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Robotics surgery.. the future!

An update with some major trends in robotics surgery for the coming years as well as several promising 'new kids on the block' that could redraw the competitive landscape completely.
Simon Wostyn

In our previous insight (cfr ‘Robotics in the operating room today’), the market of robotics surgery was sketched, as well as some limitations to adoption and key takeaways for optimizing the use of robotics in the hospital setting.

According to RBC Capital, the share of robot-assisted procedures will increase up to 35% of all procedures in 2024. Therefore, this second insight indicates some major trends for the coming years as well as several promising ‘new kids on the block’ that could redraw the competitive landscape completely.

Technological advancement is a core element of permanent developments in healthcare. Digitization, automation/autonomy and miniaturization are buzzwords in today’s futurists’ talks and describe many of the efforts in both academic and commercial R&D settings, as was also highlighted by Catherine Mohr, VP Strategy at Intuitive Surgical, at the Singularity University’s Exponential Medicine Conference. This California-based giant is still dominating the global market, but might soon be facing new competitors. Who are these competitors and what technologies can we expect?

Let’s unravel what the future holds.

Small, smaller, smallest

Reduced length of stay, fewer complications, faster return to professional activities and less pain are the most heard advantages of robotic procedures – especially compared to open surgery. The main reason for these benefits is the ability to operate in tiny or hard to reach spaces with unprecedented stability. In the short term, companies will focus on leveraging this even more by continuing the miniaturization of their existing or new robotic systems. Instead of developing a fit-for-all robotic system, we will see robots that are developed for very specific procedures or for specific aspects of surgery since cost price for these dedicated devices can be much lower than for a generic fit-for-all robot, thereby overcoming the widespread hurdle of the financial burden of a robotic system for hospitals.

Currently, 90% of robotic procedures are urological of which 80% are prostatectomies.1 Robotics will be introduced (or have recently been introduced) in otorhinolaryngological, neurological, pulmonary, orthopedic and ophthalmic procedures. Companies such as Medrobotics (ear, nose and throat), Medtech (brain and spine), Cyberknife (tumors) and Auris Robotics (lung cancer) are some of the key players following this trend.

How do you feel?

Next to miniaturization and specialization, robots will become much more intuitive to work with (cfr ‘Surgical robotics: the next 25 years’, UK-RAS Network). An experienced surgeon is a main requirement for achieving the promised benefits of robotic surgery. Several studies found that low-volume surgeons had a 30% greater likelihood of complications, 10% greater length of stay, 60% greater readmission rate and incurred 20% more in costs compared to high-volume surgeons (cfr ‘Can the robot be cost-effective for general surgery?’, General Surgery News). Speeding up the learning curve for surgeons is thus very much welcomed.

A major technological advancement to quicken the learning process is introducinghaptic feedback to feel softness and resistance of tissues via robotic instruments, which can for instance help surgeons to differentiate between benign or malignant tissues. This evolution will bring back the sense of touch in the diagnostic tool set of the surgeon during robotic procedures by integrating human and machine much more. Since this way of operating will be more similar to standard surgery, we can expect learning to be faster. Medtronic is expected to present this technology in robotic systems in the coming years.

Smart, smarter, smartest

Miniaturization and haptic feedback will improve current robotic systems and are expected in the coming years. A true breakthrough will happen by integrating robotics much more with medical imaging. Since robotics is used for minimally invasive surgery, imaging is crucial. Current robotic systems only incorporate imaging to visualize the narrow space to operate in. The first big step will come from image recognition (e.g. automatic tissue detection or color analysis) which will support the surgeon in real-time by displaying relevant information on tissues or detected anomalies (augmented reality).

The second step will be to apply deep learning algorithms (neural networks) to use footage and determine optimal ways of performing the required procedure. The surgeon’s expertise will thus be complemented by artificial intelligence based on vast databases of similar cases (potentially from other surgeons and/or hospitals) thereby boosting human-machine integration. The robotic system could even make several suggestions to proceed during surgery like driving a car by using a GPS system. Potentially, robotics might even be capable of performing surgery by itself, autonomously, like self-driving cars. A very exciting collaboration was announced in this respect in 2015 when Verb Surgical was founded as joint venture between Ethicon (part of Johnson&Johnson) and Verily Life Sciences (part of Alphabet) to join knowledge of surgical instrumentation of Johnson&Johnson with expertise in machine learning and imaging analysis of Google.

The (new) robots are coming

Today, the Da Vinci robotic systems Xi and Si (Intuitive Surgical) are still dominating the market. Several of Intuitive Surgical’s patents are however expiring in the coming years, which creates opportunities for new players, often startups (cfr. ‘New surgical robots are about to enter the operating theatre’, The Economist). Many of them were mentioned in this insight, but specific release dates often remain unclear. Prices of new robots are still to be communicated too, but it is likely that financials will be the main driver in reshaping the competitive field. Razor blade business models are expected in which the initial investment is low, but usage costs and maintenance amount to the largest part of the total cost of the robotic system. Companies might even introduce ‘service as a product’ business models in which medical outcome is sold instead of a robotic device thereby including maintenance, medical support and optimization programs in the robot’s price tag. It is important to mention laparoscopic instrument producers as well since they are also updating their products (mainly by improving the flexibility of the instruments). By doing so, laparoscopic instruments are likely to remain important competitors for robotics given their lower cost.

The graph below indicates some of the main players on the market. In the future, we expect advanced robotic capabilities in conventional procedures and miniaturization of current robotic systems towards very specific types of surgery.

 

 

 

Managing the future

Technological advancements and changes in the competitive field of robotic surgery are expectedin the coming years. Many new competitors will enter the market and robotics will become more accessible. Given the importance of the total financial picture, robotics might leverage the transition to value based healthcare. As already discussed in our first insight (cfr ‘Robotics in the operating room today’), governance, management and usage should be optimized to make the implementation of robotics program viable. Mistakes in the past regarding these basics, should allow to achieve an acceptable OEE level (‘Overall Equipment Effectiveness’, a performance metric that evaluates how effectively a manufacturing operation is utilized) and to valorize robotic investments within hospital networks in the future.

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Simon Wostyn

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