MiniRAS a whole new category - Virtual Incision moving the robot inside the patient
- Steve Bell
- Dec 17, 2024
- 25 min read
Updated: Jul 30
Before heading out to the HQ of Virtual Incision - in Lincoln Nebraska. I asked myself “what are your thoughts on the system?”
But I also asked many of you to tell me your thoughts on their system: and well it was a mixed bag…
“It’s single port so has no future…”
“It’s interesting. But why?”
“Like a daVinci SP but with only two arms.”
“Arms are too small. Too weak to do real surgery.”
“That's a big incision - that is a massive hole in the umbilicus. No one is going to use it.”
“I don’t get it?”
“Is that the same as Vicarious Surgical?”
Etc etc.
Now I’ll fess up. I too have been very sceptical. And I know this space, and I have even sat on the system and played with it at SRS 2024. And I was embarking on my long trip to Lincoln Nebraska (BF Nowhere… right? Hold that thought…) with a little more than scepticism. But "The fact" my long term colleague Kin Cheung (probably one of the most knowledgable people in the world of surgical robotics) was insisting that “it’s way more than you think…” had me curious and willing to winkle myself out of home for a trip half way around the world.
Note: I just can’t help myself. I’m too geeky and nerdy to not go and see inside the robots.
Now (after the trip) as someone that also knows this space, and has sat on nearly every robot that exists. My conclusion is: “It’s way more than you think.”
So let me explain "why" in my extended field report.
Let's start with: It’s not a single port robot
I have placed it in this category since I first knew about it. And well that in itself has always had me on the back foot. I lived through the whole “SILS” (Single Incision Laparoscopic Surgery) fiasco. An application looking for a problem in my opinion.
I watched the daVinci Si with its 5mm flexible instruments do a cross over single port - and always thought - “Okay transoral - I get it.” But abdominal was just not doing it for me.
Since then, I’ve watched the launch of the daVinci SP and seen it in transoral and transanal surgery and been suitably impressed. But then watched the company do everything to push it to abdominal… and slowly add ports for retraction, ports for bedside assistance and staplers and advanced energy. I’ve been shaking my head as we go from SP +1 to SP + 2 in some cases - which in my book is “Multiport” by any other name. Oh so very cool as a technology. But I just keep asking why in the abdomen?
I then watched the SPAC of Vicarious Surgical. Watched their two arm design with funky camera. Enjoyed their story of decoupled actuators - and admired their great story telling. I like Adam and his team, but again have to say “SP +1” or even 2 will be the final destiny. Plus the camera system… I am waiting to be proven wrong on illumination capabilities etc. But Vicarious is for another day.
NOTE: In a minute I’m going to explain something that is a major “Ahhhhhh” moment. And probably something that will suddenly make sense. But for now you just need to remember that both SP and Vicarious - have a pretty big robot outside the body - and drive their flexible instruments via long cables that pass the fulcrum. So lots of hardware outside of the patient - which means you still have a significant footprint around the table.
Now SP and Vicarious are down at about the 2.7cm (access port) for SP and a claimed 1.5cm incision size for Vicarious surgical. And that is getting down to the realm of “acceptable” incision sizes for a single port device. We must always think of cutting and stretching the fascia - and needing to close it. Or we must think about possible pain from pushing muscles around that incision.
The MIRA comes in with a rather sizeable “incision,” which in my opinion makes it hard to justify to place through an umbilical port. In fact it had me asking “Why so big?”
So now having been there and talked with the inventor Shane Farritor, I’ve had my “Ahah” moment. I’ve understood why so big. I’ve understood what it’s designed for. I’ve seen first hand what that translates to.
So you need to understand that this is NOT a single port design. In fact the IFU clearly states you need a second port. It is a dual port or even multiport system. They have never pretended it is a single port application. This is why they don’t call it SP - but instead insist on calling it a miniRAS.
“Makes no sense!” I hear you cry. It will.
Move the robot from outside the patient - across the abdominal wall - inside the patient
Now you have to first understand that Shane is not a surgeon - and Shane is not overly contaminated by the dogma of surgical practice. He is from NASA and has worked on projects like the Mars Rovers. So he doesn’t exactly see the surgical robotics world as traditionalists do.
If you think about laparoscopy… the robot (sorry the surgeon) stands outside the patient (obviously) and puts long instruments through a port and into the patient. Forces and movements are translated through the instruments - across the port and to the instrument tips. This causes some fundamental control problems.
Now daVinci took that concept and with say… the Xi - put the robot outside the patient - and controlled instruments via cables through the shafts to get wrists in the patient. But it is still robot outside the patient - instruments controlled at distance inside the patient.
Even the SP or Vicarious used that paradigm; but through a single port. Long instruments where all the movement is controlled from the big (expensive) robot (it has to be) on the outside via long instruments through a fulcrum (to the inside.)
So in both laparoscopy and all other conventional surgical robots - the control happens outside of patient and the instruments move inside. Meaning mass and bulk (humans or robots) with lots of movements around and above the patient. Lots of feet on the floor or booms, or individual carts. It is busy around a patient in the OR with a robot or lap procedure.
A guy from NASA clearly looks at this and scratches his head. He understood that (I won’t go too technical) having everything outside and controlling everything inside by wires, pulleys flexible tubes etc creates a lot of issues. Including… there are limits to how much force you can get through small flexible instruments. And just how smooth you can make them move.
So how about moving the entire robot across the abdominal wall and placing all of those motors and gear boxes inside the patient. Doesn’t that make more sense?
Well to do that you need to make the robot parts way smaller. And use miniature motors and gearboxes inside the patient. Not easy.
But if you do that… you actually change everything. And this is what was my massive sudden understanding in the lab with MIRA. It firstly explained to me why the diameter of the thing is bigger than SP. Because you are having to get all the cabling and power and electrosurgery and the flexible scope control through a single shaft. That is a lot of gubbins to get inside the patient. But it becomes transformative in what it does for the robotic paradigm.
What do we gain and what do we lose?
Nothing in life is for free. If you win on somethings you lose on others. MIRA is living in that paradigm.
The minute you move the robotic arms across the abdominal wall you get a huge amount of benefits. (In no particular order.)
The first thing that happens is that you no longer need long flexible instruments (reposable or disposable) passing through trocars. You end up with two full robotic arms inside the patient and instrument tips can simply attach directly to the robot arm. This means that there is little complexity in the instruments - and that means - these relatively inexpensive instrument tips can be disposable. And with this design a very cost effective disposable.
That is not necessarily just about reducing “cost” per say. Instead it is about the main theme of MIRA - reducing complexity. You attach them - you use them - you throw them. The entire sterile services department avoids that super complex reprocessing of long, hollow wristed instruments. It’s just gone.
As long as you have a supply of tips - your hospital is ready to do surgery.
Next - and I felt this first hand. You can have a good-sized set of instrument tips. You are not limited by pulleys, cables, flexible segments. You can also have brand new instrument tips each time. So scissors do not degrade in sharpness. Bipolar graspers do not get residual eschar build up that remains through cleaning. Each case you get a brand new instrument - and that makes a huge difference in performance. But it is the new tip in combination with “direct drive” that gives a sense of precision and control I have found in no other system to date. The tip cutting of the curved scissors was exceptionally good. I pushed it to its limit (I think the team were watching me wondering why I was doing very stupid little tip cuts of the foam.) I was testing a few things. First was how sharp the scissors cut. (Exceptional.) Next was how well they cut at the tip (Exceptional.) How strong they were (Exceptional.) How smooth the control was (now… exceptional because you do not control them via cables and spokes. There is no force build-up down the shaft of a long instrument. It’s buttery smooth instrument control through direct motor drive over a very short distance.)
When you bring the robot inside the abdomen… you take out all the shitty things about long tubular instruments via cable drive. The direct drive is just something else. Something new.
Now on that - it seems a small thing - but it is not. They have done a technical miracle. Not only have they delivered a robotic arm - but that robotic arm delivers full monopolar and bipolar directly to the instrument tips. Through the robotic arm. It’s a masterful piece of engineering. And that (I will come back to in a minute) changes everything on electrosurgery cabling and simplicity.
The next thing you get is that “fixed” triangulation paradigm that other SP systems give you. Your camera articulates in a centred position in relation to the two arms. And as everything of the control software is all past the pivot point of the abdomen and concentrated in the surgical zone - the system has very precise understanding of the shape of the arms, where the arms are relative to the scope and each other. That allows some pretty nifty help through the graphics interface. You can easily know where you are in relative space - and that is graphically represented so that the user is always situationally aware. Even if arms go off screen.
It also allows some very cool tricks of having the first automations of re-centering the scope on any instrument - or bringing the system back to a central neutral position with the press of pedal. It’s these clever little things that help make the system extremely usable. It’s what makes workflow better. It's a benefit of having the robot inside the patient.
The next thing you get is an incredible strength of the arms. The arms inside are powerful little Maxon motors and custom gear boxes. And as they are directly there close to the tissue - they are very very powerful. This does not feel like the power of an SP compared to an Xi instrument. This feels super strong. In fact they have given haptic rumble feedback for when the arms are pushing against things. That power is transmitted directly to the jaw closure and spread of the instruments. In fact… you can set the power of the closure between strong and regular - yes they are that powerful. It allows a setting between traumatic (you don’t care as the sample is coming out) and non traumatic (you don’t want tissue damage.) Well that was my interpretation of that setting. But one of the strengths of moving the robot across the wall is well.. direct drive strength.
I’ve saved the most important to last
There are a few other benefits much like the SP systems - such as easy quadrant to quadrant movement and set up. And others.
But there is one thing that absolutely staggered me about this method of designing a surgical robot. There is virtually nothing outside of the patient to get in the way. And even more important - there is no movement of the “arm”. Something that plagues multiport systems.
I have discussed in long details about how when you have big Z-rails outside of the patient - there is a chaos as the arms move outside in big movements to make the smaller movements inside the patient.
MIRA is so small - compact and uncomplicated. I was literally blown away standing bedside at the minimal impact of that system on the OR. There is a “calm” to the whole procedure that is not seen even with a Single Port system, but especially with a multiport system…. And even more so - with LAPAROSCOPY. This is something totally and utterly new. This is what makes this a new procedure. You must get your head around this.
At bedside - nothing moves !!!!!!
At bedside there is no big robot at head height - nothing - nothing.
At bedside there is no footprint. The MIRA sits on a slim metal arm that is attached to the bed. No Footprint.
At bedside there are just two cables to the system. Yes two. One for the camera and one for the entire robot (forget light cables and electrosurgery cables - they are in those two cables!) It’s bonkers what they have done.
If you didn’t know the robot inside was moving - you’d wonder what was going on.
Note: That utter lack of movement in the abdominal wall - unlike laparoscopy and even remote centre and VPP robots - seems to be (anecdotal) reducing pain. Less movement and stretch should cause less abdominal wall trauma - less stretching - less complications and less pain. Still to be seen in clinical trials. But as a physiologist it makes sense.
The single camera cable has - comms to the camera (it’s a fully robotic camera that flexes). It has power to the camera. It has light to the camera - it has image data back from the camera. All in one tiny.. lightweight cable.
There’s that word again - simplicity.
And the robot. It has one cable. And in that cable you have comms and power to the robot arms. But you also have bipolar and monopolar in that one single cable. The decluttering above the patient of this system is extreme. In all my years of surgery I have not seen such a clean - calm - easy access surgical filed as with MIRA. It is an utter game changer.
So as we start to think (more later) about where this system is targeted towards - this simplicity of the entire system - the thinking behind it - is something that will make OR flow something else. The space above the patient is like nothing you will ever see in any minimally invasive procedure - lap or robotic. It is the utter opposite of HUGO or the Xi. Or even smaller cart based systems like Ronovo Carina are nothing like this. It was the single most important thing I took away from the lab.
It creates a simplicity of set up - a simplicity of use - a lack of drama and a complete change in how this system is used.
That one technical decision to move the robot inside the patient is what makes this system unique. And brings advantages to places that need simplicity - lack of space - have challenges with CSSD - need staff efficiency. Places such as Outpatients and ASCs (clinics.) - I can tell you. This is something very different. It is no coincidence that MIRA is targeted here first. In this type of environment there is nothing even remotely close.
You can’t put Virtual Incision in a box… but you can put MIRA in a box… and they did.
It’s swings and roundabouts
Okay so wow!! And yes WOW.
But in order to get all of that complexity inside the patient you do end up with several tradeoffs. And I want to be clear what they are.
People buy robots for many reasons. Key ones are - wristed instruments and stable 3D vision. I’ll add in another important one - “minimally invasive.”
So let’s tackle a few things. If you want a scope inside the same entry structure as the robotic arms - you are limited on real estate. That means the camera diameter is limited. That means the tip size is limited to how many sensors you can get on it. So MIRA has a 2D scope.
For many that is near blasphemy from a robot.
What I will say is that the illumination is phenomenal - the picture resolution is superb - colour rendition very neutral - great black point.
The advantage of a 2D camera is that the full 1080P resolution is put up on the screen. So for me this was an impressive 2D surgical image as good as any 10mm camera. Gain control was excellent - and there was no flare - even against the white arms of the robot. As 2D goes - it was extremely impressive. But it is not 3D (yet.)
The entire team acknowledged that 3D is asked by a lot of surgeons that try the system. SP has 3D. Vicarious has 3D. And all other robots have 3D (not quite true but…) So 3D is on the roadmap for sure.
The articulation of the scope is great and helps to always give the optimal field-of-view. And I must say after a few hours you do start to get used to the 2D - in combination with the single view paradigm - it’s manageable.
But honestly - I feel a large enough % of mainstream customers will want 3D. And I did make that clear.
The next issue that you get is instrument exchange. Well technically there are no external instruments to exchange. Today they have a scissor and a bipolar grasper in the commercial released version. But in the hysterectomy study they also have a needle holder. Not a lot to exchange. But when you do want to do it - it means removing the whole robot. Unscrewing a tip - putting in a new one and reinserting the whole system through the gel port and access device. It’s clunky, and prone to frustration in a normal everyday operating team.
But the team at VI fully understand, and do have plans to make that easier. I myself think that with training it is manageable - but for mass adoption - the new modifications will definitely make that a non issue.
Now let’s talk about the elephant on the table - the diameter of the system. This is not something that can be used through any normal umbilical incision. Period. Physically it can be done - but no surgical community will accept it. An over 3cm diameter incision is just too big.
BUT it was one of the explanations to their procedure strategy - and roadmap. It all suddenly made sense why they went for colorectal as a first procedure. The insertion incision becomes the extended excision for the anastomosis. So that issue in that specific procedure goes away.
Their second procedure is in benign hysterectomy. And again - through a mini Pfannenstiel incision where the uterus will be extracted… well that too can make sense. But is clear to everyone that for their full commercial system (wait hang on - didn’t they already launch…. NO!) They will need a smaller diameter than their M1 version. (M1 = MIRA M1)
So step in M2 (MIRA M2)… more later. (I’m a tease.)
More on the bed and the footprint
I want to circle back to the part that had me saying - wow. That is the bedside management. Because this will be important for competition and their claims - along with telesurgery - which we will get into.
So. The system has a console like many other systems. It has an arm that locks to the side rail of the bed. And it has a bedside cart.
Let me dig in to the arm on the bed. It’s a very simple low profile (ie not thick) arm that holds the handle of MIRA and locks it solid. It allows the bedside user (under surgeon instruction) to simply point the MIRA at any desired quadrant - making multi quadrant easy with no redocking. It is simply “re pointing”.
I thought there would be a lot more of that re-pointing around the abdomen - but the sideways reach of MIRA and the all the way up and all the way down gives a pretty impressive working volume from any one fixed position. They have a cool model that is like a half volleyball to demonstrate the working volume.
But should you want to move to a totally new quadrant - it is very very easy. I personally would not try and over complicate that as it feels very elegant and calm.
But what this means is that the “zero footprint” bedside crown goes to them. Ottava have touted this as a major feature - but MIRA has won that one already. Because not only do they have ZERO bedside footprint - there is no patient cart or load delivery arm. There is only one slim static arm attached to the table. Not four payload delivery arms like Ottava (which is great.) So for MIRA table space occupancy is just ridiculously small. There is absolutely nothing above the table - along side the table or next to the table. This is unique.
Ottava also claims “Unified motion” which means that as you move and tilt the bed the arms are fixed in space to the bed so move with it. Well again MIRA has them beat to the punch. It already uses unified motion as part of its inherent design. But doesn’t have four big payload arms moving around as you tilt the “custom” table. They don’t have a custom table - psyche.
So here is where MIRA wins hands down in the table game. This design fits any table. Any table. And can be added after draping and patient induction. It is the workflow king based on the table.
It can be removed at the end of the case - and the “robot” is not blocked in the OR during recovery and turn over. Bed based robots are.
It is really well thought out from an efficiency point of view….. oh and a telesurgery point of view (more later on that tease.)
Now we turn to the “tower” that they have. It has two main components. The control box for the robot and camera with integrated light source. But it also has a modified Bovie unit to supply electrosurgery energy. And this small comapnion cart becomes a big feature later in telesurgery.
It is the simplicity and small footprint of this bedside companion cart with the simplistic two cables that makes this so easy to set up.
“Well of course Steve it’s just a two arm system!!”
Nah!. Let me explain this better as it took me a while - and it rolls back as why this is not an SP.
The MIRA robot is another game changer
I’m going to spend some time here to explain M1- and explain M2.
I’ve waxed lyrical about the two components of the MIRA. The Virtual Incision built robotically controlled camera (equivalent to arm 1)
I’ve then said that they miniaturised the arms and put them inside the body - (arm 2 and arm 3.)
And I’ve said that they mandate an extra port - why - because all Single Ports systems need it for clippers, retraction - staplers - suction irrigation at some point. (arm 4.)
So if you want to mimic the full functionality of an Xi - you need to have the equivalent capability of 4 arms. MIRA… very strangely… has this.
Now very interesting - so we have four arm equivalent - but with no boom and no “arms”. We have an integrated camera and disposable tips but no instruments (as such.)
This is where my brain went into meltdown when I suddenly go it. Hey do you get it yet?
Well the entire work flow and commercial model has just been flipped on its head. You see everything is about a minimalist reduction to simplicity to make workflow as easy as possible from pre sterilisation - to set up - to use - to tear down - to cleaning - to sterilisation - to storage.
MiniRAS sets a new paradigm by its inherent nature.
Firstly - the cost to build this thing cannot be anywhere near the realm, of a multiport system or even an SP. It doesn’t have the mass of metal - the hardware - the plastic - the multiple complex drive units - the complex arms etc etc. It’s a robot you hold in your hand, in one self contained piece.
It doesn’t have a super complex image chain tower - it’s a simple hand held scope and built in light source and image processor.
I pushed on getting the COGS (cost of good sold) but that remains a trade secret. However - I’ve been around long enough to say definitively - these COGS are transformative. It means that you could place multiple of these into a hospital on the shelf ready to go — multiple. You could have one or two in every OR and not feel it as a company. That opens up whole new models of business.
The next big change is that you sterilise the whole thing (robot included) - in a "standard" and simple tray. It can be cleaned and sterilised easily. And that tray can be walked from OR to OR. It can be stacked on shelves with little space. (There are not booms or carts filling valuable floor space.)
There are no instruments as such. No complex cleaning and sterilisation - no reprocessing. Instead you have a simple disposable tip. No drapes - no connecting wires. It’s so fucking simple it’s silly.
An OR can become robot ready (as they claim) in minutes. It’s true. I’ve seen it.
So what about servicing? Well that is the next revolution. Use the robot 15 times and ship it back and it gets a tune up and sent back. So the super complex servicing structures for the robot and all that high associated cost has just been nullified. It’s a very clever back to base strategy - much like is done every day with Orthopaedic equipment. There’s nothing new in this - except that it’s being done in soft tissue robotics.
Again... there are no drapes - no bulky boxes in the OR, no drape costs, no drape disposal costs. Nope. And no learning curve for draping.
Disposable tips and one small disposable scope seal connector. It’s nuts.
All of this does genuinely transform the economics. I was asked “how will this ever work under ASC economics?” Well - if all the in my head calculations come true - this is going to really change the economic profile of surgical robotics. I think it is the first robot that will really - genuinely do this in an ASC. Make ASC four arm surgery viable.
And all of this - everything - starts with a complete rethink of which side of the abdominal wall you place the robot. And doing that has not been easy. I’ve seen their prototype museum. But like everything in life - it’s an iteration and a progression. So let me take you on this exciting journey.
Crawl - Walk - Run
When most companies fail - it is usually because they want to boil the ocean on everything at once. I think that Virtual Incision, led by John Murphy, has genuinely watched the industry and seen many of the mistakes that have cost multiple robots their lives.
The road to miniaturisation is often long and hard. And in fact M1 (Mira M1) is their first clinical system. It is too big for every day use in all specialties and procedures in my opinion. But as stated earlier, it is perfect for colorectal.
In that spirit of learn - reiterate - reduce - the company has not (as I had believed) launched their product post FDA.
Instead the company has take the sensible decision to run a program they are calling “First Access” in a select and limited number of sites across the USA. Hyper selection - hyper care within colorectal to gain user feedback on everything. System - back-to-base service - set up - commercial - usage - training - and more.
I would call this their crawl phase as they start to get their hands around the “commercial reality” and then build from that ever growing knowledge base.
In parallel - the engineering team knows that a key limitation to wide adoption of this device will be the diameter... and hence “hole size” in the patient. They know that they need to get down to the sub 2.5cm mark for the diameter of the MIRA.
Step up MIRA M2. It is clearly the culmination of understanding the real world feedback of MIRA M1. It feels more than an iteration - it feels like a complete rethink. I can’t go into too many details to maintain the confidentiality of the company - but it is not just about a major reduction in diameter.
Although that (from my back of a napkin math) will yield a 60% reduction in cross sectional area of MIRA. 60% !!!! That is big (or is it small…. You know what I mean.)
We are now in the territory of single port systems that push instrument inside the body. But instead, at a small diameter you will have a whole frikin’ robot on the far side of the abdominal wall. I used it in a lab - and it is as strong. The image quality feels even better (maybe some software tweaks) - ease of use and insertion and extraction are way better. They are about to enter their walk phase.
M2 is what (in my opinion) they need for a mass adoption commercial product.
This is what will unlock the "mini" in miniRAS. It allows minimally invasive surgery with four arms through a small incision and an accessory port.
Now we start to make sense. It is not the same as single port - it is not the same as traditional multiport. It is a four arm procedure through two small access points. Get it?
(And all of this is already connected to a very capable companion app. I met the software team and they are doing a lot of exciting things with a an array of very interesting data.)
This is why I have to say we must define this as miniRAS and not lump it into single port. It’s neither multiport nor single port.
“But what about the run phase?” I hear you impatient people say. Well I was taken into the inner circle of their R&D. A very smart bunch of engineers from the local area of Nebraska…
Quick note: You will all have your thoughts in your head about the words “Lincoln Nebraska” maybe the uninitiated are thinking backwater - midwest yokel town. Forget that. It’s a massive city with an impressive healthcare system, state of the art facilities, massive university (one of the biggest) to draw on. It is not what you think - so don’t ask “Why on earth is it in Lincoln Nebraska????” Just forget that thought. Understand it makes total sense to be in Lincoln Nebraska.
So, a super smart bunch of engineers that are not tainted by the history of medical devices and robots. They are not being constrained by “what should be done” with surgical robotics. They know what is needed to be done to make a miniRAS., But more so - they are working on the future. They kindly showed me it all - and I have to say - I am more than impressed. Imaging - AI - Instruments and autonomy are all words that they reel off with ease. But it’s not bullshit. They have “stuff” working - impressive “stuff.”
And in their museum of MIRA versions they have a space for M2 - but after that they have another space… M3?
When they make the "Run" phase public - I think most of you will be pretty blown away.
Let’s talk telesurgery
Now this is becoming more and more of a buzz word. The rate of adoption and the amount of noise coming from China and India has taken me by surprise. The technology is already there. Cases are already being done (even across the world.)
In fact if you want to talk about the ultimate telesurgery - you have to look at Virtual Incision and spaceMIRA - a modified version of MIRA customised for the ISS. They did remote surgical simulation from Nebraska to the space station. And that is pretty firkin amazing.
I thought at the time “That’s cool” but like the Gen X plonker I am - I missed the key signals that were there… and why this is very different. Let me explain why MIRA is different for telesurgery.
Miss 1: They got a whole surgical robot into space. That means it is light, transportable and fits in a NASA box.
Miss 2: In that box they also included a light source and power source - in a mobile box. An entire vision chain was in that box for the demonstration.
Miss 3: Where the F was the console? They didn’t send a console. MIRA does not need a console on the patient side to work. You don’t need a patient side console for telesurgery with MIRA. That components stayed on Earth in Lincoln Nebraska.
Miss 4: The connection to the space station is slow - it is not 5G or hard cables fibre. It’s slow - but MIRA had no issue with remote surgery. It didn’t need complex infrastructure.
Miss 5: The demo had surgeons from Earth driving a robot in space (in zero G). But I missed that they also flipped to an autonomous surgery. Yes MIRA is already doing autonomous steps of surgery in space.
So when you put this together - you start to understand how MIRA (modified with remote capabilities in the future) could be very different in real world telesurgery on earth.
If you wanted to do telesurgery out in a rural town by having an expert lead a specialist procedure… MIRA will be capable of that.
In the near future you could UPS the control box and the electrosurgery generator and a MIRA (or two) in sterile shippers. By UPS not massive truck. You pull it out of the box and you are ready to go. The remote site would not need a console. It would not need a massive bedside cart. You won’t need a permanent robotic set up at the remote site. It could be sent “on the fly” case by case. Day by day.
That is transformative for the logistics of telesurgery.
You can use very simple standard end to end infrastructure. I did a telesurgery demo from Nebraska HQ to the lab about 12 miles away. It was absolutely fine in terms of latency and security. If they continue to develop the backbone with SOVATO - the regulatory will be fixed - the operating rights and a secure network will all be easy. It’s coming folks.
The learning curve for bedside of MIRA is ridiculously easy - as it is not complex to set up. There’s that word again - simplicity. The local surgeon can easily handle the bedside - while the remote surgeon does the case. It’s ideal for telesurgery. In any size OR - in any capability OR - in any set up.
And these are the real barriers to say having a DV5 do remote surgery anywhere any time. MIRA is built for it. I guess when you have a CTO that has put rovers on MARS - this is all pretty obvious.
Summary
It was a lot of information for me to process in a two day trip. I went there with a few misconceptions about this two armed single port massive diameter oddity. But walked out understanding the genius to remove everything from outside of the patient, move it inside the patient. It simplifies the whole thing - yet retains much of the capability. It is no mean feat.
Does it have wrists - no. So in the deep deep pelvis or the paraoesphageal space it will have issues of having the instruments at 60’ to the arms. Elbows won’t replace wrists there.
It does have limitations with 2D.
But it clear that all of this is not news to the MIRA team. And they are very very smart.
They also know that connected app, data, energy devices, and stapling are all “table stakes.” But let’s leave that for the run phase. They know what they need to do, and in what order. They have the capability - and the humility. They are listening to their customers (surgeons, nurses, hospitals) and taking the feedback and acting on it. But it is the speed they act on it that is astonishing.
In some of the things I saw in the pipe - they are already years ahead of the competition. In some areas they are way ahead of even Intuitive - and I do not say that lightly.
I’ve walked away understanding where we are going with the evolution here. Main frames went to desk tops went to laptops - went to iPhones went to iWatches. Trade offs of some power and functionality for the benefits of miniaturisation.
We are on this evolution here in surgical robotics. This is a category that is now spanning multiple specialities of healthcare. Microbot in endovascular. Interventional systems in many specialities like percutaneous, neuro. Both abandoning the vast external structures for smaller mini robots that change the game. MIRA is that game changer in soft tissue surgical robotics.
I’ve said it adnauseam - we are seeing a segmentation of the market. And MIRA is part of the emerging miniRAS category - and the first to do this in soft tissue. It is not a single port. That transition from the robot being outside the patient to the inside of the patient is the game changer I was not expecting. As said (and I’m still processing) - it changes everything outside when you cross the abdominal wall and move everything inside.
I cannot wait to see how they do in this first access phase - and then shock a few people with M2.
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Disclosure: I have not been paid to write this article - to give this review. Virtual Incision picked up my travel only - and graciously have allowed me to include anything public I want to in this article and write anything with my own opinions. These are not the opinions of Virtual Incision..
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