Please stop saying we are only 3% penetrated in soft tissue surgical robotics - these are the numbers to care about.
- Steve Bell
- May 27, 2024
- 14 min read
Updated: Jul 30
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So firstly, I think I’ve found the source of this urban myth about the fact “we are only 3% penetrated into surgery with surgical robotics.”
I keep seeing this nonsense and just wondering if marketing departments are actually doing their jobs anymore. Instead, it seems like some companies are just latching on to a “sound bite” that fits their narrative.
The citation often quoted is this one:
Cepolina F, Razzoli RP. An introductory review of robotically assisted surgical systems. Int J Med Robot. 2022 Aug;18(4):e2409. doi: 10.1002/rcs.2409. Epub 2022 May 4. PMID: 35476899; PMCID: PMC9540802.
Where in the introduction an unsubstantiated claim is made with no data reference that I can find:
“Globally, it is estimated that about 3% of surgeries are performed robotically, offering patients the benefits of MIS, fewer complications, shorter stay in hospital, and faster return to normal activities.”
No reference - and the clue is in “estimated.” and "Surgeries" not applicable surgeries.
I’ve now seen this “data” quoted more than 22 times in an effort to estimate the surgical robotics penetration - and I think I know exactly why this narrative works for some of the companies entering or trying to enter the surgical robotics space.
I encourage you to dig into this paper and ask if an entire industry should be basing much of its rationale of investments, hype, R&D on this data, this paper.
It is even more important to read this paper in depth - as it discusses many discontinued systems, poor data on what systems are in development, ortho robots, spine robots, needle navigation and even cardiovascular end-vascular robots. I don’t want to say it is a bad paper. I want to say it is not a paper to base a penetration of soft tissue surgical robotics upon.
So I struggle to see how this claimed 3% - can be related to the penetration of soft tissue surgical robotics. I think we need to stop using this reference for that purpose.
Why does this matter?
Firstly, it matters because investors and investment firms are relying on statements by companies to decide if they should buy or sell the shares of the company. (Of course not only this.) If the fundamental data in the thesis of companies is flawed - then calculations based on this will be flawed.
Internal think tanks can soon latch onto these memes, and very few people ever go and read the actual source data. Meeting after meeting, a slide goes up with the 3% claim and a small (1) which relates to a reference. A reference that I don’t believe senior management has ever read. It just happened to be the only sort of number outside of a market research report that could be found - and somehow it becomes the truth.
It also matters because quotes on social media in 2024 are being based on publications of 2022, using data as far back as 2017. Any % penetrations from 2017 just do not hold water at all in 2024. They are not comparable.
With the most accurate numbers on soft tissue robotics from Intuitive (I think), because they had the monopoly - so all soft the robotic procedures were (and are) done by them annually. In 2017 the number of procedures was under 1 million per annum. Last year it was 2.2 million - a 2X jump.
So, even if you believe in the 3% number, can it still be 3% when the penetration has doubled. Surgical procedures did not double in the same time period.
So immediately any reader should be super suspicious.
It matters because company marketing spiel should not trump science and data. And many of the readers out there are scientists, engineers, surgeons and care givers. So these “facts” matter when people are taking major healthcare decisions.
It matters because time and time again companies have this internal think - where there are Green fields abundant - and Intuitive has a tiny fraction of the market - and there is room for everyone.
Then when they launch the robot - they quickly discover that is not true. It suddenly feels like Intuitive is in “all the accounts we want to sell into.”
And I’m going to come back to this shortly to explain why this 3% is causing such a disconnect between expectations and reality.
And that matters because some of the biggest companies in the world are getting, and are about to get a very rude awakening when their quarterly sales results don’t match what they have been projecting in a set of ever upwards hockey stick spread sheets.
What procedures do you care about for surgical robotics?
Don’t get me wrong here - I’m talking about “care” as in market analysis care, numbers “care”, not caring If patients get treatment - so please put it in that frame. I care deeply about patients - but I want to talk about why as an industry when calculating market share, penetration etc what numbers we should care about.
So let’s get into some numbers that might give an indication of what we care about…
According to the the World Health Organisation (and others)
There are over 300 million surgical procedures performed annually.
So do we care about all those 300 million when thinking about soft tissue robots?
No! Of course not. That includes spinal procedures, vascular, neuro and a host of procedures that will never, and could never be done by soft tissue surgical robots.
And here’s where the first confusion starts. “But we do have robots for vascular procedures… so they must count… right?”
No. Different category of robot. Just as different as a knee arthroplasty robot.
So when we take the 300 million number - were need to back out all the procedures that are just not in the target of a soft tissue surgical robot.
We care about - all laparoscopic procedures, and thorascopic procedures, some trans oral, some trans anal. We might care about some minimally invasive breast procedures, and some thyroid procedures - but then we start to reach the limits of what should / could be done with soft tissue surgical robot - like a da Vinci.
Note: Companies like MMI have built some micro surgery robots that are suitable for things like micro vascular work (soft tissue) but that is not what we talk about in this category that is competing with where da Vinci works.
Let me also get something off my chest here - because I’d like us all to start to talk with technical precision and clarity. I often see “Lap” surgery as a catch all for anything done with long instruments through trocars.. And technically that is wrong.
Laparoscopy refers to abdominal cavity work using a scope and long instruments through trocars.
If you want to include the chest - you should really talk about thorascopic procedures. (Not trans bronchial - different space - different robot like Ion or Monarch.)
If you want to use the da Vinci style robot in the mouth or in the rectum - that is technically not laparoscopic. It is either Trans Oral Robotic Surgery (TORS) Or Trans Anal Robotic Surgery (TARS) - which then often gets sub divided into things like Trans Anal Minimally Invasive Surgery (TAMIS) etc.
Understanding what a da Vinci or da Vinci competitor is actually capable of performing is critical to understanding where we are with penetration of surgery.
So what is “fair game” that we care about?
The biggest lump is “laparoscopic” surgery. Because technically anything you can do (laparoscopic or thorascopic) today - you can do with a da Vinci style robot. The Xi is capable to do any manual laparoscopic or thorascopic procedure. Get that in your head - it’s important. The DV5 (da Vinci 5) doesn’t suddenly allow you do different laparoscopic or thorascopic procedures. It may make them “more appealing” but technically it has the same procedures cleared.
Estimates range from 15 million to 25 million surgeries are performed “laparoscopic” globally - with mixed data reports including some thorascopic and others not.
The best estimate I can get to from published data is circa 20 million procedures - with a largest % performed in the USA, Europe and Asia. Followed by LatAm and then some countries in Africa.
I personally think this is massively underestimated as many healthcare systems are not systematically collecting all of their surgical data. But honestly - it doesn’t matter. Because we have to come back to procedures we “care about.”
If - let’s say - there is a laparoscopic cholecystectomy being performed in Nepal in a small government hospital - using a donated 20 year old laparoscopic tower, old reusable trocars and 20 year old instruments. Is that a primary target for a $2800 per case soft tissue surgical robot?
Of course not. So there are literally millions of procedures that “could technically be done” with a soft tissue surgical robot - but are never in my lifetime going to be done. No matter how cheap we think we get the cost of the robot. We have to be realistic.
Secondly, estimates are in 2024 - so we have to look at the reality of the market TODAY not in 30 years. When we ask about robotic penetration today - we need to look in a framework of the reality of today.
If we do that - then the number of realistic laparoscopic procedures performed each year “That we care about in the context off converting to robotic procedures” is about 20 Million. A good round number. So let’s use that.
Laparoscopic procedures are made of straight stick manual laparoscopy and robotic assisted surgery. They are both laparoscopic (most people don’t get that.). So here’s one quick way to slice the cake.
2.3 million soft tissue robotic surgeries were performed last year. Of about 20 million laparoscopies that we care about.
So a first penetration is about 11.5% of laparoscopies (that we care about) have been penetrated already.
Do we care about all laparoscopic procedures?
Again - tread carefully on numbers - as you can rightly argue - “but there are way more laparoscopic procedures in the world.” And you’d be right - but again you have to come back to “Which ones do we care about.”
In the USA - we have a diagnostic laparoscopy. So a scope goes in, and a 5mm port to put a grasper through to move some bowel. It takes 15 minutes to do the procedure skin to skin.
It’s coded as a laparoscopic procedure. It forms part of the data set of laparoscopic procedures.
Is anyone draping up four arms of a da Vinci - storing two - then using the robot to do this quick 15 minute diagnostic laparaoscopy? Come on…
There are millions of laparoscopies we just do not care about in the soft tissue robotic paradigm. So stop including that bulk of procedures to make the penetration look lower so you can justify your numbers to the street.
So that's 20 million laparoscopies performed, but not all of those are “line of sight” that companies should be looking at when thinking - what could be converted from manual laparoscopy to a soft tissue robot.
Ah but what about the open procedures that are not yet done laparoscopic?
Great question.
There are many many procedures that are still done open - manually - that could come across to laparoscopic to make that 20 million number grow.
They are done open today for a multitude of reasons - including surgeon competency, willingness, training and a host of user variables.
It is also often determined by site of care and reimbursement. But if we could overcome all of these barriers there is a raft of open procedures that should and could NOT be done laparoscopically / thorascopically / TORS / TAMIS etc.
Wait hang on - my fingers are tired - let me do something very bad and group all those together into a bit into an acronym. We could use Minimally Invasive Surgery (MIS) - but honestly if I’m taking you entire bowel out by small cuts it’s pretty damned invasive. I personally prefer Minimal Access Surgery (MAS). The smallest possible cuts we make in you.
So - we need to think about how many procedures can go from open to MAS.
And this is where it gets difficult and subjective. You can’t just take all existing open procedures and automatically say “That could be done MAS so that could be done robotic.” It just does’t work that way.
Let me give some examples:
In open surgery we have a whole bunch of Caesarean Sections - they are considered open surgical procedures (making up that 300 million) - but no one in their right mind is going to try and deliver a baby using a robot via a trocar. (Crazy example I know.)
Okay let’s take colorectal surgery. There is still a significant % of colorectal surgeries done open. Surely all of those could be done laparoscopic and thus robotic?
No. There are plenty of procedures that for multiple reasons are just impossible (or rather not reasonable) to do laparoscopically. Take surgery for mega colons.
With the best will and highest skill, that is not a procedure suitable for minimal access surgery.
Maybe more down to earth is hernia. Again hernia is a catch all for many pathological conditions - so with precision let’s discuss hernias in terms of what we care about. Generally Inguinal hernias and ventral hernias. (Yes there are some hiatal as well.)
Some ventral hernia are just so massive (40cm X 50cm) that practically they are not the main target of MAS. You could do it with a robot - but it’s not a mainstream feat.
Likewise in Inguinal hernia - for a bunch of reasons - not all will ever be done with a robot. Most could be - but many will not - (15 minute quick Lichtenstein in an ASC with low reimbursement will be a challenge to justify on a robot.) Many will be done - but many won't.
So that means that our total pool of laparoscopic procedures that could be done with a soft tissue robot is actually probably less than the 20 million procedures I quoted earlier.
So what are the bloody procedures we care about?
I'm probably frustrating you now...
So it starts to become a blended mix of opportunities. It’s a mix of some of the open procedures that could be done robotic.
It’s a % of the laparoscopic procedures that could / should be done robotic.
It’s a % of the healthcare systems that will be willing to pay for the robot.
It’s a % of the procedures that can fit into the current reimbursements
It’s a % of the procedures that actually make sense.
It’s a % of users that are willing to learn and come across to the robot.
It’s a % of countries where the robot is cleared in procedures that are cleared.
It’s complicated. Way more complicated than just the 3% plucked out of the air.
Now has anybody actually every been motivated enough to sit down and work out what are the likely number of procedures - and pool of potentials - looking at things like the list above.
Hmmmmm any one motivated enough - involved enough to try and work out the “line of sight” and the barriers to getting to that line of sight?
Of course. The company that dominates the market and has the most to gain and the most to lose if they don’t get this right.
So Intuitive released this image - but be aware it is not as straight forwards as it looks. This chart has Ion in there - and that means it’s slightly different than the purity of just soft tissue surgical robotics when we think of “laparoscopy”. But it’s a great indicator.
So you need to read this with the mindset of “what do they care about.” And the reality of barriers that stop unlimited penetration of those 300 million procedures (Doh!).
They have 7 million procedures TODAY -as their line of sight. So you need to let that sink in. The biggest - baddest - most capable company on the planet in soft tissue surgical robotics think that's what is possible - and within reach (knowing all the challenges, having all the clearances, having the huge global footprint) think there are just 7 million procedures they can attack - TODAY.
I want you to get this into your head. Because when other companies say “Ah but our robot will allow more procedures.” - BS !!!!!
The Xi is THE most capable (and cleared) robot today that “Could” do more procedure types than any other robot on the market. Period. So no other robot will suddenly gain access to a huge chunk of market that da Vinci cannot technically do. They just don’t!
So if the king of robotics is saying there are a possible 7 million procedures today - that they can go after - you should take that number as an important number.
Hang on - according to others... if 2.3 million is 3% that means the line of sight should be 76 Million procedures (100%) per annum. You see the disconnect? Others that don't know the reality are claiming 76 million procedures to go after, 70 million more than Intuitive think. Get it?
Now project on to that realistic 7 million number another number from earlier - 2.3 million RAS procedures.
So we are 2.3 million penetrated into that 7 million. That ain’t 3% - that is 33% penetrated. And they know what they “care” about.
So we can bandy about 3% all day long in our fantasy numbers and “there are green fields for everyone”. But the actually reality is we are probably 33% penetrated today into what can be done and what could be done TODAY.
So when every robot company is butting up against Intuitive in every account where anyone cares about robotics. When they are in every market and tender - that is why - it's 33% not 3% of what everyone is going after. I hope that’s clear. You won’t bump into Intuitive in a small hospital in outer Mongolia that does no laparoscopy today because they can’t afford the basic equipment. (No offence to outer Mongolia.)
You’re going to bump into them in every hospital with a chance of buying a robot in the next 5 years that are doing the 7 million procedures that they care about (including now ASCs with DV5) - and the other companies care about... but just haven’t done the math properly yet.
Sales rep to Manager: "Don't get it. Every account I go to talk about our robot... Intuitive is there..."
Manager: "Did you try any accounts that don't want or need a robot?"
If we now look at the 21 million number they display in their graphic above. That is the future possibility - as Ion expands, alternate sites of care start to do procedures, clearances (small) start to help, reimbursement works out, cost per procedure drops, workflow improves. etc etc.
So what they are saying is that the 7 million can expand to 21 million with some open procedures that come across, some surgeons take on the robot as technology improves, some new indications cleared (not technical ability - very different), some new markets come online, some patient numbers grow, some shifts in reimbursement, some sites of care start to adopt robotics etc etc etc.,
But even with all those ifs and buts and honey and nuts - (and a lot has to happen) we are already 11% penetrated into those 21 million procedures that we care about in the next 10 years. What they care about. And what they care about - you should care about.
Summary
Now of course at 11% penetrated - and that already being a multibillion $ business - you can turn it around and say “there’s still circa 90% to go after in the coming years.”
And I feel that is a better statement. A more accurate statement.
But just because a company plonks a robot on the market - it does NOT automatically mean they get a big chunk of that 90%. Far from it.
The company that stands to penetrate the majority of that “green field” is still Intuitive. And they have several factors that mean they will be the 70% to 80% market share owner of that 21 million in the next ten years. (If that market can be penetrated.)
Firstly, the DV5 (da Vinci 5) got the golden clearance USA - the same procedures as the Xi - and that barrier is huge for any competitor. All the others must get procedure by procedure cleared - and that takes years. And it is predictive the same may happen with MDR - and if DV5 gets a broad clearance through MDR (based on their millions of Xi data points and DV5 clinical data) it will give them five years start on everyone. (Forget all the bells and whistles they have). And finally don’t forget the Xi is still a beast, and the number one robot. Just beating that is tenders is frightening. They are going nowhere - and I think they will gain massive ammounts of that 21 million pie.
Their technology with force feedback - the connected tower and all the advanced instruments - gives them a decade of technological leadership.
Tie all that into their vast data lake of nearly 12 million procedures and they are untouchable on outcomes data.
Oh sorry forgot… they also start from 97% market share of global installed base - and 96% market share of all procedures - which also keeps them in a very very very strong position to own that 21 million procedures.
They would have to have a near total collapse of market share for any other company to become the leader… it ain’t happening. The DV5 has secured that.
So with all this said - I’d like us as an industry to get a little deeper into the numbers - cross reference with reality and stop saying BS statements of “We are only 3% penetrated” as if to say “Here comes the cavalry and we will change that.”
I can also be wrong... but whatever way you want to look at it - ask about the penetartion of what anyone actually cares about.
These are just opinions of the author for educational purposes only and no data should be used for investment purposes.
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