Is time running out for the strategics in surgical robotics?

Is time running out for surgical robotics

Let me start with a short recap of history

During the nineties and naughties a series of large strategic medical device companies dominated the field of laparoscopy. That went hand in hand with open surgery, wound closure and mechanical staplers.

Johnson & Johnson had sutures all sewn up (Pun intended) with its Ethicon division, and early on USSC (United States Surgical Corp) dominated mechanical surgical staplers. To keep up Ethicon split of out Ethicon Endo-surgery and made a bid for mechanical and laparoscopy as USSC encroached (rather foolishly) into their sutures. The battle of the duopoly in Laparoscopy had started.

But they were far from alone - as they focused on trocars, staplers, energy devices, sutures and disposable instruments. In parallel there was the boom in imaging and towers with Olympus, Karl Storz, Richard Wolf and others.

And there were multiple other providers that worked around the edges - but one - Applied Medical came up with a multi size reducer for laparoscopy access ports and through legal battles and licensing they took a large amount of both market share and royalties (I’m condensing a few decades here - stick with me.)

In the late 90’s cardiovascular was in vogue and one of the technologies that emerged from DARPA was surgical robotics. (Again cutting  it short.) But at that time (and I know as I watched it) - the laparoscopic companies thought surgical soft tissue robotics was some oddity in Cardiac surgery and the idea of "urologists and prostates" was a mild laughing point.

The battle between Intuitive and Computer Motion raged on in a small forgotten region of surgery - and no one gave a shit.

March forwards and stapling patents - trocar patents - energy patents either expired or got work arounds. Slowly the most lucrative part of the laparoscopic business - the laparoscopic (and open) mechanicals (Staplers, energy trocars) started to slip to a commodity market based on GPO contracts - tenders etc. (It's way more complex as the need for training - which created the fans of USSC or EES - as they owned it - diminished and the drift to commodities and purchasing contracts continued.) The companies took their crown jewels and thought in cost savings by mashing divisions together. Oh dear what a strategic blunder that was. Talk about reinforcing the commodity story.

Enter the market the Chinese stapling companies - low cost but acceptable quality - and the steady erosion of pricing - market share in the consumables continued as it spiralled into a commodity tender and GPO led market.

In parallel more companies started to get into the tower and vision market with Aesculap - B Braun, Arthrex and others. Competition increased and prices stagnated.

But on the side lines - that odd little company Intuitive was making massive gains in Urology - and prostates where there was near 90% conversion from open to robotic assisted prostatectomy. It was a revolution.

But hey - it was off in prostates - where USSC (later Medtronic) and JNJ (Ethicon) didn't really care. They were fighting their battles in the every commoditising market of mechanicals. A blind mark share war - where if anything was converted to robotics - it was not counted as market share loss but category loss. Hell… you could lose accounts to Intuitive - and as long as they were competitive accounts - your market share could improve!

But what they didn't understand fully were a few critical points. Be that blindness, wilful blindness, arrogance or simple stupidity? I know some people knew this was happening - but they were literally silenced.

Firstly (and see my other misconceptions post) people continued to believe that this was a prostate robot and no idiot would ever use it for general surgery, gynaecological surgery or thoracic surgery.

Next - most strategics didn't make much money in prostates - and urologists were not a core customer group. Small and unprofitable. The KOLs (key opinion leaders) in laparoscopy continued to reinforce the delusional stance that robotics would never replace manual laparoscopy. It was a curiosity that no one would take on. They even had abstract after abstract how robotics had no benefit but just added cost. Manual laparoscopic zealots defending their own skills?

Also Ethicon had licensed the Harmonic technology and stapling technology to Intuitive  - so for those rare cases they would get their slice. They just did not fully understand what they were giving away. But it highlighted they had little intention to get into soft tissue robotics themselves. They may have been smug at their little side deal.

I am reminded of H.G. Wells- The war of the worlds… (I’ve changes a few words for fun…)

“No one would have believed in the last years of the twentieth century that this Specialty was being watched keenly and closely by intelligences greater than theirs and yet as mortal as their own; that as managers busied themselves about their various concerns they were scrutinised and studied, perhaps almost as narrowly as an analyst with a microscope might scrutinise the transient creatures that swarm and multiply in a drop of water. With infinite complacency managers went to and fro over this globe about their little affairs, serene in their assurance of their empire over matter. It is possible that the infusoria under the microscope do the same. No one gave a thought to the older worlds of robotic prostates as sources of corporate danger, or thought of them only to dismiss the idea of life upon them as impossible or improbable. It is curious to recall some of the mental habits of those departed days. At most terrestrial managers fancied there might be other managers in robotics, perhaps inferior to themselves and ready to welcome a missionary enterprise. Yet across the gulf of the operating room, minds that are to the strategic’s minds as theirs are to those of the beasts that perish, intellects vast and cool and unsympathetic, regarded general surgery with envious eyes, and slowly and surely drew their plans against them. And early in the twenty first century came the great disillusionment.”

Now hear Jeff Wayne’s glorious musical intro…. (Dating myself)

On the energy side - ERBE was providing a pretty standard energy generator to Intuitive  - and as I imagine -  Valleylab would continue to think - it was on the robotic stack and used just for the prostates - and absolutely no threat to their jewel - Ligasure - where all of their focus was on in a battle between Ligasure and Harmonic in... general surgery.

But what none of them were realising in the early naughties was that Intuitive (through a hard fight) were slowly establishing a beach head in many key hospitals. Year after year more robots were being established in operating rooms - "Pffff - just urologists.”.

But this today is their biggest and most essential strength. Installed base.

But what many people missed was the curious pioneers of general surgery, gynaecology and thoracic surgery that were starting to do cases on the da Vinci system. Giving solid feedback on the improvements needed in vision, architecture, energy and stapling. Intuitive were listening and listening with great attention. Because they had understood that the prize was not the smaller urology market - but general surgery - gynaecology - bariatrics - thoracic surgery. The gold mines for JNJ and Medtronic - impenetrable for now.

The Si morphed into the Xi - and the stage was set for that installed base to be targeted towards the big juicy part of the laparoscopy market. And that is what Intuitive have been doing since the mid 2010’s.

In parallel the hardware companies - towers and accessories - reusable instruments etc didn't pay much attention. Why? Because a urology robot used for two cases per week was zero threat to their imaging business. Some started to look to big integrated OR programs like Storz OR1, Olympus EndoAlpha etc. That had nothing to do with that odd robot that was parked in the corner of the OR, every so often by those quirky urologists.

But in the late 2000's some smaller companies are paying attention - and understanding that the key IP that protected Intuitive would soon start to expire. And a raft of about 40 small companies (and some not so small) started to think that there was gold in them there hills. And they set to work laying down IP, tech land grabs and more.

About 2014 with the launch of the Xi, a suddenly capable multi quadrant design, and evidence building that robotics was actually not so stupid... general surgeons, gynecologists, thoracic surgeons (especially in the USA) started to take some serious notice of the growing capabilities of the robot. To them it was clear that robot - plus data was actually quite intriguing. In fact the stable 3D imaging, wristed instruments would give them even more capabilities.

At this point - some voices in the big strategics did start to realise there was a slight potential threat to their business; as they saw month on month conversion to robotic procedures - slow at first but accelerating.  But more concerning was the fact it was now in their lucrative markets of General Surgery, Gynaecology and thoracic surgery. A rich land of trocars, staplers, and energy devices. The core of their profits in MIS.

As Intuitive improved capabilities in energy - with their advanced energy - Valleylab and Ligasure was now also suddenly under threat. “What if laparoscopic surgeons did the case on a robot? - They wouldn’t use a hand held Ligasure… for sure.”

Intuitive steadily upped the game in imaging, stapling, instruments and data. Their towers were getting better - and very craftily they launched (under the radar) a hand held camera (just for access right?)

Suddenly bursting onto the scene were improved Chinese staplers, hundreds of generic trocars, energy alternatives, new imaging companies. All of this pressuring ASPs, margins and market share for the strategics. This multibillion dollar laparoscopic market was becoming fragmented with JNJ and MDT the  leaders to lose the most.

Medtronic clearly went hard into their Hugo program. They’d understood that they needed to act.

JNJ went for the Moonshot - known as Verb (a strange - some may say arrogant play.) My advice - Never listen to Google dreamers for surgical products - just saying.

They then realised they needed more so dropped cash on Auris - by Fred Moll - one of the godfathers of surgical robotics. And a terrible mess ensued within the company that is currently playing out in a few manifestations. Fro the outside to me it looked like you had three teams all melding. The Verb team with their nose out of joint - the Auris team with their “we know what we’re doing.” And the masters - Ethicon - that know everything about surgery and at the end of the day it was about getting staplers and energy on robots - not the other way around. Well that’s how it looked to me as an outsider.

My observation was that in both Medtronic and Ethicon - you seemed to have people in charge that absolutely - 100% did not understand surgical robotics. They made the rather odd assumption that people that know “surgery” know robotics. People that know sutures and staplers must… must … must be able to understand that robotic thing… right. I mean how hard could it be.

And that for me is where the issues started:

My outside observation is that Ethicon fluffed Verb, then realised that the Auris design wouldn’t - couldn’t work - so then went back to some aspects of Verb. So you went - four arm - and then an amazing six arm (never mix straight lap and flexible robots) - then a four arm. And Ottava now is a mix mash of Verb and Auris with z rails and consoles. Work that software out !!

My observation of Medtronic is that they went for bed mounted DLRs - then I presume they realised that doesn’t work (Bed mounted DOES NOT WORK!!! Clash management is horrific.) Then ended up with the big Z rails of Hugo. That then (as you go backwards up the arm) ends up with those massive bedside units. Each one almost as big and heavy as an Xi boom. (I’m exaggerating but that’s what people say it feels like.)

Both started with some bought in experts in surgical robotics - then (I fear) allowed in the suture and stapling folk - and well - this is what you end up with. Frustrated teams - confused projects - backwards strategies - delays, and (in my mind) poor design choices.

On the other end of the spectrum you had  imaging box companies. What I mean is imaging companies that like to sell boxes - light boxes - imaging boxes - energy boxes - insufflation boxes - etc etc. All stacked up neatly on towers - all with their own costs and servicing contracts that go with them. The box companies were trying to spread their bets a little and some managed to get their imaging and boxes sold through proxy by some of the emerging robotics companies. It seemed a good way to get some extra revenues.

But little did they understand what the tomato risk was as robot companies learned and made their own advanced imaging systems.

End of Part 1: Get full blog post access to read the second and most interesting part...

Part 2:

Roll forwards to 2024.

So since 2000, there has been a landslide shift in minimal access surgery. The robot is the absolute future (I cover this in a lot of my articles on my blog, read it to understand why a surgical robot.)

So one of the key issues that potentially plagues and could plague Ethicon and Medtronic - is what I observe as their seemingly fanatical obsession with “protect our stapling and energy devices at all costs” by building a robot around them.

I can’t be too sure - but it looks that way - and if it is, it is the most dumb approach to surgical robotics you could ever imagine. Start with our core technologies of staplers and energy and work out how you build a robot to deliver them. No!

Work out who our customer base is and where we have the biggest market share in staplers and energy devices - and go after those places first. No!

People need to step back and understand  that the market is dominated by Intuitive - that has an immensely sophisticated and capable robot - first and foremost. It is robot first. That robot happens to have some accessories of staplers and advanced energy, and advanced imaging. But it is a super capable robot at the very core. Let me say it again - The business model is a robot at the core (see my post ongoing to a service model and why that will ill the other companies).

Intuitive just dropped the da Vinci 5 - and now they have just firmly hit at the tower (box) companies. It has a fully capable and connected lap tower which means that many hospitals (if they buy a DV5) - will not be buying new lap towers soon. Well not as many - and when you’re going for annual double digit growth - that is going to hurt.

The DV5 is smart and connected - and you also don’t need to drop all that cash and effort on a smart integrated OR. It makes any OR smart - just wheel it in.

Companies with imaging towers as their core foray into laparoscopy - Stryker with Novadaq - Arthrex with their tower - BBraun with they tower and reusable instruments - can see that market (especially in the USA) start to slowly diminish. I guarantee it.

You are now looking at Ethicon - who many years ago (in my opinion) de-specialised when they merged Ethicon sutures and Ethicon Endo-surgery. They have spent billions on Verb and Auris - and to date still have nothing on the market in soft tissue surgical robotics. They are scrambling to get Ottava through to IDE - but I imagine surprises await as “software doesn’t quite work”. “Instruments are a struggle.” “Harder than you think to get a stapler on it.”  “Clash issues and clash management…” etc.

I imagine there could be a dawning reality that a provisional Ux  (user interface) cannot be put onto the market post DeNovo without a 510k. A system with no stapler and limited specialties will be a limited launch in my mind. And rumours abound (by some upset urologists so take it for what it’s worth) that Ethicon are ignoring urology as their first procedures - instead going after the big stapling cases in General surgery and Thoracic. I do hope they launch with a stapler or that will all fall flat when the clinical implementation specialist says “Oh Stapler. No you have to use on of our hand held staplers.”  -If they launch into Thoracic and Bariatric without a …. Stapler…. In the USA… Oh!

The management of JNJ needs to watch this one closely - as if the “real” launch gets past 2027 - Ethicon could fee in trouble by then. And it is very easy to hear promises from management on deadlines for robots - and even easier for deadlines to pass - time and time again. I know that pain, I’ve lived it!!!

Medtronic launched Hugo RAS - and again (only what I hear from various market feedback) it is not very well accepted in some accounts. I’ve heard - Too few instruments - instruments with issues - way too big - too complex to set up - not that smart - no Ligasure as promised - old 3DHD imaging tech. (Nice control though) and software reliability issues etc crop up a lot. The tender rests and number of installs indicate they struggle to sell in Europe. And from what I hear across the market  - several have been sent back. Too little (or too big) too late? Rumours abound that they need a complete redesign for it to get acceptance and that is even discussed internally. But just rumours.

As an aside: I can only imagine robotics is an utter money pit in strategics at the minute. I’ve said it before and will say it again: The surgical robot could be the hill that some management will die on.

Stryker - they have a great hard tissue robot in Mako - and next to it one of the most unusual and non strategic bags in the history of laparoscopy. They bought a world class imaging system in Novadaq - and could have utterly dominated the imaging world. And seemingly then didn’t.

I think they had one change to break open the monopoly of JNJ and MDT by leveraging soft tissue robotics to target general surgery - by getting in early (leveraging their knowledge and learnings from Mako.) And, again, then didn’t.

Now their imaging towers and advanced OR business I(in my mind) is about to take a tangential hit from DV5 (especially in the USA where Stryker are stronger in OR footprints.) The management must be looking at a strategies for during up their business in cardiac and general surgery. I don’t believe that strong ortho alone will any longer be enough in a contracts based world and leveraged product lines of the future. In my mind it is a risk for any big strategic not to be able to cover multiple specialties. Contracts will hurt. Data sharing will hurt. Owning patient pathways will hurt.

Becton-Dickinson (BD) bought Bard some years ago and made a bigger play into general surgery. Hernia and Lap hernia with advanced meshes and tackers was booming. Until Robotic hernia started to take over - where a simplified pre-peritoneal trans abdominal was easy. and shifted the need from tackers  You don’t need tackers - because robots are great at suturing mesh in place - and then you don’t need advanced meshes as a simpler mesh will do - and is better pre-peritoneal. Opening and closing the peritoneum is relatively easy on a robot.

So I think they are sat in general surgery (specifically Hernia) needing to work out a next strategy.  And they must see the imminent threat on the horizon that if Medtronic and JNJ get robots on the market - they will bundle their mesh products right into the hernia offering. And why would anyone need to buy a Bard mesh ever again. Robotic hernia kit with sutures - mesh and all you need.

Karl Storz and Richard Wolf have been the primary supplier of imaging systems to the upcoming robotics world - as it has been a way to get their technology and boxes into the world of relevance in robotics. But as long as robotics was a niche it was a nice side hustle (how I see it.). But with the advent of the DV5 tower and more and more upcoming robots with their own imaging technology. And as Medtronic and JNJ look to their own imaging and advanced imaging chains - there is a clear and present danger to tower and box movers.

Karl Storz have done what I see as the first smart move of 2024 by looking to acquire Asensus - and gain access to Intelligent Surgery unit technology (the software suite that will help with the future against system like Touch Surgery.). Plus they get a footprint into surgical robotics with Senhance - gaining people and understandning of how you really actually run a robotics business. Plus they have bought in at the end of a development of a next gen robot LUNA.

Richard Wolf continue to supply CMR Surgical and well… that leaves what I think of as the odd ball that is Olympus.

Great company - great products - with advanced imaging and a great advanced energy or two with Thunderbeat and the newly launched Powerseal. They had forays into robotics with Endo-samurai and some apparent stealth projects of their own robot. But without an actual robot play - they risk to be consigned to being just a flexible endoscopy company.  They are relatively a fringe in laparoscopy as it is today - but with the march of Intuitive, as well as MDT and JNJ working their way in to imaging  - the squeeze will be on them.

Then you have some peripheral strategics like Boston Scientific. Not known for their laparoscopic prowess - but maybe they are now waking up to the fact that the robotics companies will eventually infringe upon some of their areas. They are marginal in urology - gynaecology and some other more obvious areas. But without an offering in full line general surgery - gyn - thoracic - they could start to become seen as that sort of odd supplier of strange accessories. Often heard surgeons and hospital managers refer to them as a catalogue of accessories. Unfair? But no having a solid footprint in connected surgical robots could marginalise that image further.

If ever they want to get into surgical robotics - I think that the window is now.

So why is time running out for all of the strategics in surgical robotics?

Firstly - the march of Intuitive is utterly relentless. Five years ago I often heard “Why should I buy a robot?”.

Now all I hear is “So which robot is right for us for now and the future?”

The train has left the station and the march to robots across soft tissue, hard tissue, endo-vascular, pulmonology, endurological, endolumenal - is in full swing.

Data and smart connected devices will rule the OR space and much of the therapeutic device space. If you are a strategic without a robot in some of these spaces - you are just… well history.

The linchpin robotic technology and critical space is that of Soft Tissue Surgical robotics for now. (Endovascular is a decade away to dominance). If you don’t or won’t have an offering in soft tissue surgical robotics for the next ten years - I think you are all but irrelevant.

I am-predicting a few things. Take them just as crystal ball gazing - but this is why I think the strategics are running out of time:

Medtronic: I don’t personally think they will fix HUGO with this version (prove me wrong). The architecture is just wrong for me. Too big, too ugly to set up- the worst of boom robots and complexity of modular robots combined. Old school non-collapsable Z rails and monstrous drive packs  swinging around - all seemingly centred around getting their existing Signia staplers and Ligasure technology on at (as what I see) the cost of the robot.

In the worst case scenario - they system is potentially a black swan that could do them serious financial damage. I think they need a radical rethink and serious change in design. They absolutely have the muscle and training power and technology in house to start on it. But my humble opinion is that if they are coming from “how to build a robot to deliver our tech”  - it’s a strategic error. The dawning reality that (especially in the first 3 to 5 years) this is not an 80% margin business - wristed instruments suck at margins - it’s complex - it isn’t a central “toy” that allows you to contract staplers and take market share from JNJ and Chinese competitors, stops the slide to Intuitive… etc.  May be landing.If the highly anticipated robot “From the house of Medtronic  - a leader” doesn’t live up to the hype - you potentially frustrate even loyal customers. Possibly drive them to the capable arms of intuitive!

My gut tells me that Medtronic need to look at systems that Hugo needs to be. The obvious one for me is CMR (best modular option) - but beyond that a smaller looking HUGO is Carina by Ronovo. It’s everything HUGO should have been out of the gate.

Hey but what do I know.

JNJ (Ethicon): False start after false start - moonshot verb - to six arm Auris - to 4 arm “Verbris” - and coming with no rendezvous procedures - and basically a bed mounted boom robot called Ottava. I’llsay its gain - loudly - I think It’s too late. Way way way too late. The last to the party “spin” where “we see all other’s mistakes” is a poor mantra as da Vinci eats your lunch week in and week out. What lies ahead for Ottava in the next three years is potentially the most painful lesson Ethicon will ever learn. Your size and might has no bearing on how successful your robot will be - out of the box.

If there is one thing I personally know - when I hear “we will apply for IDE” — “apply” for IDE 2nd half 2024. You need to raise an eyebrow. That means they are in cadaver labs with 4 or 5 prototypes. Still potentially working through User interfaces - still dealing with he legacy of the merging of an Auris controller with four Verb like arms onto a table and get it al to work flawlessly. I would no be surprised if they don’t soon hit the safety software was that has confounded every robot in history. That moment when development software of the arm gets a secondary layer of safety systems on - and all hell breaks loose as that “annoying clashes” now become case stopping medium or high priority alarm.

It cold be that time when the software engineers attached with laptops that can get you out of trouble with back end software will all be withdrawn - and the reality of a stand alone embedded software system bites.

Hey - I am speculating 100% - but in my nightmare drenched sweats (I have by proxy for them) I am imagining these issues coming in one after another. I hope they are not sitting in weekly progress meetings where “What does that mean for the time line?” Becomes the mantra.

Or maybe that’s all behind them and they are now easing into production for a launch in 2026? They know.

But what I do know is that every single robot is utterly unique and you learn little to nothing from past launches of other robots.

I fear the clock is ticking way too fast for them - as more cases move to robotics (and Medtronic doesn’t even have FDA yet). Add in the possibility that the cost of goods on Ottava spirals week in week out as lessons get learned. Then as selling capital just disappears quarter after quarter. Cross checking the two spread sheets of diminishing revenues and increasing costs - some people could ask “is this still viable?”

One group might be saying “We need something now - how about one of the working systems out there?”The others could  be saying “You will get Ottava on the market in 2026 and it will crush Intuitive."

For me - buying an on the market robot would be the safest move they can make right now while they are cash rich. Buying two systems that were not even on the market was “interesting” and maybe a little “arrogant”? I would be buying something that is on the market. Not for revenue - but for footprint - reality - learnings - credibility. Time is ticking way too fast and if Ottava stretches to 2029 (as I predict) - and it costs a fortune (you need to buy a bed) it could be irrelevant in most of the world. (On top of that for the USA you need to 510k staplers, energy, advanced imaging etc etc) and then 3 years to work out how to do instruments right, squash all the bugs and do it all at cost… etc etc.

Stryker - they need to decide if they are in or out. If they are in (and I think they need to be and could be)- they need to get serious. Go buy Applied Medical and CMR surgical - mash the two together and get serious in lap and robotics in one swoop. Get Novodaq loaded up and all the smarts of the integrated OR and - well that would be a formidable roll up. I’d invest in that bad boy.

If not - they just maybe need to sell off imaging and integrated ORs as they will both be irrelevant as stand alones in ten years. This in my mind is about do they strategically want to be in general surgery, thoracic etc. or not.

Karl Storz - the roll into Asensus unlocks a lot of value if they use it t go public. They get their world class imaging on a robot - and get access to a future platform - LUNA - which they could absolutely use as a “Relaunch” that Asensus can’t do due to their legacy image with Senhance. Storz cold strap rockets on it - they have capital say people, servicing, infrastructure - reach - footprint and knowledge deep into surgery with a Rolex of friendly customers and distribution networks globally. Leverage leverage leverage.

It allows smart ORs, integrated towers - data - ISU, and a lot more. It’s a shrewd move that protects their “Boxes” and yet  brings value - and could eventually make them a very attractive target for a bigger strategic. Either way - as a stand alone or a target - they have covered themselves for the next decade by having a robot in the bag (if they do the deal) and what a great price for them! 10 years head start into robotics - protecting their market share and imaging all for $75 Million - bargain!

Olympus -  experience tells me a Japanese company must go with a Japanese company - Medicaroid. If those two Japanese management teams are not sitting around a table in Tokyo talking about how Kawasaki brings world class robotics - a significant footprint in Japan already with Hinotori. And Olympus espousing two energy devices - world class imaging with Endo Eye - integrated Ors and smarts. Then they all collectively need their heads knocking together. That JV or partnership or whatever they decide is so obvious it hurts. Not only a logical tech fit - a super cultural fit! It would dominate Japan, and a big part of SE Asia, and actually could be the unlock for the US market that both companies desperately need.

BD - I feel they must protect their hernia business - as I see it… it’s at massive risk. One robotic strategy I believe that is as valid as being. Broad procedure provider - is to be just the world’s greatest hernia and Gyn robot. Done in ASCs - low acuity where suturing is key - and every case with a robotic friendly Bard mesh. 800,000 in the USA alone - 2 Million worldwide. Fast throughput - simplified robot needed - stay at the table so solo surgery placement of meshes and sutures through ports can be done - - - they need to be talking to Distal Motion about Dexter and talking now. This is the perfect system for those applications. Inguinal and ventral hernia - sacrocolpopexy  - wristed suturing - when needed - quick simple - small. Stay sterile - improve workflow.Of course Dexter is capable of more - but BD needs a hernia bot and that in my mind is utterly perfect for that job. Keep the strategy simple and focused.

There are of course other left field companies out there that could go a little off piste and see this as a way to get a slice of the lucrative general surgery pie. But for some it would mean a major change from where they play today.

GE health, Philips,  Siemens, Getinge - are all in the big iron space - but as Siemens showed (it was a fit granted) with their acquisition of Corindus - that they have some appetite for robotics. Could one of these companies benefit from a robotic company acquisition? Does that unlock some areas of surgery to them? If they care?

And finally there is the lower acuity asset of Moon Surgical orbiting out there. Not full main frame robotics - but could that some strategics in the OR today want to take a middle ground route into Advanced Assisted Laparoscopy? Whatever these strategics do with an eye to laparoscopy - it needs to be a form of digital laparoscopy to remain relevant and differentiated.

So why do I think the clock is ticking so fast?

Intuitive and daVinci are setting the pace - and momentum is gaining. Recent articles about the death of laparoscopy are correct. The data is compelling. Both open and laparoscopic cases are converting to robotic assisted cases. And it is not just in the USA. It is in Europe - take the UK for example with its massive rush to robotics. Italy, France, Australia, Japan, S.Korea and of course China.

As I’ve said many times - forget the cases and countries “no one cares about.” But look to where the lucrative money is in stapling - energy - etc - in countries that pay for those devices: In those critical markets - that shift to robotic surgery is accelerating.

As JNJ land MDT load up their staplers and energy on their systems  (if they can get them right) - this could vey quickly become a three horse race. Although I will caution again - that in my mind - an it is just my perspective… if Medtronic don’ get to Hugo Mk2 fast - and JNJ don’t get Ottava out of the door by the end of  2028 latest - this will again become a single horse race. But this time that single horse will own a vast vast landscape with unbridled power. Most of the small companies will have run out of money or be niche players if no one buys them up. It could be a graveyard.

So as we see Karl Storz potentially taking out one of the only FDA cleared main frames. I also see other strategics circling the upcoming robotics systems - and I predict 1 by 1 they will get bought up throughout 2024. For IP, for technical know how (service set up isn’t easy), knowledge of implementation, digital assets and above all the people with the know how. Much of the success of any strategic will be to retain the best R&D (they are special in robotics) and the scar tissue laden commercial teams that actually know how to do this. Suture and Stapling reps cannot and will not sell a robot.

As those “robotic chips” gets taken off the table - any strategics that are left without a robot will be consigned to history in those fields. They don’t have the 15 years to start their own program. It’s over by then. The window is now - and strategics need to buy into the last ten years of knowledge - footprint - placements etc.

I cannot stress enough that buying assets that are out there now is the only way to secure their future. If HUGO 2 is not almost near launch… I think it’s too late. If Ottava gets even 6 months delay - it’s a challenge. If any company is thinking - “Let’s start our own robotics program now.” - They are done.

The first domino - Asensus is falling, and now we will see company after company - IP portfolio after IP portfolio - team after team get scoped up by strategics that have decided they will not be left behind. Those strategics have a chance of a future against Intuitive in this space. All others with no chair when the music stops need to be working out their divestiture strategy now on their general surgery products.

Those that think “we don’t need to be in that space” have not read the future crystal ball,  and the move to ownership of the OR, the Cath lab, the bronco suite and the endoscopy suite. I’m not going to tell you now how it all fits together today - but the soft tissue surgical robot is the core of that future ecosystem.

Tick tock - time is running.

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