On October 18, 2021, Lin Jin, professor of joint surgery at Peking Union Medical College Hospital, once again broadcast the robot-assisted full knee artificial joint replacement surgery under the real-time attention of the whole network audience.
The surgery is still significant. At any moment, the slightest mistake could "sever" the partnership between the notorious expert and the robot he was involved in developing, which is still in clinical trials, and be labeled "unreliable."
Before the live broadcast, Lin Jin had been working with his robot partner for nearly two years. Since the first use of the Hehua Surgical HURWA joint robot on January 6, 2020 to complete China's first robot-assisted full knee artificial joint replacement, in the operation of Lin Jin's main knife, the proportion of robot participation has become higher and higher, from 30% to 50%, until more than half a year ago, he has been 100% using robots for surgery, self-proclaimed "robot doctor".
On many occasions, Lin Jindu has made a bold statement: "I don't want to do traditional joint surgery anymore, I will not go back to the old road, and at present I am the only one in China who does this." ”
Lin Jin during surgery
Perhaps this live surgery represents the perfect collaborative relationship between the orthopedic surgeon and the robot of the future, but today, he is still a complete minority.
In the Chinese medical equipment market with trillions of space, the track of orthopedic surgical robots has just begun to be laid, with non-rigid demand, limited market, extremely low penetration rate, and unclear commercial prospects.
Whether it is convincing the surgeon who has done surgery for twenty years with his bare hands and even uses a fixed model of the scalpel to embrace the robot, or whether the top three hospitals are willing to spend tens of millions of yuan to purchase innovative medical devices with unknown clinical value, for the manufacturers who are engaged in orthopedic surgical robots, every link from research and development, admission to commercialization is a hard battle.
However, in the past two years, orthopedic surgical robots have leveraged the high expectations of investors. Start-ups poured out in batches, and hot money poured into orthopedic surgical robots, pushing one product after another to be approved, financing hundreds of millions of yuan, and even successful IPOs.
The primary product in the eyes of doctors, and the hottest track in the eyes of capital
In the field of surgical robots, da Vinci is almost synonymous with the industry, and all manufacturers hope that their products will be benchmarked against Leonardo da Vinci, but they never dare to speak lightly.
Whether it is the online video of Leonardo da Vinci stitching grape skins, or the interviewee's experience of operating Da Vinci cutting rubber, the experience and praise are similar, "smooth and silky, and achieve true human-machine integration". Futuristic pictures that used to be available in science fiction movies are now becoming standard for major surgeries in some top three hospitals, and even standardized diagnosis and treatment programs for some diseases.
Ideally, as long as the orthopedic surgeon sits in front of the machine and knocks on a few instructions, the system will automatically plan out the best surgical plan, accurately go to the parts that are difficult to reach with the freehand operation instruments according to the path, and the doctor only needs to make small repairs and changes the surgical plan according to the patient's situation, and from time to time glance at the electronic screen to do a good job of supervision.
In reality, the relationship between the orthopedic surgeon and the surgical robot is like the driver and the navigation, which needs to be manually entered into the place of departure and destination, and the navigation gives three recommended routes, and the decision maker and the operator are still doctors.
For novice drivers who shuttle through unfamiliar cities, intelligent navigation has indeed played a great role, but old drivers have long been familiar with the road. The first buyers of surgical robots must be the top three hospitals, and for the main surgeons of the top three, conventional surgery has long been easy, and it is faster to do it with bare hands, and the use of surgical robots will only be considered in extremely complex cases.
It is true that surgical robots can add icing on the cake, but it is definitely not a breakthrough from 0 to 1, and when it comes to paying nearly 10 million yuan for 0.8 to 0.9, the number of hospitals and doctors willing to buy is very limited.
When asked "when will surgical robots be used for surgery", a chief orthopedic physician involved in the development of the robot joked, "You need to send a press release, just start to make one." Although he has high expectations for the products he participates in research and development, he believes that if it is free, doctors will be willing to use it; if he spends money to purchase, his psychological price will not exceed 6 figures, which is far from the price of millions of dollars.
But in the eyes of investors, there is another interpretation of the situation. Although it seems that the clinical value is limited now, it is precisely because it is in the early stages that it is an excellent time for capital to enter.
Among the five potential subdivisions of surgical robots, the market size and maturity of endoscopic robots are the highest, but the fastest growing and most high-profile is the orthopedics.
According to a report by Ekay Capital, orthopedic surgical robots are the hottest segment of the capital market, with overseas investment increasing by more than 300% since 2016, with a total investment of US$1.36 billion; the total domestic investment has also exceeded 10 billion yuan.
Almost every month last year, an orthopedic surgical robotics company announced the completion of financing. According to incomplete statistics, there are 13 domestic surgical robot financing incidents of more than 100 million yuan in 2021, of which 6 are in the orthopedic surgical robot track, of which Nagagi Valley announced the completion of a 540 million yuan B round of financing, becoming the largest financing project in the orthopedic track since 2021.
Optimistic about robots, not only have capital, but also equipment manufacturers.
Medical device giant Johnson & Johnson not only joined hands with Tianzhihang as a "hardware" partner, but also cooperated with Nagaki Valley to launch a preoperative planning project. Similarly, in the field of endoscopic surgical robots, in November 2021, the local innovative company Shurui completed the B+ round of strategic financing, and the exclusive investor is Medtronic.
The first to enter the game is the first to win. "The first five domestic surgical robot companies to enter the market segment can be regarded as on the same starting line of competition, but if they enter too late, it is difficult to compete with the first mover." Qi Xiaohuan, vice president of Yikai Capital, analyzed the eight-point jianwen.
After the consumables are collected, the surgical robot accelerates into the field
From the perspective of the manufacturer, this is not difficult to understand. Traditional implant consumables and surgical tools have not seen subversive innovation for nearly a decade, and seeking robots that can create new value is the inevitable direction of the industry's development.
Qi Xiaohuan told Eight Point Jianwen that in 2015-2018, there was a wave of spinal robot entrepreneurship in China, but most companies failed to wait for the blessing of capital to declare bankruptcy, and the spinal boom gradually cooled down in 2019.
One of the few spinal robot companies that survived that year was the "first stock of domestic surgical robots" that landed on the science and technology innovation board in July 2020 - Tianzhihang.
Zhang Shenggen, chairman of Tianzhihang, recalled the early days of the business to the Economic Observer, describing it as "we were very difficult to lie on the ground and get China's first medical robot registration license, during which we did not make a penny." ”
The first generation of surgical robots, from research and development to approval lasted 5 years, in 2010 after the approval of the listing but did not sell a single one; the second surgical robot in 2014 to obtain a certificate, sold less than 10 units. At present, the "Tianji" sold on the market is already the third generation of products, but the feedback from clinicians is still mixed.
To some extent, the difficulty of Tianzhihang's start is the epitome of the era of orthopedic surgical robots: the rough imperfection of the original products, high pricing has become a stumbling block to entering the hospital, and the medical insurance payment coverage of innovative medical devices cannot be talked about.
At that time, in 2010, Da Vinci had monopolized the international market for surgical robots for more than 10 years, and China's best public hospital "301" had only 4 years to introduce Leonardo da Vinci. After 2015, Da Vinci entered an incremental outbreak period, began to appear frequently in the promotional texts and operating tables of various hospitals, and the orthopedic surgical robot track was still very deserted.
Until 2020, the collection of orthopedic consumables rekindled the enthusiasm of capital for orthopedic surgical robots. The joint field, which was first cut, has clearly become a more active track.
Money is the most direct inducement for the industry to speed up.
Last year's orthopedic consumables collection broke the orthopedics prevailing interest structure for decades, when the profits of traditional consumable implants were squeezed, the pursuit of more clinical value of surgical robots, it became a common goal of clinical and manufacturers.
People believe that surgical robots are the trend of the times, and if future consumables cannot adapt to robots, they will easily be eliminated by the times.
According to the statistics of Yikai Capital, there are at least 25 orthopedic surgical robots in China. Except for 7 companies whose products have been approved for marketing, the rest are in the clinical or research and development stage. At the same time, there is a constant influx of new players into the industry.
"2022 is the time for everyone to concentrate on getting the certificate, it will take more than a year from the time you get the certificate to the hospital, and the amount will be at least until the middle of 2023." Qi Xiaohuan estimates that if calculated according to the number of units, the growth rate of China's orthopedic surgical robot market in the next three to five years will be about 50%.
In addition, on the clinical side, there is also the blessing of the "14th Five-Year Plan for the Development of the Medical Equipment Industry", which removes the barrier to the admission cost of high-priced equipment, so that manufacturers have the opportunity to enter the hospital and rely on technical services to charge first; at the payment end, Beijing and Shanghai have included surgical robots into medical insurance, seeing the possibility of innovative medical devices entering medical insurance, which means the popularization and volume of the future market.
Surgical robots are not a hammer deal that ends when the equipment is sold out, "system + consumables + services" is the basic income model of the entire industry, and it is also the business model established by the world's most successful surgical robot "Da Vinci".
As a result, manufacturers began to explore another way: the model of "putting printers + selling ink cartridges".
That is, temporarily reduce the barriers to hospital admission caused by the high price of the system itself, and use the start-up fee, consumables and services required for a single operation to achieve a part of the revenue first, while increasing the volume of surgery.
Makers of orthopedic surgical robots are looking forward to snowball growth. "For every additional robot you have on the market, the corresponding number of surgeries will definitely increase, and with it comes the growth of consumables and service revenue." Huang Junhui, secretary of the board of directors of Tianzhihang, said.
In the view of Zhao Luyong, head of IQVIA China Medical Devices, the admission of robots at a discounted price and the use of consumables as an assessment index is a strategy for foreign manufacturers to verify effective strategies in the US market, "If you just sell machines, you can't form a closed loop, it will be a less sustainable business model." ”
For manufacturers, closed-system surgical robots open up a sales channel for high-value consumables. But for doctors, all-purpose platforms with more options tend to be more popular.
Got the robot, got the orthopedic world?
In the field of medical devices, the situation of imports dominating and domestic rapid follow-up has been prevalent for a long time. The most mature endoscopic robot, Leonardo da Vinci monopolized the international market for many years, making it difficult for latecomers to cross this mountain.
However, in the field of orthopedic surgical robots, domestic and foreign manufacturers have the opportunity to stand on the same starting line, in a market that has not yet been opened but has high hopes, in an area where industry barriers are not so high, each of them has emerged and jointly expanded the market.
After the collection, the opportunity belongs to the surgical robot. In addition to local start-ups such as Tianzhihang, MicroPort, and Xinjunte, there are also old oropaedic giants such as Medtronic, Stryker, and Zimmer Bangmei who are making efforts to the Chinese orthopedic surgical robot market in the same period.
The advantages of the two sides "holding hands" are obvious:
The established foreign enterprises have a very strong mature system from registered clinical to commercialized, and joining hands with domestic start-up surgical robot companies is the fastest way to promote China's localization. Domestic startups are often born out of the clinical projects of the top three, closer to the clinical trial habits and processes is its potential advantage, with the help of the aura of foreign companies and mature resources, it helps to occupy a place faster.
A typical collaboration is Johnson & Johnson and Tianzhihang.
Johnson & Johnson, which has the largest market share of orthopedic consumables, is one step slower than rivals such as Stryker and Medtronic in launching orthopedic surgical robots. However, driven by the collection policy, the digital and intelligent transformation of China's orthopedic market has occurred so quickly that if it passively waits for the parent company's products to be listed in China, Johnson & Johnson may fall behind in the future expansion of surgical robot business.
Moreover, one focuses on robots and one focuses on consumables, and there will be no conflict of interest.
Gary Guthart, CEO of Intuitive America, a supplier of Da Vinci, once said, "Competition is not robot-to-robot, but ecosystem-to-ecosystem." ”
This iron law also applies to Chinese orthopedic surgical robots. "In the absence of a substantial gap between the technologies, whoever can lower the price and do the service will win." Qi Xiaohuan said.
In the next five or even ten years, persuading hospitals to purchase, persuading doctors to use, and driving through the top three clinical drives are still the focus of manufacturers.
People in the industry can't accurately predict when orthopedic surgical robots will truly become the right-hand men of Chinese doctors.
Zhou Wenyu, chief physician of the Spine Surgery Department of Shenzhen Second People's Hospital, is looking forward to the robot's real growth. In the beginning, it was like a doctor's assistant, who could only help write medical records and sometimes write mistakes. Just as it takes a long learning cycle from trainee to chief physician, robots also need to complete a truly iterative upgrade in clinical applications.
But no one doubts that robots will be more involved in orthopedic surgery in the future. "Robotic-assisted surgery is a trend, a trend, but it's not fashionable, and it doesn't go away like a gust of wind." Lin Jin believes, "The robot is the most loyal first assistant of the main surgeon, it is not afraid of tiredness, it does not make trouble, it obeys your command faithfully, it is also more accurate, minimally invasive and safe than you, these advantages are not much more reliable than ordinary assistants!" ”
Written by Zhang Yuqi and Chen Xinshu
Chen Xin 丨 is responsible for editing
This article was first published on the WeChat public account "Eight Points Health" (ID: HealthInsight)
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![Break the foreign monopoly! The domestic endoscopic surgical robot was approved for listing and can complete a variety of difficult surgeries[fig]](data:image/gif;base64,R0lGODlhAQABAIAAAP///wAAACwAAAAAAQABAAACAkQBADs=)