Surgical robotics: surgery will never be the same again
Coming to a healthcare facility near you
TL; DR:
One of a series of articles on surgical robotics
Surgical robotics has been in commercial use for over 20 years, and Intuitive Surgical is the leader with over 10 million procedures performed to date
Robotic surgeries can reduce scarring, healing times and significantly extend the careers of surgeons (e.g. 10 years and beyond)
Outside of the US, Asia is seeing growing uptake, and more and more surgical robots from China are coming to market; JVs are a popular way for foreign surgical robotics companies enter the China market
Still, only 3% of surgeries worldwide use surgical robotics at the moment
Picture this – you’ve picked up an unfortunate niggle, and the doctor says it’s best to operate on it. You’re already squeamish about these things, but the thought of experienced surgeons putting themselves to work and the success rate calms your nerves.
It’s minimally invasive surgery they say…
Great, you think, hopefully less scarring, and I might even make a quicker recovery
It’ll be done by a robot, they say…
Shocked, the image of flailing metal arms coming to mind – is this even a thing?
Yes, it turns out. Surgical robots have in fact been around for a few decades, and they are changing the way we are receiving medical care. This will be the first in a few articles on the subject.
So, let’s find out how the industry got going.
The original trend-setter was the Da Vinci Surgical System family of surgical robots from Intuitive Surgical (ISRG). In 2000, it became the first FDA-cleared surgical robotics system for commercial general laparoscopic use in the United States - as of end of 2021 their revenues have reached US$5.7 billion, and so far a whopping 10 million procedures have been performed worldwide using their system - a clear market-leader to this day. 1
How does robotic surgery work?
Surgical robots have grown in popularity because they can enhance minimally-invasive laparoscopic surgeries (AKA keyhole surgeries) by improving accuracy, reducing scarring and patient recovery times. One major benefit people might not be aware of is it reduces a whole lot of tiring work for surgeons, significantly extending their careers over the longer term.
Generally speaking, robotic surgery in commercial use today involves a surgeon sitting at a console using a set of controls to manipulate surgical instruments to perform minimally-invasive surgery. This is also known as a “master-slave” type of robot, and is the most common on the market.
After calibrating the robot, a trocar (a tube with sharp edges at one end) is placed into the body of the patient to provide an opening through which other instruments such as an endoscope camera (a long, thin tube with a small camera inside), surgical scissors and graspers can be used to carry out the surgery.
Three to five trocars are typically placed, and the surgeon is able to view what is happening inside the body through a computational workstation with a high-definition display.
Prostatectomy (prostate removal), cholecystectomy (gall bladder removal), hernia repair, are some of the most common procedures where surgical robotics are used, but orthopaedics (e.g. spine, rest of the body) and radiosurgery (using radiation instead of a blade to get rid of tissue) are some areas seeing growing adoption.
With a chronic shortage of skilled healthcare professionals, and the punishing work that surgeons do (some studies have shown 30% of surgeons cut short their careers due to repetitive strain over long hours), surgical robots offer a big opportunity to make surgery sustainable for hospitals, surgeons and, of course, improve outcomes for patients.
Unfortunately, he world is ageing, and the rising tide of chronic health issues against a shortage of healthcare professionals, including surgeons, opens up a big opportunity for surgical robotics to solve such problems.
Here’s a cheeky video about what robotic surgery can achieve using a Da Vinci surgical robot – let’s hope for everyone’s sake we never experience it like this!
An ever-growing, global market (the US is steaming ahead)
The US has far and away been the biggest market with 71% global market share in 2020, and the shift towards robotics has been unquestionable since the first FDA cleared robot in 2000. By 2015, over 50% of US hospitals had already adopted them. Europe and Asia have been neck and neck with 13% and 15% respectively of total market share in 20202. Whilst the biggest adopters in Europe are the large Western European countries, many of the robots used there still originate from the US, and most local players are still at the pre-clinical stage.
In Asia the push has been from government initiatives such as China's 14th Five-Year Plan on Medical Equipment Development which encourages development of local endoscopic, orthopaedic and other intelligent surgical robotics capabilities. Oh, and China wants to be world class by 2035 (see page 8 of document).
So there’s a big market in China – how does it compare to the rest of the world?
The global surgical robotics market is forecast to grow to US$21 billion by 2030, and it’s no surprise Intuitive Surgical leads the pack (61% share in 2020).
In China, Intuitive still takes top spot by virtue of their early foray into China when they sold one of their first Da Vincis back in 2005 to the Prince of Wales Hospital in Hong Kong through their distributor Chindex.
Chindex was eventually acquired by Chinese healthcare behemoth Fosun, and Intuitive’s China business then moved into a joint venture with Fosun in 2019. This seems to be the way that foreign surgical robotics companies will continue tackle entering China in the future.
It’s a lot more open in the rest of the market. In second place is publicly listed Tinavi, China’s surgical robotics leader in orthopaedics, also the first local player to receive local regulatory approval back in 2010 (in 2019 they also set up a strategic collaboration with Johnson & Johnson). The market for medical robotics in general is growing at 30% year-on-year3 in China and, thanks to the government’s quota on foreign-made surgical robots, local players are fully encouraged to tackle global leaders head-on.
One major development has been Intuitive Surgical’s patents starting to expire. This has led to flurry of upstarts entering the surgical robotics arena.
Just take a look at this – in terms of orthopaedic robots alone, China expects 18 new orthopaedic surgical robots to come to market by 2023.
The reality is there are 100s of exciting smaller players coming up worldwide. For China, rapid growth in published medical robotics papers has mirrored the growth of a crop of local players.
That said, despite a 20 year run-up, and plenty of companies building these things, surgical robots are still only used in 3% of surgical procedures worldwide.
We’ll look into some of the reasons for this in the next article.
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All views contained in this article are my own and do not necessarily represent the views of any other organisation.
None of the above constitutes investment advice in any way.
Intuitive reaches 10 million procedures performed using da Vinci Surgical Systems (Dec-21)
https://isrg.intuitive.com/news-releases/news-release-details/intuitive-reaches-10-million-procedures-performed-using-da-vinci
Market sizes (US 71%, Europe 13%, Asia 15%)
GlobalData (2020), https://alirahealth.com/wp-content/uploads/Alira-Health-Report_A-RAS_Review_Full_Report.pdf
China medical robotics market growth
Medical Robotics: Opportunities in China Yao Guo, Weidong Chen, Jie Zhao, and Guang-Zhong Yang (2022)