Since its approval by the FDA in 2000, Intuitive Surgical's da Vinci robot has been the dominant player in the field of surgical robots. Previously, CMR, Medtronic, Titan medical and other companies joined, but none of them shook the dominance of intuitive surgery.
However, in recent years, da Vinci surgical robots have encountered a crisis, and due to the impact of the epidemic, Intuitive Surgical has suffered a decline in revenue growth. Gary Guthart, CEO of Intuitive Surgery, announced significant R&D investments in 2023 for clinical trials, expansion of new categories of surgical robots, and operation of new systems. Intuitive Surgical spent $879 million in annual R&D expenses in 2022, up 31% from 2021. This means that in the future, Intuitive Surgical will invest more huge amounts of money in innovative surgical robots.
In addition to its own weak growth, the surgical robot track has also ushered in more strong players. Johnson & Johnson's trans-natural orifice surgical robot is performing strongly, and the new surgical robot platform is poised to take off. At the same time, in the primary market, the market dominated by laparoscopic surgical robots in the past is also changing, microsurgical robots, soft tissue surgical robots, and natural orifice surgical robots have begun to become the protagonists of refreshing large financing.
In what direction is the next generation of surgical robots going, and how intuitive surgery will complement the da Vinci surgical robot system, which has been launched for many years; Does the new type of surgical robot have the opportunity to become a large single product market such as laparoscopic surgical robots? The arterial network was combed.
How elephants turn,
How did da Vinci surgical robots evolve?
The da Vinci surgical robot represents the pinnacle of medical technology, but the da Vinci surgical robot is actually a product of the last century.
In 1998, the second generation of surgical robot system Zeus system was born, Zeus system is characterized by the integration of surgical arm and endoscopic arm in the robotic arm. The advantage of the Zeus system over the fuggle surgical robot is that the doctor can perform laparoscopic surgery while sitting upright. The da Vinci surgical robot was developed by Intuitive Surgical in 1999, and the Zeus surgical robot and the da Vinci surgical robot were integrated into one enterprise after a long patent war.
In the 20s of the last century, Zeus surgical robot and da Vinci surgical robot were integrated into one enterprise after a long patent war, and the design of robotic arm + console + cart became the model of laparoscopic surgical robots for the next two decades.
In 2016, with the expiration of Zeus' surgical robot patent, including the British CMR surgical, Medtronic Hugo and other surgical robots gradually entered the market, this type of laparoscopic surgical robot and da Vinci surgical robot is different in that it adopts a split design, each trolley has a robotic arm.
From the perspective of the evolution of the da Vinci surgical robot, although today's da Vinci surgical robot has not been revolutionized from twenty years ago, Intuitive Surgical has actually undergone three innovations. The direction of these innovations has also become the main direction of the improvement of da Vinci surgical robots.
The first generation of da Vinci surgical robots was introduced in 1999 and has four robotic arms. Compared with the first generation of surgical robots, the improvement of the second generation of da Vinci surgical robots launched in 2006 is that it has 3D high-definition vision, and the improvement is mainly reflected in improving the quality of intraoperative vision.
In 2009, Intuitive Surgical released the third generation of surgical robot system, the third generation of products is dual consoles, the overall is more compact and efficient; The third-generation da Vinci surgical robot entered the Chinese market in 2011.
In 2014, the da Vinci Xi system (fourth generation) was released, and the fourth generation entered the Chinese market in 2018. Compared with the third-generation da Vinci surgical robot, the da Vinci Xi system has improved imaging and flexibility, using a suspended mounting and mobile platform to meet the surgical machinery reaching the surgical area in all directions, and the surgical arm is smaller and thinner than before.
The da Vinci surgical robot introduced superior real-time 3D images with a natural depth perception in a 2014 improvement. The significance of this technique is that in laparoscopic surgery, doctors usually see two-dimensional images, but must think in three dimensions. The 3D image can restore the three-dimensional surgical field in real vision, which is conducive to the identification of lesions, accurate resection and reconstruction, so that surgeons have good hand-eye coordination in the operation, and significantly improve the efficiency of surgery.
The innovation direction of da Vinci surgical robots also includes the innovation of minimally invasive surgical instruments. Although Intuitive Surgical is a surgical robot company, in the research and development of minimally invasive surgical instruments, Intuitive has always been consistent with the leaders of minimally invasive surgical instruments such as Medtronic and Johnson & Johnson. Taking the stapler as an example, the intuitive stapler, like Medtronic's smart stapler products, can also reduce damage to soft tissues through intelligent tissue thickness recognition.
In China, from the perspective of installation, the current domestic installation of da Vinci surgical system is mainly the third generation of products, and only a small number of fourth-generation Xi products are installed in China. Domestic doctors are more proficient in operating the third-generation system.
In 2018, da Vinci Surgical Robot also launched a revolutionary single-port surgical robot, FDA approved da Vinci SP® system (single port) for adult single-port urological surgery, which has not yet entered China. The da Vinci SP uses 8.5 mm pre-bent instruments. However, da Vinci single-port surgical robot still does not solve the "chopstick effect" of small operating space and interference of surgical instruments in single-port surgery, and the current surgical indications are narrow.
From the above improvements, it can be seen that the improvement direction of da Vinci surgical robot is mainly in three aspects: improving image quality, improving operational accuracy, and expanding indications. This is also the direction of continuous improvement of da Vinci surgical robots.
In terms of improving image quality, one of the major innovations of Intuitive Surgical in recent years is the use of fluorescence imaging technology, which also provides doctors with images that cannot be seen by the naked eye during surgery.
In 2019, da Vinci launched the Firefly near-infrared fluorescence function based on years of optical and imaging technology. The fluorescence imaging system operates in the range of 400-900nm, and in addition to providing images of the surface layer of human tissue, it can also realize fluorescence development of subsurface tissues (such as cystic duct, lymphatic vessel and vascular development) at the same time, which plays a key role in accurate positioning and reducing surgical risks during surgery. At present, this technology is also widely used in endoscopy.
By exploring fluorescent agents that can target critical anatomical structures or abnormal tissues such as ureters or prostate cancer, the Intuitive team hopes to help surgeons improve surgical outcomes by reducing damage to vital structures and provide surgeons with enhanced visualizations that will help surgeons perform complex surgeries more reliably.
The second core issue is improving haptic feedback. The da Vinci robotic surgical system still has many problems to be solved. First of all, the most obvious is the lack of tactile feedback, the doctor's initial knot is easy to break, the clamping tissue is easy to damage, and it is necessary to constantly learn to make up for it through hand experience and visual feedback. Advances in sensor technology and artificial intelligence are improving the precision, grip, feedback, and autonomy of robotic surgical systems.
In terms of clinical application, da Vinci surgical robot focuses on expanding indications, especially single-port surgical robots, in the world, the most used field of robotic surgery is urology, especially in the treatment of prostatectomy and partial nephrectomy two operations, and there are many departments that robots have not yet penetrated, such as otolaryngology, these departments have become the focus of da Vinci surgical robot development. At present, in 2019, the FDA approved the da Vinci SP surgical system for oropharyngeal transoropharyngeal oropharyngeal surgery, which is limited to adult T1 and T2 benign tumors and malignant tumors.
Other improvements include improving the way surgeons are trained, changing the traditional model of teaching surgeons, and reducing the learning costs of doctors, especially for complex surgeries.
Overall, intuitive improvements focus on the use of advanced hardware, software, and digital intelligence to enhance surgeons' senses.
The strong enter the game,
How Johnson & Johnson rewrote surgical robots
In the past, the surgical robot market was defined by intuitive surgical, but with the expiration of a batch of patents for da Vinci robots. With more strong players emerging in the surgical robotics space, Medtronic and Johnson & Johnson are expected to capture a piece of the expanding surgical robotics market.
On the track of trans-natural orifice surgical robots with product layouts in both Intuitive Surgical and Johnson & Johnson, Johnson & Johnson's Monarch is leading the way in its indication and is currently approved for use in lung and urological surgery. Monarch has completed more than 20,000 cases of lung cancer diagnosis and treatment. Monarch's next priority indication is kidney stones, and the first adjuvant kidney stone surgery has been completed.
In the field of orthopedic surgical robots, Johnson & Johnson has also expanded into the orthopedic field through the VELYS platform, which is used in knee replacement surgery to improve the accuracy of bone cutting, which has been approved by the FDA.
In addition to Monarch through the natural cavity and the orthopedic digital system VELYS, Johnson & Johnson has a soft-tissue surgery robot product with greater potential, Ottava. Johnson & Johnson's soft tissue surgery robot Ottava is quite different from the da Vinci surgical robot from the available published data.
The Ottava Soft Tissue Surgery Robot has six robotic arms, which are integrated into the operating table to reduce floor space. However, it is not clear how to avoid interference between instruments if six robotic arms are used at the same time.
The advantage of the Ottava surgical platform is that it can be combined with the Johnson & Johnson Ethicon platform, which is a global leader in energy surgery equipment and will have more advantages in improving the performance of surgical instruments in the future.
Another advantage of Ottava is integration, and many surgical robots around the world are currently independent products. For example, laparoscopic robots and vascular interventional robots, Ottava is expected to become a platform that can integrate vascular interventional robots and laparoscopic robots at the same time.
The R&D and launch progress of Ottava has been affected by the epidemic, and as the epidemic gradually normalizes, Johnson & Johnson will add more products in the field of surgical robots.
Compared with the behemoth of the da Vinci surgical robot, from the perspective of the research and development direction of Johnson & Johnson Ottava, the surgical robot is evolving in the direction of modularity.
Ottava blueprint
New direction:
Microsurgical robots have become a new track
The giants in the surgical robot market are fiercely fighting, and there are also track giants that have not yet set foot in. Although the da Vinci surgical robot is well used in the field of laparoscopy, it has not been used on a large scale in reconstruction, lymphatic and ocular surgery so far. These tracks, which require more refined surgical robot operations, have become fertile soil for the growth of innovative enterprises.
Taking microsurgical robots as an example, traditional microsurgery relies on optical and precision surgical instruments to complete the operation. The operation needs to be performed manually by magnifying the operating department under optical instruments of 5x to 40x. Microsurgery usually anastomises 0.3-0.8 mm lymphatic vessels, blood vessels or nerves, and there are a large number of unmet needs in multiple departments such as ENT, lymphoid surgery, neurosurgery, and plastic surgery.
Taking ophthalmic surgery as an example, in the field of ophthalmic surgery, the instrument moves around the scleral puncture point, which is easy for patients to tear the incision tissue and affect postoperative healing. Moreover, the precision of eye surgery is extremely high, with an ideal accuracy of 10 microns. However, in eye surgery, there is a natural shaking of about 100 microns in the human hand, which is easy to cause retinal damage and affect vision recovery.
This neglected market is ushering in a breakthrough, and several innovative companies are starting to develop innovative products. These include the Symani system developed by Italian company Medical Micro instruments and the MUSA system developed by Dutch company Microsure.
Microsure's microsurgical robot works by reducing motion to filter tremors, keep hands stable in microsurgery, and improve the doctor's ability to repair anatomical structures in microsurgery. MUSA applications include lymphatic vein anastomosis, distal nerve repair, vascularized tissue grafting, and many other complex microsurgical procedures. MUSA has been shown to be safe and effective in suturing blood vessels to reduce lymphadenopathy. Microsure has raised €2.7 million in funding.
Symani is designed to improve the surgeon's natural flexibility and range of motion, allowing physicians to go beyond the range of motion of the human hand. For example, suture veins, arteries, nerves and lymphatic vessels as small as 0.3 mm in diameter. Medical Micro instruments has also raised $27 million.
At present, there are also two domestic companies that have laid out this track, Angtai Fine Micro and Disie Medical, which have obtained financing. Ontai Micro has a number of products such as general-purpose microsurgical robots, ophthalmic surgical robots, and transgastrointestinal endoscopic robots. DySee takes ophthalmic surgery as the starting point and goes deep into the field of microsurgery. The DySee Medical Ophthalmic Surgery Robot has completed the type examination.
The field of surgical robots has always been the pinnacle of medical technology innovation, after twenty years of development, surgical robots have reached a new level in terms of technology and clinical recognition, which also means that the market has the opportunity to brew new changes, looking forward to more transformative innovations in the field of surgical robots.
Resources:
Progress in Pediatric Surgery|Development Status and Prospect of Pediatric da Vinci Robotic Surgery--Tang Shaotao
Past, present and future of surgical robotics——trend in urology & men health
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