So how could Intuitive fall from the number 1 position

Could Intuitive ever lose the number 1 slot?

I really have to preface this with a strong word of caution. This post is by far the most requested post I’ve been asked to write. I think everyone is a little fed up of my sycophantic praise of Intuitive, Gary, the team and the product. My gushing on how they are a basically unstoppable juggernaut.

So I’ve been asked to be a little fanciful and actually give some thoughts - as remote as it may be - how they could slip up and leave the field open for others to catch up. Let me be clear I do not think they are losing their number 1 spot for at least two decades. But if if if - then how could that potentially happen.

Let me give you my thoughts on where the soft underbelly of the beast might be. And this is in no particular order so please don’t read anything into the order.

Open consoles

With he launch of the DV5 Intuitive has doubled down on the paradigm of the closed periscope console. It’s immersive and it is pretty amazing. But it does pull the surgeon away from the action at the table and study after study- (well that I’ve seen or been involved with) say that the majority of OR staff and bedsides prefer it when the surgeon is able to have a wide range of situational awareness of the OR.

You also have a large degree of surgeons that do prefer it as well (almost 50% interviewed. Many of the surgeons come from a laparoscopic background (unlike urologiststs where it all started with robots) and they like that open console with a screen; and an ability to see the robot arms move around.

For teaching - there is no comparison. A good 3D open console allows a group of surgeons to sit around the console - see in 3D what the teacher is seeing and at the same time see the hands of the teacher - the manoeuvres - whilst also understanding the movements of the bedside arms. As a teaching tool it has some merits over a dual console type of training.

So why doesn’t everyone flood to open console systems? Well if you had a an Xi capable boom (equivalent capability, reliability, instruments etc) and an open console. I bet a ton of surgeons - (and maybe even over half) would prefer to have an open console. But the robot needs to be comparative.

So Intuitive could miss a chunk of the market by simply having only a periscope paradigm. If someone comes up with an amazing bedside robot - with an open console - then that could be one area Intuitive could lose ground to. And as we move to new technologies that are emerging such as “glassless” 3D screen (I just tried one and it is freakily good) then that could be an area where a competent competitor could gain serious ground on them.

Modular systems

Likewise - a lot of laparoscopists prefer to do the procedure the exact way they do it laparoscopically. They want the same view - the same port placements - the same instrument angles. It seems to accelerate learning curves, and allows a fluid flow between lap and robotic in those early cases. Even reverting to lap if they have to.

Intuitive is boom boom boom. They love their Goliath of an X beam, but in many people’s opinions it constrains port placement and approach. And well… a lot of people don’t like it. They will tolerate it for a highly competent robot. But I think if you gave them a modular Xi vs a current Xi - quite a lot of the market would chose the modular version. Watch for if they like Carina from Ronovo.

I think that when companies come with say a HUGO 2 - or Carina - we could see a choice of modular vs boom. I think that this could be a partial undoing of Intuitive that they do not cater for the laparoscopists that want modularity.

Hey maybe they have decided that they will just take the entire next generation of surgeons - skip over manual laparoscopy and that will then not be an issue? ;)

5mm wristed instruments

Now the world has seemingly accepted 8mm instruments as “not an issue.” But there can be absolutely no denying that a smaller hole in the patient is better. If a company (step in Asensus Luna) can make genuine 5mm instruments with compact instrument wrists (say a Versius) - that have the same capability - reach (internal working length) and reliability as an 8mm. Why would people not want that? How could they morally choose an equally capable robot with bigger “holes” left behind.

Maybe a weak point here is the continued belief that 8mm instruments are the optimal trade off. Well when a fully capable 5mm wristed system comes we might see a shift.

ASC - site of care - They don’t cater for it properly

The direction of travel for patient care is as short stay as possible in sites like out patient departments, ambulatory surgical centres and clinics. Especially for lower acuity procedures that are ripe for that time frame - fast recover and site of care. It also makes sense from a reimbursement / payer point of view. It just makes sense.

As we see more and more healthcare management teams trying to move that surgical load in that direction - should any “robot” deliver great robotic surgery - but be way more capable in an ASC - from a turnover - work flow - staffing and pricing point of view. Why would procedures stick in the main operating block? Except for the reason to be able to use a da Vinci on them. But if over at the OPD or ASC there is a perfectly capable robot that actually fits that site of care? What we may see is that the market moves away from Intuitive… to be treated at more appropriate sites of care. If someone does that better - say a “Moon surgical or DistalMotion or Virtual Incision” then that could greatly impact Intuitive. The new definition of robot could be a partial undoing of Intuitive.

Drug therapies like GLP-1 and more

GLP-1 drugs have hammered the bariatrics market (22% to 30% procedural drop) - and that has had a direct impact on Intuitive. There could just be a bigger reduction in the need to actually use a da Vinci. Now role that out to a whole host of new therapies that are on the horizon, and we could actually just see a mass drop off of surgical procedures (full stop). Those procedures that are treated by intuitive today. Bowel cancers, lung cancers, cervical cancers.

As we see directed gene therapies, and targeted personalised cancer MRNA vaccines emerge - we might see a vast drop in the core “high acuity”surgeries that da Vinci excels at. We may still see lower acuity structural surgery like inguinal hernia repair, cholecystectomy and other benign surgeries. But that could have moved to the ASC on a lower acuity robot.

If enough surgery just stops - then Intuitive could be exposed as they see their core business decline.

Alternative targeted therapies

And it’s not just drug and gene therapies. We are seeing a meteoric rise in targeted therapies - from proton beam, to aquablation, to HIFU. From image guided robotic needle ablations to histrotripsy with Histosonics. We are seeing early see n treat diagnose and abate. Diagnose and deliver.

Promaxo and in office treatments of prostate might make that a non market for Intuitive?

We could see death by a thousand paper cuts.

Could they miss on cardiac

The two biggest potential threats to Intuitive still remain JNJ and MDT. And both of those companies have something Intuitive don’t. A leg of the stool that is cardiac. The next big frontier in robotics will touch cardiac - from inside the heart. Intuitive should get a cardiac business and the most logical step is MIS robotic therapies. But what if this is just off their roadmap. They decide to stay away from the heart.

Well from a cardiac surgery point of view (trans thoracic approach) they could leave the door open to an SSi and show JNJ and MDT a way to get trojan horse systems into the hospital

But more so is Auris technology deeply embedded in the JNJ psyche. If a company like JNJ or MDT decide to go via the heart and have their other robots as a tag along. This could be a weak spot for Intuitive if they have no plan here. Contracting and tenders have seen stranger things. Start in ultra high acuity - ultra high payment procedures like structural heart or even say stroke (endo neurovascular) then other companies could go in with a premium play - win th heart (literally) of the C suite and then use general surgery and gyn surgery etc as a “commodity” all along in terms of payments.

If Intuitive don’t have a strong thought on this - I feel this could be an area where one of the big companies could take a parallel path to go for long term dominance. Utilising broader robotics and contracting - rather than trying to beat the Xi head on.

Not pushing MIS endolumenal

ION has a substantial lead in bronchial endolumenal robotics. But should they rest on their laurels there and not zoom into urological, endo GI and endovascular, they could look stale and not have what might be considered a “full offering.”

Currently, I feel there’s little room for “major” innovation in the large format robots. We are not at the pinnacle - but much from an approach point of view if fairly well set. Be it boom, modular or bed mounted robots. The next big leap will be autonomy.

If Intuitive want to retain leadership as “the robotics innovator” they may need to play catchup in the endolumenal space. It’s not going to steal away all the market from normal surgical robotics. But if other companies get there first and best… it could be seen as a “tip of the spear” technology that helps to drag along the rest. I mean if you get used to one console that drives all those technologies- you just need different bedside units. Could a unified driving experience across platforms be the way to get buy in - working backwards to the multiarm?

If Intuitive doesn’t have these tuck in robotic solutions - there is a possibility they could stutter and allow the pioneer surgeons to switch. They do that by the way. Any company that comes up with a gangbuster approach to alternative robotics could do some damage, by coming from a different angle.

Don’t advance imaging more

A lot of surgery is about what you can see… and in the future what you can’t see. Intuitive have sat on firefly with it’s black and white mode for a long time. Lots of other companies are ahead with white light ICG such as Versius, Hinotori and soon the be HUGO. JNJ have touted advanced imaging as a key pillar of Ottava. A lot off the Chinese systems have bespoke ICG imaging chains.

Hyperspectral and laser speckle and a lot more imaging modalities are coming. And Intuitive could get left behind. If they decided not to get to 4K 3D white light ICG, and everyone else goes there - imaging could (if the robot works well) be a deciding factor. If Intuitive falls behind - you could well see market share erode faster.

Like wise - if they have all that power under the hood of the DV5… and then decide not to unleash it - while company after company unleashes imaging solutions for guidance, and assistive vision and seeing more… then that could be a point of weakness for Intuitive that could see competing systems get selected ahead of them.

Don’t advance energy more

We’ve been stuck with ultrasonic and advanced bipolar on the robot for a long time. Yes the generator has given improvements - but. But there are new forms of energy emerging every day. Combination devices, new lasers, microwaves, new pulse field ablation technologies; and a whole host of smart advanced energy systems that hold the promise of better sealing and way better cutting. Faster - cooler - more tissue selective.

If Intuitive decide that Synchroseal is their pinnacle technology - they could get left behind by a great articulating “ligasure” or “Enseal.” We might see a Thunderbeat like articulated robotic combo device. Or a small form factor microwave device.

We might see whole new systems come out on other robots that make it just sexy enough that it’s the deal breaker for surgeons to choose another non Intuitive platform. The innovation in end effectors could start to be the decision factors as the “robots all start to feel similar in delivering payloads.” It will become the payloads that count. And if other companies deliver more fancy and capable energy payloads… well that could see market share erosion. How much would have to be seen.

Don’t see ablation therapies coming

Ablation therapies for all kinds of metabolic disorders, conditions and diseases are going to come full steam. Some of them will negate the need for colonic resection by calming inflammatory bowel diseases. We will see appetite suppression, we will see tumour reduction: all through advanced ablations. We will see more advances and uses for ablation in renal, cardiac and neurological. And the best way to deliver those payloads may be advanced endolumenal robotics. But again - in a world where all the robots can deliver the payload in an equal fashion… it will be the proven ablation therapy that will determine which robot someone will chose. If companies can develop next generation ablation and energy therapies - then maybe the reign of Intuitive is over. IF intuitive decided not to advance that technology for themselves.

Don’t open up their data to more integration

You only have to sit in any AI and digital session and hear everyone talk about the future world of connected data and digital devices. The interplay between large data sets - medical records - synthetic data, and more, is what will determine the best insights we can get,

Intuitive today dominate the data lake of surgical robotics and brachial navigation data. They have over 16 million cases vs the sub 50,000 of anyone else. But (as of today) they don’t have the open and laparoscopic comparative data - although DV 5 plays into that.

Also they are not well known for share and share alike - and why would they - it’s a huge moat against competition. But eventually that attitude could bite them. As everyone else decides that the greater good defeats quarterly numbers (yeah right) and the rest of the robotics world, lap world, OR analysis world decides to allow open access via APIs - they could quickly get a data lake that dwarfs Intuitive and is way more interesting to the broader hospital management. It won’t just be about “which robotics procedure is best” it will be about which course of therapy of all modalities is best. And that will crush a lone wolf of data in robotics. If all the other systems open up their data and share share share - it will be an isolating coup. Choosing any system but Intuitive could open you up to a wider understanding of health. And then when AI gets on those broad data sets we get better healthcare.

If intuitive decide to stay in their data castle behind their moat - you could see a move away from that type of company to the open companies with a much bigger picture. Again if all robots become equal - people may chose based on the bigger data picture and the way AI delivers broad insights. If Intuitive don’t get involved.

And it’s even beyond that. It is only going to be 50% about the data of the surgical field. As companies like Caresyntax and Moon Surgical gain broad insights into the full operative field. Multiple operative suits - and they become and embedded data provider, work flow enabler - and Intuitive does’t want to share with them. Could Intuitive look isolated. If all other companies (maybe even through JNJs Polyphonic) start to pool data - lap, open, robotic from many systems, endoleumenal, cardiac, ortho, spine and more. Could the man data sets suddenly dwarf Intuitive as millions and millions of cases flood in. Will intuitive take part? Could other companies be more attractive as their robot sits int he middle of a vast and interesting data lake?

AI not taken seriously

We hear that we have 10,000X compute power and Nvidia partnerships. But if that stays as just “talk” and not meaningful action - then all of the others companies are going to leapfrog them with AI power very quickly. Feature sets - insights - really time help and assistance - image analysis - AI agents and physical AI— etc etc etc All the good stuff AI will bring and AI Agents are already being put to use with companies like Moon Surgical. If the 10,000X just stays as a nice graphic then this is where every other company could attack. 5 years from today a marionette robot is not the answer. Insights- automation - assisted and supervised autonomous actions by AI agents will be coming on line. If the power of DV5 is not unleashed… then it may seem a bit “quaint” and it’s polish may diminish. So if Intuitive are not taking AI seriously (yeah sure) then this is where they could fall foul, as others simply overtake them. And when I write this I write looking more to Asia and Europe…

Too many product lines - lack of focus

Why has Intuitive been so damned successful while other big companies have floundered? For me a key part of that has been a maniacal focus on the robots they have. Especially the da Vinci. It has also been the rigorous containment to as few models and SKUs as needed. That helps everything from upgrades, to field service, to training, to regulatory, to inventory management, to supply chain etc etc.It’s good business practice that a small focused product line allows.

They have also been electro mechanical, software and instrument experts to date. And the product line to date has allowed those core competencies to grow and develop deep tribal knowledge and expertise. Each system builds of the learnings of each system. You don’t get much robotic learning from making a better suture.

So a danger in the next decade is a portfolio creep. You have X, Xi, SP, DV5 and maybe next SP2, oh and Ion bronch and Ion urological and GI and Endovascular. You have ablation sub divisions, and then what if you add consumables and valve clips, and more staplers, and hernia mesh etc etc If Intuitive were to wake up and think hey were a big multinational medtech corporation and be competing with JnJ and MDT and needed to be like them. Then that is when the wheels might fall off. Look at the early days off Apple when Sully took over and products and line mushroomed.  It’s a weird double edged risk. You need to expand but not go too far from the core of the business.

If Intuitive did this it would be a defocus that would add so much risk and potentially crash the business. Supply chain could look horrendous, core competency focus could be lost, and it could start to look like a broad medical device company, and lose that appeal that it has today. The urge for continued expansion and growth and 17% YoY etc etc could become too tempting - too dictated by the street… and that could be a risk. A defocused Intuitive could lose it the top spot.

Become bloated and crush under their own weight

They are getting big. It’s a lot of people - a lot of money - a lot of sales. A lot of levels of management. There is always the risk that Intuitive becomes another bloated medtech company that has layers of people just waiting until retirement. Whole swathes of professional career managers that care more about they next move than the next product.

They become what they are surrounded by.

Eventually they just become a bloated company that crushes in under its own weight. Too many people at the table eating and not enough people out there scavenging the food. And that can happen if they lose some key people and bring in B player managers… The risk is they need so many bodies that any warm body will do. And that is where empires collapse.

Lose some critical people

The best companies are the best because they have the best people. But as Steve Jobs left and Johnny Ive departed… I feel that Apple lost a lot of its mojo. Space X is Elon Musk, Tesla is Elon.

The top teams drive the best companies and that is true for Intuitive. They have one of the best teams ever at the helm that is guiding them through this “pitch up on on the S-curve.” The launch of the DV5 said it all. Competent people driving competent well informed and tribal decisions that just don’t miss. But what if some of these key people drift off in the next few years. What if much of that mojo goes with them. What if more off the management gets replaced from the other med device strategics or Pharma companies… consumer companies. What if we have another Pepsi invasion of Apple. We know how that went.

If some of their best talent walks, retires or just moves on… I think that is a potential risk to Intuitive. If by some twist of fate - JNJ or MDT could entice those rockstars over (Okay okay okay we’re doing this right!) Then potentially that could put a huge hole in the boat.

It would be that kind of landmark leadership change that could set Intuitive back and make them vulnerable to losing the top spot. If Intuitive doesn’t have a best in class succession planning in place. Well that could be one big risk.

Lose the amazing culture

I don’t think people always fully appreciate how culture determines success. It is clear there is a strong top down culture in that company from Gary down. It exudes an aligned culture. It is a minimally invasive deployed through advanced robotics culture (from what I see). But if they were to lose that culture - I think they are open to fall from first place. I think if they slip into that comfortable culture of “good enough, as we are now big and number 1” I think that will crucify them. One of their key edges is their culture - and if that goes… well.

Left field "Anti trust" action

As a leader buy a long way - let’s look at the sort of left field asteroid that has not been unheard of in business before. Something odd happens and some government forces somewhere decide that they are just too big - too powerful - too dominant. Someone gets a bee in their bonnet in a branch of government and says - “we need to break this party up.”

Of course I’m being dramatic - but what if they say you need to split off your endolumenal business, or digital business or something. Or say you have to open up the system to third party consumables and instruments. Third party apps. Anyone can make a stapler for the da Vinci. Anyone can make consumables, or service the system. That lovely 70% revenue stream and then entire business model could be at risk. Lots of companies are edgy about wanting to reprocess their instruments.

That sort of action - as totally remote as it is - could be a devastating blow. It could be a result of no one else just able to get any traction. So the resort is to ask for a break up by either completion, or healthcare providers.

Don’t smash the R&D pedal

Someone wakes up one day and says - “You know what. No one is even close. Why are we doing all this R&D and future looking stuff when we could just milk this cow with little chance of competition for the next decade.”

Other companies have done this a go-go throughout history and have paid a hefty price. There’s a complacency that takes over. Wall Street wants more more more profit - and the decision is made to simply cut back that vast spend on R&D. Go into cruise mode. They decide to lay off a good 25% of their R&D engineers - the good ones (just saying - of course they are all good.) And those geniuses go off to MDT and JNJ and China.

Well first that cut in R&D would be so demoralising and send such a message to the market I could see a mass exodus of talent from R&D. It would then also be foolish at a time when everyone is playing catch up. Serious catchup. Very quickly other companies could make a revolutionary leap - and getting that R&D magic going again would be near impossible.

I think that sitting back now and not hammering that R&D pedal with so many new systems coming, and experimenting, would be a blow that would knock them off the number one spot quite quickly.

Ignore telesurgery

Telesurgery is real - as I’ve explained in this post here >> Post LINK <<

I think a big mistake by Intuitive would be to say “this isn’t happening” “This isn’t important.”

Their lack of telesurgery - teleprecepting at distance - tele robotics would be a big miss and leave them open to competition.  Maybe not an everyday use, but certainly a tender tickbox across the world and a demand that will come from many hospitals wanting to deploy hub and spoke systems. If one of the big companies gets this on HUGO - or OTTAVA or Toumai gets that as a “must have” outside of China. This could be a blow to Intuitive. I think a DV5 and Xi with no distance telesurgery infrastructure (and later AI Agents at distance) would seem a little feature lacking. It’s a badge systems need to have; and the lack of could be that chink in their armour where an attack could come in. Kodak didn’t see digital cameras replacing film.

Don’t see a disruption - they just miss it

Nokia is a shadow of its former self. Blackberry was doomed. Kodak doesn’t do film. Etc etc. A lot of companies just missed it. That one technology that came along like an unobserved asteroid and they just didn’t see it.

I’ve touched on it with medical therapies and such like, that just “wipe out surgery.” Someone invents the real Tricorder Jim. Some advance comes out of left field and surgery simply goes away. It wipes them out (and an industry by the way.) Do people still take tonsils out? Asking for a friend.

Or less dramatic, a company comes out with a da Vinci slayer - just out of left field. Fully autonomous hands off does surgery better than surgeon. A company that comes out of something like project Stargate. It’s just so amazing everyone needs it. And a big big healthcare player just buys it up and puts retro rockets on it. Or Apple fooled everyone and their car project was a surgical robot.

No? BCI - brain computer interface? Where was Neurolink a decade ago. It happens. Sony and the open microsurgery demo - who saw that coming? I know a lot of stealth projects that are moonshots but if they work… watch out. And if a JnJ or a MDT say “that will absolutely crush what we have - let’s get it.” Then that new robot, new device, new way of doing surgery with no surgeon needed (no more than supervision)…. Could it be an asteroid. Could DV literally be not needed as it’s leapfrogged.

Enough. It’s even painful for me.

Okay I’m tailing this blog again with my disclaimer. Do I think this is going to happen… no not for one second. But people asked and asked me to say the what If’s. And well this is my list of what If’s. Of course these apply to many companies - but hey I enjoyed the exercise and be fun to hear what you think. Maybe it gives you some ideas.