Strategies to sell against "Modular" Main frame robots

The second in my series of "Strategies to sell against": I now focus my attention on how - If I was selling a boom robot or a mini robot - I would sell against the modular main frames. That's Hugo, Senhance, Versius, SSI Mantra and Carina style robots

All good robots - don't get me wrong - but like all products there are Pros and Cons. And if I was out there today selling against them - these are some of the strategies I would use. Again - try not to bash the competition - it's never a great strategy - but I'd definitely be pumping my strengths which would highlight their weaknesses.

One of many modular robots

Complexity of set up

There are many advantages that come with modular robotics - I should know - I sold the most successful modular robot to date.

But If I was a "boomer" the one thing I would be pushing hard is - with a boom you get a much simpler set up. You dock the one single boom to one side or the other side of the table - "That's it." One position - one placement and one set up.

With freedom of choice for modular robotics - you end up with an infinite number of possible configurations. How many arms left of the bed? How many right? Between the legs? Near the head? All good for helping to allow multiple choices in approach - but it massively increases the setup complexity for the bedside teams. And what a learning curve eh?

Implementing a new surgical robot into a surgical team’s day to day routine is - in itself - a steep learning curve. That goes for every system on the market. But if you need to learn positioning of just 3 modules - console - tower - boom bedside unit. You limit the learning curve on OR set up. It becomes fairly standard fairly fast.

The same is true for mini robots like Vicarious Surgical or Virtual incision. Console and Tower need working out - but the robot simply sits over the patient on an arm attached to the table for Virtual Incision. That's it. Simple.

Vicarious has a single small format bedside cart for reduced set up complexity.

Now with modular robots - you need to position console - tower - and now up to four arms. And that is where choice becomes complexity.

Instruments from the left or the right? Camera from left or right ? From the head or from the tail. Base close to the bed or far from the bed for today's case? Do that dance between the bases - angles of bases need to be right to avoid clash (especially some systems) - the buffet menu goes on and on. "Wow what a headache all those choices you're going to need to make for every case..."

Selling a da Vinci, or Medicaroid - I would push very hard on - 3 components - very few set up options of the base, and then let the magic arms from the boom give you all the variety. The learning curve of component placement is one "easy step" with a boom robot. .

Space around the bed is critical

One major advantage of mini robots is that their arm takes low to ZERO floor space around the bed. None for Virtual Incision - and importantly zero lateral space. The boom robots occupy one side of the bed - but leave ample space for the bedside team on the contra lateral side, or down between the patient legs.

The more arms you use with a modular robot - the more floor space you take up - and importantly the more "air space" around the patient in some models. Let me explain. With small modular units like Versius or Carina - you can get the small base unit right in at the bedside. The arms more or less arrive from a base close to the patient. That's their design ethos.

With a Senhnace or Hugo - the bases generally sit further away from the bed (a design philosophy to de clutter the space around the bed) but the arms sort of crane in over the bedside staff at about head height. Higher for Senhnace than Hugo. So those incoming arms occupy space all around the bed effectively making a cage that the bedside staff have to negotiate around. Avoiding their heads hitting the arms.

As a boomer I would be pushing hard that you have one overhead boom support that occupies only one zone of airspace next to one side of the bed. The bedside team has freedom to move around 2/3 of the available airspace without having to duck or move around a base or arm. For me I would challenge comfort, ease of doing the job and just access to the patient from more angles by the bedside team.

Note: I know Intuitive has a lot of this messaging off pat. But there are multiple incoming boom robots. I'm trying to help everyone get on the same page.

Space distributed across the OR

With the multiple bases - big or small - there is a combined total footprint that has to be placed under consideration. As a boom company I would know my exact footprint (square inches / feet / cm or meters) of floor occupancy - and I would work out the total square footage of floor occupancy of all the other systems - and I would have a side by side comparison chart to hand.

I'm not sure that I'd be saying my boom is smaller - as it may not be - but inch for inch - I bet there's not as much difference as you might think, even with some smaller systems. Interestingly, some boom systems could have a smaller footprint than some of the bigger modular systems. Anyhow, I'd have that chart and be ready to combat the claim" Booms are big" by saying that OR occupancy is not much difference. That is what counts - not the size of any single component.

However - I would then as a boomer - be saying that occupancy is similar but distribution of the components is better. We have just 3 sites of occupancy versus a potential of 6 sites of occupancy to get a scope and 3 instrument arms. And I'd be asking staff - "Do you prefer less carts in one place... or several carts in your way all around the OR?"

I'd certainly be making sure that was firmly in the mind of bedside staff that have to do all the navigating - head avoidance - leaning in - and setting up whilst avoiding trip hazards.

Cabling is an issue

On trip avoidance. The more bed side units you have - the more cabling is required for power and comms. And not only that - the complexity of cabling goes up as each set up may need different cabling configurations. Instead, if I was a boom robot, I would be highlighting that only one bedside unit needs only one cable (more or less). I would certainly we looking at the cabling layouts suggested by companies in their IFUs and doing some comparisons and asking "what does that mean to actual movement and working in a real OR?" Side note: I have been watching with immense bewilderment the da Vinci 5 images plastered all over social media. And that even though it has incredibly nice cable management options - the cable management by the teams on the ground has been sloppy at best. A gorgeous system where they let all the cables run from the front and back and top of it in all directions - all over the floor like spaghetti. Come on guys !!! Makes it look neat!

Because with a boom robot - you have the chance to make neat and simplified cabling and imply reduction of trip hazards as a major advantage. Nursing staff are literally sick and tired of having to deal with cables from all sorts of "connected" systems - not just robots. When you have a robot - with light cables - camera cables - electrosurgery cables - return pads - console cables - tower cables and now bedside unit cables... I would be on a mission to make cable management a massive differentiator.

This is absolutely true for the mini robots - super super simplified cabling is a massive winner (I know you know that Virtual incision I watched your nice demo!) But I would be all over that like a rash!

Mobility sadly often means multiple trips

One of the key claims of modularity is that smaller units are easier to mange and roll between ORs. So modularity is becoming synonymous with mobility.

So how would I be fighting that as a boom robot?

"We can move our system as easy as 1-2-3."

Only 3 components to move = 1 staff member between 2 ORs just does 3 trips to move everything. Whereas with a modular unit you end up with 100% more trips as you need to move 6 components to get the equivalent arm count. That is time, effort - and ultimately non-convenience - right?

Mini robots are even easier - you move the console and the tower and just plonk the robot on the tower in its sterilisation case. 2 trips! Now we are talking convenience !!!!

I'd also be pointing out you need twice as many cables on modular systems - so staff need to transport all that as well. In fact the benefit of size and weight is negated by the number of trips and time wasted. Would be my mantra to combat "mobility."

Mass = stability

The "Big and bulky" works against boom robots in one sense. But I would be reminding the world that one of the most important features of a robot is tremor filtration. And well - what's the point of filtering user tremor if the arms shake and judder and instrument tips wobble around in space. I would certainly have footage of the stability of my boom instruments in space as a side by side of a modular instrument waving around.

I'd just be talking physics. Mass = stability.

Now of course some of the modular systems out there use software to help reduce bounce and movement - but I'd be asking...

"Look you've got a lot of arms you end up weaving in and out of around the patient. It is way more likely you are going to bang into an arm during an operation. That is when light and small arms become potentially risky. Not having that mass means that they could get knocked - and what then happens to that instrument tip?"

"With our big boom robot - yes we are heavier - but take solace in that - it's all in one place so you are less likely to bang it accidentally - and if you do... that mass has inertia so it is less likely to affect your instrument tip inside the patient." Or some sales talk track like that.

For Mini robots - it's simple - they work in a totally different way with totally different actuators etc etc - that whole mass stability thing is just irrelevant. We engineered our way around all of that debate - what you as a user move is what you get. And for Virtual incision >>> "Mass????? Mass means nothing and we can prove it. We did it in Zero G where mass was irrelevant - you couldn't use any other robots in space. We removed that entire mass thing."

Mass can be greater than a single boom on a modular robot

Now let's actually talk about that mass back on earth in real operating rooms - because in my post against booms I talked about floor ratings and accumulating that boom mass in one area of the OR.

So how about a little Judo move for the boomers.

Yes the mass in modular systems is smaller per bedside unit - so maybe we should look at the floor rating when we look at each individual arm that could be 2X to 6X lighter than a boom bedside unit.

As a boomer I would be saying - so that's okay and good as long as then you don't store all that mass in the same place - right?

What I mean is - during the case - yes you may be distributing that load across the OR floor in different areas - so during the case the mass at any point is below the weight bearing limit of the floor.

But what happens if you take say 4 arms and 2 spare arms and "as the manufacturer "store them all snuggled together between cases?” You end up with 6X the mass all in a concentrated spot - so what's the difference ? If my boom weights 800Kg - and the 4 arms all together weight 4 X 200K = 800Kg.

Erm... when they are stored together between cases - don't they weigh the same?

And in fact - one of the claims is the ability to "swap arms in" then you could end up with 6 arms together reaching 6 X 200Kg or 1200Kg !!! And the smaller those units are the more they can be densely packed together, and more load per square meter can be created.

I would be using this as the defensive logic against the attack of the weight of the boom robot arms. Now if the modular arms start to get to 300Kg plus (as some are) - I'd have the calculator our all day long.

Variable procedure set up and port placement

As said earlier - a big advantage of the modular systems is freedom of base placement and bringing the base to the ports. This translates into freedom of port placement - allowing surgeons to use their currently proven port placements. Right?

Well - that can be more true for some systems. But arm clash is an issue for all systems - some way worse than others - but there are limits to "how free" your port placement can actually be in reality. The closer the ports - the higher the likelihood of clash. Just physics.

The issue is that every patient is different - with differing BMI, body size and anatomical landmarks. Each base placement is one more variable. And they stack up. So now I have infinite port placements (well sort of) and matching infinite bedside unit placements to match those ports. The permutations become massive very very quickly.

With a boom robot - base position is kind of eliminated from that complex equation. And the architecture of the arms from the booms is fairly fixed (less places you can put them) and the downside is that you end up with more constraints on port placement. Not good for some surgeons for sure.

Boomers - I would be flipping that around to - reducing variability - reducing variables and moving to standardisation. That translates into simplified learning curves and less "trial and error" time for each patient. You don't need to work out base placements for every case. Follow the tried and tested manual.

Sometimes - less is more.

Servicing multiple arms vs 1 boom

Slight tangential one here - but when I service the boom robot I am servicing just one bedside unit cart. Yes it's bigger but it's one. Of course there are still 4 arms to service - but it is sort of a single unit with multiple components I'm servicing.

On modular systems - each cart and each arm needs servicing - plus any back up arms they have lying around as swap ins. There's nothing defined and I have no data - but logic dictates that servicing 1 base unit must be easier and faster than servicing 4 base units? Right.

And the logic of that flows downhill. So if I only have one serviceable base unit - there should be 4X less chances of a failure because I have 4X less units that "could have an issue".

It's a bad logic I know - and not maybe held out by real world numbers. But connectors and pins do break. Brake mechanisms jam. Wheels get wonky - and if you have 4X the number in the room - there is just a statistical possibility you will get more points of failure.

Each time you plug in a cable you risk some damage - so having 4X less cables to plug in must be better... right?

I would certainly be talking with the biomechanics engineering department and getting their thoughts on those sorts of lines of thinking. See if they see it as a possible real issue or not. If you get my drift.

The mini robots that have no servicing go one further. Use it X times and ship it back to the company for a refurb. Less arms - less complex = less service issues. If it breaks bang a new one in. No service issue..... erm no. This issue is tower and console. You reduce bedside service issues but console and tower may need TLC every so often. So use the service story wisely.

Struggles for automated set up

Much of the future battle ground of surgical robotics will be all about workflow and efficiency. A big part of that will be set up and tear down and how the system can improve that.

As a boomer I would 100% be talking about 2X more components to wheel in - drape up and plug in. Then find the right spot. Find the right place and angle from the bed - find the right angles of the arms etc etc.

I'd be raising the spectre of choice meaning it could become confusion, and that leads to errors that may lead to repositioning etc. Delays - time - etc etc.

But then one of the things that DV5 (da Vinci 5) has now sparked ideas on is automation in set up. It is probably way easier to have automation help in set up on a single boom with all 4 arms with a known spacial relationship. There are only so many configurations you can arrive at. And because it all comes from one point you can probably more easily automate that positioning of the 4 arms to be optimal for each procedure type. Store positions and give teams a big head start.

The problem with modular arms today is that each arm is independent and must be placed with a relative position to all the other arms . But it's very manual today as there are billions of permutations. Some modular systems give you a very complex set of arm angles you need to set the arms up with to avoid clash and get the best angles for certain procedures. For other modular systems it is really human skill, judgement and guesswork with "rules of thumb"that get you to the right set up.

As a boom robot - and especially if I was now driving DV5 - I would be pushing automation help in set up as the reason to go single boom. Keep it simple.

Angles of approach for modular robots vary every time you do a case

Much of the reason for this is that every operating room is different - every bed is different - every patient is different - every user is different - every preferred port placement is different... the list goes on.

The downside of a boom is that it generally constrains your port placement.

The upside of a boom is that is generally constrains your port placement.

It's all about how you position that issue as a pro or a con.

Modular systems allow variability of the starting point of the robot arms relative to each other.

Boom systems lock the origin points of the arms to each other (within some movement constraints of the hanging boom). As a boomer I would be saying - "yes" we reduce your choice - but that is a great thing. The boom base is always 90' to the bed - the arms arrive from the boom in the same place - the arms are always constrained relative to each other and we control that.

I'd be asking - "So as you can move the bases of the modular arms anywhere - how do you get consistency between cases? How do you ensure that the setup will work for every patient in every procedure? How much help do you need with that set up?"

Would it not be easier to have known origins - and modify port placement slightly to our known positions - and reduce all that thinking time - and planning time - and then hoping you got it right, or deal with arm clash?

Eventually teams will of course work out the modular placements - and they do - but as a boom seller one of my strategies would be focus on my simplified learning curve - especially as it is stressful enough introducing a robot into the OR without having to go through all that trial and error of base placements. Surely standardised has to be better? right?

For any customer considering a modular system - I would draw a patient abdomen and ask - "Can you show me where the bases would potentially go and explain why you put them there - for a modular system."

And then I would draw one square and say "My system goes there... end of story."

Summary

Again - I'm not picking on any system - any type of system - and I'm being equal in selling against booms, modular systems, and next it will be single ports and mini single ports. I'm trying to show the community there is not one single answer - it's not black and white - it's very nuanced.

Ultimately it will come down to user preference - as all systems have merits and weaknesses.

My aim is to start to get people to think about the right questions and we should move to "right robot, right site of care for the right surgeon doing the right procedure."

These are simply opinions off the author and these views are expressed for education purposes only.