital owned then they often use the same centralised services. But let’s focus in on a main hospital block with 3 DVs and they want a fourth, fifth and sixth robot. (Just to keep it simple for now for this thought experiment.)

Another part of the ecosystem is servicing. Today I can schedule with one proivider that care of all three systems - and maybe even get a servicing discount in either lease or PPC fees. And their system works - up time is insane - I never lose cases, software rarely crashes, instruments rarely fail.

And in comes the new robot with higher failure rates, software blips, instruments that fail (scissors that don’t cut after half a case.) I now have two service systems to deal with, two instrument ordering systems, compliant systems - why would I do that and add that complexity - especially for a system that is not proven.

I’m into their digital and training ecosystem: Why split data across multiple providers

I can’t stress enough how this is a lock in. And will become a bigger lock in.

So across my three DVs I get oodles of data for the surgeons via the My Intuitive app and I get tons of hospital data on usage, instrument usage, efficiency etc for my robotics program (and soon to be lap program with DV5).

I have great comparator data - surgeons have complete robotic logs they can compare - trainees have training logs etc all across an apples for apples set of systems… and now you want us to split that data 75% da Vinci and 25% into your digital system.

So you want us to start to fragment our knowledge, data and insights across multiple systems that just don’t talk to each other. So our teams now have to do manual gymnastics to be able to make sense of all the data. Or we could just get another da Vinci and have all that data pooled in one place and simplified. Erm … right.

And not only that, the da Vinci data sets are the most complete comparator data sets out there with 12 million cases and historic data. I can compare to what’s good - and you have 10K cases in your history for me to compare to.

Oh and their digital offering has everything (well the most complete today) in terms of what it gives me… and how it talks to the da Vinci to get set up and work flow better… etc etc etc.

So why would I take a less capable digital eco system and split my data between the da Vinci data system and your data system. Where is the logic?

Procedure application

So today with my three da Vincis I can do every specialty I cover in this hospital in soft tissue surgical robotics. I can convert every single lap and open procedure if I want.. Any one can do any procedure on any of our systems in any OR and any OR slot. If I add another Xi or DV5 - any one can do anything from day one - anywhere - any time. And all we do is massively boost capacity - with simple OR scheduling. And we are buying a robot to get capacity.

And your proposition is to bring in your super new robot. Great… erm but you can only do urology today, or hernia, or thoracic. (Depending on clearances.)

So let me get this straight - I have the option of any procedure - any specialty - any team and immediate increased capacity…. Or…

I can have an odd ball that only does one or two procedures for the few teams we disrupt from their daily jobs… again and train. Oh, and nothing is interchangeable - not even usage by OR teams. Effectively it’s a super niche system that only helps my capacity in one area of surgery… am I hearing that right?

Erm… why would we do that? - and add more complexity and be out of our comprehensive data system we have today. Double inventory and disrupt our sterilisation and servicing departments.

Well maybe you have more instruments, or staplers, or better imaging, or advanced energy?

“Maybe. Maybe soon.”

And now the hospital needs to stock two advanced energy systems for the robots, they need dual stock of staplers and reloads, and they throw off data for surgeons and managing inventory to two different disparate systems. If and when they come or get cleared? Am I hearing that right?

And for some providers - “No we don’t have a stapler… but you can use any manual stapler you want and go backwards and have to have a bedside assist fire the staplers you love - use the manual energy devices you love.”

So not only does it have limited procedures, it has limited instruments, functionality, staplers, advanced energy, imaging (maybe no ICG out of the gate.) And you get all those non features for the simple pleasure of disrupting the entire robotics program and adding layer upon layer of complexity.

Sounds like a great deal.

This is not like switching manual staplers my friends

Historically there has been revolving door of providers of things like trocars - staplers - even (more limited) energy devices. Ultimately if a GPO contract is awarded to one of the big players and it’s “all change” there may be some grumbling and a small learning curve - but the switch over of analogue - manual devices is relatively easy.

Switching robotics programs is another ball of wax. Smashing two robotics programs together is even harder.

The old thought processes of “we just need to win the contract and then it’s some intense in servicing” is a fallacy in surgical robotics. And I know that many people will say -“But it’s happened in Europe, and India and even Japan.”

60 plus systems for Hinotori (3 years)

100 plus systems for Hugo (3 years)

160 plus systems for Versius (5 years)

These are great numbers - I know how hard it is to get to those numbers. But remember, many of these are in “virgin” hospitals that have no robotics programs.

And this absolutely makes sense. It’s where you should target. You have nothing I describe above to unwind.

Others are into teaching and academic hospitals that must use other systems to remain current, impartial, unbiased and produce research. They can tolerate mixed systems (but they’re doing it begrudgingly.)

Other systems have gone into hospitals where they have a da Vinci in say urology, and other specialties have not yet started with robotics. So that again is easier and one of the places to go hunting.

But look deep into those cases, numbers, usage and you start to get very interesting picture. The “second” systems are often used for lower acuity procedures. The main system is still considered the da Vinci and considered the “main system.” Few da Vincis have gone back because it’s been replaced by a new up comer.

But again - once a hospital or hospital system has 2 or 3 da Vincis in house. It is a workhorse system that needs volume and no disruptions - then the promise of “deeper discounts” per case will not be enough to encourage systems to integrate more variants of robots. (ASCs may be different - another post in the near future.)

But the majority of the “business” and “profit” where there are multiple DV systems in will be very very hard to break into. Very hard. For all the reasons above.

Why this hurts?

Intuitive are now accelerating - and with their lease options and Pay Per Click options - multiple hospital systems are signing up to 3 or 5 or 15 da Vinci 5’s at a time. And some of those deals have been with multiple adjunct towers.

For many other companies (especially in the main hospital) it is game over. Sorry - just being realistic.

Let me say again - Intuitive are accelerating - and the “no capital up front” will mean that any system can now get robotic programs with multiple robots today. Easy - just bring cases across to the robot and sign up to a PPC model.

Unless you’re asleep at the wheel, it means that alone is going to create more and more 3 plus DV systems in hospitals - and that is closing the door - locking the door and putting a barricade in front of the door. Once a hospital is 3 deep in da Vincis. You are not getting in.

To all the other companies - time is now everything (especially in the USA.) I’m seeing maybe three or four multi system deals for DV5 each and every month. I am, sure there are multi deals on XIs also going in. Every one of those is a locked door to your company in the main block.

If you’re system is aimed at ASCs then maybe there is some sense in there - and I will post on this in another post.

But every multiple DV system that goes into a main block (especially if it is a DV5) is just impossible to get entry for a system with less procedures - features and functionality. And cost is no longer a weapon. You have lost on cost. PPC and Lease has closed that door.

Every month competitors do not have a fully loaded, fully capable system across all specialties in the USA - you lose access to 3 or 4 hospital systems for the next 10 years. The oxygen is literally being sucked out of your room on a daily basis.

A single DV system in a single specialty will be winnable. Can be fair game.

A robotic virgin hospital is absolutely fair game. Go for it at full speed.

But if you think Intuitive is not going after those hospitals as well - and every other competitor on the planet is not being forced into those ever shrinking tidal pools.. again - you are delusional.

The switching cost and pain for any hospital to go from 3 or more DVs, and bring in “an outsider system” is just unimaginable. It’s painful and doesn’t not help with capacity as much as just taking another DV.

And we see it in evidence - I won’t embarrass any particular company - but just go see recent clinical papers and work out the numbers of cases per month. It is clear that in places where they have a DV - the DV is the workhorse and the “new system” is a curiosity to do clinical publications (I generalise - but go do a little googling.) Or read my blog posts on market shares - it will become clear. (HERE)

What can companies do?

Well the reality is they will end up with the market shares I predicted in that blog. Still a good business - don’t get me wrong. A few billion is nothing to sniff at. BUT it’s only 10% and 15% market shares at best. But if they want to even get to those market shares - here’s my thoughts.

Action 1: Get a fully capable system in all specialties on the market ASAP. Delay = death.

Action 2: Stratify the market and find those Virgin hospitals - and 1 system hospitals and be the people in there loving those customers - Now. Ready for when your robot comes.

Action 3: Build or buy system that are ASC / OPD / Clinic centric - where you go fight a kick boxer in a phone booth (Joe Mullings). Because few ASCs have DV today. Even less have multiple DVs. And if your form factor and workflow are right… you would be the winning choice. And you don’t need staplers as an absolute must.

Action 4: Look for the job listings at Intuitive - it’s where the smart money is.

(Let me be funny now and again)

These are just opinions of the author and for educational purposes only. All trademarks are owned by their respective companies. Join my blog for more in depth insights into surgical robotics and other emerging healthcare

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