Robotic Surgery

For anyone who works in surgery and specifically anyone who works in robotic surgery, you are probably familiar with the da Vinci system. This is the most common and preferred robotic system and, in my opinion, will stay that way for the foreseeable future. Intuitive Surgical, the designers of the daVinci system have recently announced the upcoming da Vinci 5 which is the next generation of robotic surgical equipment. I personally have experience with da Vinci Si and Xi. The da Vinci Si is the system that I was trained on when I was a new surgical tech. I was amazed at the advancement of technology compared to laparoscopic procedures. To see the surgeon step back from the sterile field after docking, go sit at the console, and begin operating was pretty cool. A year or so after learning this system, along came daVinci Xi. The facility I worked at purchased the new robot. The Xi was much more aesthetically pleasing than the Si, but the feature upgrades were very well planned and executed. The camera now was able to be completely sterilized which allowed the surgical tech to just throw the plug in off the field versus having to drape the entire camera. The new camera was also self-heating, no more “thermos” to keep it warm.  

There is a mode within the robot called “firefly” which is a special “light” mode that illuminates blood flow after a medication called indocyanine green (or ICG) is injected. This allows doctors to assess perfusion, when necessary, by nothing other than a control on the surgeon console. The daVinci also has the ability to pair with a bed called the “Trumpf” bed, which is not an Intuitive product, but it allows for table motion while the robot is docked to the patient. Previously, if the surgeon needed better access to the pelvis you would have to remove all the instrumentation, undock all of the robotic arms, adjust the bed as needed, redock, retarget the anatomy, and then reinsert all of the equipment- instead of hitting the “pair” button on the Trumpf bed then adjusting the table tilt, etc. as requested. A 20-minute process turned into a 30 second process- talk about efficiency.

There are so many different settings and options you can get into and adjust through the vision cart also. You can track instrumentation usage through the vision cart, adjust which lens view is being displayed on the monitors. You can draw on this screen with your finger, obviously not if you are sterile. This allows more effective communications between surgeons or between reps and surgeons when needed.

Now I know what you are thinking, aren’t there other companies making robots that would compete with Intuitive? Yes, but not there is not an actual competition at this point, and who knows if there ever will be. Medtronic created their robot, HUGO, for minimally invasive surgery, but it is only investigational and not yet for sale in the US. There are even smaller companies trying to break into the market all the time like Asensus Surgical which has a system they call Senhance, and I am not aware of any facility that has this system or is looking into purchasing this system. Intuitive truly owns the market with daVinci.

There are a few other robots like the Mazor, for neurosurgery, and the Mako and VELYS for total joint replacement, but those are on the other end of the spectrum as their capabilities are very limited to only certain steps in a small number of surgical procedures.

Every hospital I have worked at has been dominated by the daVinci system, and for good reason. daVinci dominated the market early on and has continued to expand into more and more hospitals with little to no competition for several decades.

Speaking personally from my own experience I think it will be difficult for other companies to compete with the daVinci system for a few different reasons. For starters, you not only have the surgery teams but the surgeons themselves who are trained and familiar with the daVinci line of products. It would be tedious for hospitals to purchase and retrain their staff and for the surgeons to get retrained on new equipment. Not to mention the contracts I’m sure most facilities have in place for the disposables. Unless something drastically changes with the support Intuitive provides or the quality of their equipment, I cannot see any surgeon willingly walking away from Intuitive to another company.

Hospitals that have higher surgical volumes may have multiple robotic systems and may be using the daVinci Xi and/or the Si, the hospital staff can easily adjust between the two systems since they are very similar. Not saying that would not be possible, but it would be different, inconvenient, and way less efficient to have to switch from a daVinci in one room to a HUGO system in another.

Also, from an inventory management perspective, you probably would not want to purchase a different family of robots that would perform the same task since that would mean storing multiple sets of instrumentation, disposables, etc. I could see this being different if you were at a training or research hospital that would purposefully have multiple systems, but hospitals like my own would most likely look away from having different sets.

I think it will be extremely difficult for new companies like Asensus Surgical to break into the market. Intuitive Surgical is a huge company sitting around ~135-billion-dollar market cap. While Asensus is closer to ~77-million-dollar market cap. Not only is Asensus significantly smaller but they are unprofitable at this time while intuitive has been profitable for years. Even if Asensus has a great piece of equipment, I’m not sure that a hospital will be wanting to make that kind of purchase without having a clear view of the future of the company. We are talking about 1.5 to 2 million dollar purchases here, so it’s not a light matter on the accounting side.  

On another note, the daVinci 5 was just announced, and I am excited! Just as the Xi was more aesthetically pleasing than the Si, the 5 has followed suit. One of the most raved about features of the new robot is the Force Feedback- which is an ability for the surgeon to visualize ‘pressure’ when manipulating tissue robotically. This is an entirely new concept to robotics- how exciting. The surgeon console will also now allow the surgeon to sit in a completely upright position versus leaning forward into the robot. This ergonomical change will be a huge benefit to the backs of surgeons who are operating robotically on a regular basis. There is an addition of an insufflation system straight into the vision cart so there is no need to seek another vendors product, smart move. Many articles I’ve came across have claimed that daVinci 5’s design and capabilities are giving them an even greater lead than what they already had in the robotics market. Intuitive nailed it with the daVinci robot and I think they will remain the robotic preference for the majority of surgeons for the foreseeable future.