Next generation instruments are coming to surgical robotics
- Steve Bell
- 3 days ago
- 11 min read
Get the basics right - it's not an option
As we continue the journey of soft tissue surgical robotics we are starting to see the formation of architectures. The Boom, The cart, The table, The micro form factor, The single port etc etc.
Hardware - the "robot itself" is starting to become the bare entry level. Now don't get me wrong - the robot must have several characteristics to even be in the game:
It must work. there are still lots of companies doing the Wizard of Oz. What I mean is that in demos, in trials, in labs - the system looks to be working and doing what it should do. But in reality - if you pull back the curtain there is the wizard of Oz pulling on levers and ropes to make it look like it works - but it's not real world working. Engineers are keeping the wheels on. And that is not a product.
If anything is being used that needs and engineer in the room... it's not a real commercial robot - period. It is a demonstrator.
So to be a robot it must work - work well... and be releiable. I just saw some figures that in one major review of Intuitive Xi - there was less than a 0.09% conversion rate due to robot failure. And data shows over a 99% up time now. So the robot must work and work with a reliability level that is unbelievable. No one is accepting case stops, conversions. Not in 2026.
The table stakes are now also starting to revolve around data ecosystems. No app - no party. If the system is not giving off meaningful insights that surgeons, surgical teams and hospitals can act on... then the system will be relegated to curiosity in a few places. It may also not be capable of throwing off enough data to allow meaningful insights for any AI and the coming autonomy. And again. Dumb marionettes will not be tolerated.
Case support - teams for clinical programs - service and support - economics support - etc etc.
What I'm saying is we are heading for a convergence of minimum requirements that determine if your "system" is commercially viable: i.e. will it in any way be even in the race to be considered for purchase?
So what will actually differentiate systems?
There are lots of things that can set systems apart. Controller design (pedals vs hand controls only), tethered vs un tethered controllers,, telesurgery, software design, imaging capabilities, ease of use, smoothness, precision, instrument feel and all that good stuff. Open vs closed consoles. Boom vs carts vs bed. But even in design we will see competition close the gap. And ultimately if they all "work" then we are going to start to see a renewed focus on differentiating features that must relate to better outcomes - safer usage - efficiency - and the impact on health economics.
Please don't get me wrong. We already see some of that now in systems. integrated high flow insufflation - force feedback - ICG and more. But it starts to show me that the differentiation is going to become more important as the systems become standardised.
And one of those major differentiations (inmy humble opinion) is not going to be the "table stakes" robot... but instead the end effcetors. Sorry - to be exact - the instruments you hang on the robot - and the end effectors of the instruments.
So today I'm going to zoom in here.
Let's talk instruments
There is the inherent quality of the standard instruments - such as number of lives, ability to clean and sterilise, how much pitch (up n down) and yaw (side to side) you get. reach. Tip quality and force they can apply. How well tney grasp - how well they cut. Force feedback or not.
What is creeping up in more and more is going to be" advanced instruments" and "multi function instruments." The needle holder with suture cut is one example. But also the Vessel sealer extend is another. It can grasp, dissect, cut, apply energy - all on one instrument.
And then of course - let's discuss the elephant in the room - staplers. Today only Intuitive has managed to get a stapler on its system (Sureform) and get the all important pitch (up and down) and Yaw (Side to side) movements. And maybe more importantly - get some smarts into the stapler for drive forces in... and data out.
Both Medtronic and Johnson & Johnson (Ethicon) have declare their intent to get staplers on their systems ASAP. But as said 100 times - yaw alone will not be accepted... heed me on this.
And we see companies like Reach Medical - that are coming with 90' articulating smart staplers - and are most likely building for Chinese robots. So stapling is going to be a very important instrument in the bag.
But for now I want to get back to the instruments (less staplers) as I think there is a criticality here that is maybe underestimated when we talk time, flow and safety in surgical robotics.
In n Out
No - not the burger chain (although one of my favourites) - I'm talking about bringing robotic instruments in and out of the patient through the ports; to do "Instrument exchange."
Now what should happen, as per good practice, is that the surgeon releases the tissue - closes the jaw of the instrument - straightens the instrument, and then as the instrument is slowly and carefully withdrawn the camera is detached from the robot arm, and the camera watches the instrument tip exit the trocar. The bedside assistant re-attaches the new instrument - slowly puts it in until the tip comes into view insiode the patient . And then as the instrument is guided back down to the "stop" the camera watches it all the way down. once safely inn place the camera is re-attached to the robotic arm.
Why? Because on the way out, or the way back in, an instrument tip could nick a small piece of bowel - or a vessel - all off camera. An injury that goes un-noticed is an issue.
And yes - of course some of the systems have "instrument off screen" guidance. But that doesn't answer the real issue that is if a bit of tissue got damaged out of sight.
Now some diligent surgeons do that for every exchange - and the bedside teams follow protocol to the letter. But in most cases I've seen - that sort of happens in the first ten learning cases - and then we get to "ahh it's okay." And I see multiple, quick instrument exchanges off camera all time. In fact I'd say it is super common place.
I'm curious... so let's do a poll...
Do people always follow the instrument tips in n out with the camera
YES
NO
SOMETIMES
So why do they not always do that? Well in my experience it is often time and convenince. If people need to swap graspers, scissors, needle holders and the other instruments. And it requires (let's say) up to six exchanges during a single short phase of the surgery... people don't have time for the faff. They revert back to what they did in lap surgery - but that is very very different. Plus - and this is key - the surgeon loses not only "flow" but also control. What do I mean?
In my experience surgeons enter a flow state when they operate... and operate well. It's move - act - move - act - in an almost rhythmic way. With next steps in their head ready to go. It's like a dance. Everytime that an exchange happens - the flow gets broken. They hand control over to the bedside assist - mentally there is a pause (which can be good sometimes) and then there is a re-engagement into the flow.
BTW this is also in open - lap and other types of surgery as well. But in open and Lap the surgeon is bedside and controls the actual instrument exchange - so is kept in part of the process so retains the flow. Them exchanging under their control retains the flow state. If in open - lap or robotic - the flow is broken - "wrong instrument handed" - "broken instrument handed" - that flow is interrupted, and a degree of mental flow stops and that is when frustration builds and sometimes errors happen.
In robotics, I feel it is amplified due to the surgeon not being at bedside. And that instrument exchanges are a major issue for flow. The surgeon has a momnent of downtime. Even a small one. If exchanges were always done correctly - camera detached - watch the instrument out and back in - it would be an even bigger flow interruption - and time consumption. And in an established robotics program - that is not going to happen.
Side note: As more cases go to the ASC (ambulatory surgery centre) time and flow are essential. You must be efficient to ensure OR space usage. If you add 15 minutes to a case because of "correct" instrument exchange - hmmm that might not fly.
But conversely - in the ASC world - complications are not tolerated.
So how do we fix this dichotomy?
Next Generation Multifunction Instruments
This entire blog post has been influenced by two technologies I have recently been exposed to. Both with starting points in laparoscopy... but both where I was called in to assess the "value in robotics."
The need: being able to exchange tips of instruments, or have tips with multiple functions - without the instrument leaving the abdomen.
I've now seen several solutions to this - from foldable magnetic cassettes - to tips that rotate - to end effectors with three or four designs in one: So they are chimera systems that do grasping (okay) - cutting (okay) - sealing (okay) but none being exactly what the surgeon is used to. The ideal is the right tip (single function) for the right job.
I rarely get my ass on a plane anymore - I like my house and my garden and my kids (oh what order was that in??!?!) - way too much. But occasionally someone does something that I've dreamed of for a very long time. (Oh and my wife... yes my wife in case she ever reads this. i like her too much too...phew.)
As a kid I had one of those amazing pens - you know - red - blue - black - green - all in one pen - and you simply click the back button and the right tip pops out. And I always thought. Why can't we have that on a robot.
Well f@ck me (as we say where I come from) if Nico from Symphera didn't say to me "want to see one that does that for lap instruments?"
He showed me a video and well - I was on a plane lickedy split, as I just had to see if this was more wizard of OZ... or I could personally do that exchange that fast myself.
Just watch this video snippit - because it looks like magic. And honestly it feels like it.
Yes this is the lap hand held version, and will have value in lap. But I'm a robotic fan boy!
And this solves one of the big desires for me in robotic surgery - and more so - solves a massive need coming our way for ASCs.
You see this thing does a few things quite magically. It has several tips loaded in the back of the device. And interestingly that can be set up with an SKU for each user. You literally push a button - select your new tip (see screen)
And the frikin' new tip just pops out - right there!!!
No instrument exchange. No in n out. No detach - select - reattach. And the surgeon has 100% full control, Dissect - exchange - clip (yes you heard that right) - exchange - cut - exchange clip - Exchange - dissect (bipolar) - exchange - cut (monopolar) etc etc.
This type of thinking is the revolution that's coming to instruments. It will allow "normal" fully capable tips dedicated to a function to be exchanged rapidly. That is a game changer. Why?
Injuries from instrument exchanges do happen. It's not frequent - but an un-diagnosed small bowel nick is a tragedy. And should be a never event.
It does take time to exchange instruments on a robot today. So they risk it.
Surgeons lose control and flow. And that adds risk.
ASCs need efficiency - and reducing the amount of reuse due to limitations in sterile services is real.
Imagine if this system - on a robot - had single use instruments - with a reusable drive system - that can be robotic sized - wristed -. And can be delivered with no extra cost vs the use of several robotic instruments today? I'm not saying they have promised that - I'm saying that's what the dream looks like to me. And when I discussed the "dream" with the team and engineers they didn't bat an eyelid.
I did the exchange myself... and I'm telling you it feels like a magic trick. If you get a chance to see them at any meeting (maybe SRS) make a B line for the stand and exchange the tips yourself. And then think - sitting at your console - selecting tips from the menu and changing them in seconds. Bang!
Who owns the next gen instruments owns the differentiation
Not for today - but I will post about a similar thing in surgical stapling. I've been working with RevMedica - and they too are thinking this format of smarter devices on a robot - adapted from lap - to give surgeons what they need. There are several other instrument innovations coming. CREO with microwave - other companies with built in microscopy - tissue sensors etc etc.
It is no coincidence that Intuitive thus far has owned the innovation in instruments, and end effectors. They have suction irrigators, staplers, multi function energy devices, force feedback instruments and more. Why? Becasue they have the headstart on the robot. That is stable. They can focus effort on what surrounds the robot and brings value. They are not still battling with getting the bloody robot to work.
On a side note: SS innovations have some cardiac instruments and anastomotic robotic coupler end effectors. They have managed that juggling act between - get the robot right and add some instrument innovation. I tug my forelock.
Innovations that go beyond just taking today's "lap end effector on a stick" and bolting it onto a robot. And that is the thing i want to stress to companies. (oh I'm having a groundhog day moment0 it's not about just getting your lap instruments on a robot. it's about bringing value to the robot and differentiation through innovation.
The robots allow drive packs - and motors and sensors - and lifting power. The next generation of instruments are going to start to define the differentiation.
Most companies have been struggling either cash wise, resource wise, probelm wise to get the base robot "fixed" or in some cases - even on the market. But as the engineers sort out the robot - the literal tip of the spear will be the instruments. And innovation in those instruments - not juystbolting a basic lap instrument to a robot . And, don't forget, instruments specific to sites of care - or procedures (like cardiac.) Different sites of care like ASCs will need different design features in their instruments to meet the demand of the setting.
A huge part of the innovation to come, and the differentiation is going to be here - in the instruments. And those that lag behind (again) will be seen as "old generation" robots. With basic "knives and forks."
I predict there will be a land grab very soon for companies (or their technology) like Symphera, RevMedica, CREO and others; as robot makers come above the parapet and look for ways to differentiate. And realise the battle has moved to the peripherals of the robot. Not the robot itself.
The smart ones will buy them up on risk... early. Why? Because if everyone gets a licence then the differentiatoion goes away - and that means the "reason to buy your system goes with it." Multibillion $ investments will hang on the ability to get customers to "choose" your system. And every single small feature will really count. The robots will be table stakes. The ecosystem of instruments, imaging, insights, automations etc etc will become the differentiating reasons to buy.
These are just opinions of the author for education purposes only.
