It’s no secret that there is a technology race on the horizon, with the future of the medical devices industry heading towards robotic surgery. The global corporations are gearing up for the ‘robot wars’, fighting for pole position in an industry that is set to grow to $24 billion by 2025.

This is a race to the top driven by innovation, cost and better patient outcomes. But with only 3% of the worlds surgeries done using a robotic system, there is certainly room for growth on the global stage. In this article I will be analysing the competitive landscape and outlining some of the opportunities and threats for the companies in this exciting sector.

Of course, we all know that the current market leader in this space is Intuitive with their da Vinci System. They are the predominant organisation and have been for a long time, due to being a first mover, they have blocked off the market with patents, gained market monopolisation and are now in hyper growth mode. However, enter the 2 Goliaths of the MedTech industry JnJ, with the announcement of Ottava, and Medtronic with their affectionately named Hugo. With these 2 major players entering the arena, Intuitive will need a strong defensive strategy to remain King. There is also strong European entry from CMR Surgical, the UK MedTech unicorn who are strongly positioned to develop and grow in EMEA who have also made in-roads into Emerging Asia. How much of a factor will this geographical positioning be?

Johnson and Johnson and Medtronic may have a distinct advantage over intuitive & CMR, that being their massive suite of products and resources. They are able to fully kit out an Operating Room (OR) without a second thought for a range of procedures; this leaves us to hypothesise whether or not JnJ and Medtronic might offer their systems for free or heavily subsidised, but in return gain contracts to provide the rest of the products in the OR. It certainly is an attractive proposition, offering to surgeons and health care systems, a free or heavily reimbursed robotic surgery system in return for contracts in other areas. But as it stands, the clear competition in the short term for Intuitive is CMR Surgical, who are now hitting their next gear in the commercialisation of the Versius robot. So let’s dive into each organisation in more detail!

Intuitive have dominated the space by being the clear first movers with their launch in 1999. They were the first organisation not only to develop a fully functioning robotic system, but the first to devise a full commercialisation program. By being the First Mover, they were able to patent their intellectual property and had 20 years of defence against market entry. This has allowed Intuitive to gain strong brand recognition, thus developing a market reputation and customer loyalty evidenced by their 2020 revenue of over $4.3Bn.

One of the major reasons they have been able to get such a competitive advantage and head start in this market has been due to their effective use of patents, however I now believe that patents will be one of their biggest threats. With an expiry time of 20 years, patents that once existed and protected Intuitive have started to run out and organisations have started to enter the space. This could negatively impact the adoption of da Vinci systems, as surgeons or health systems start to anticipate the availability of different, better or cheaper systems moving forward. That is not to say that Intuitive have not got a clear strategy around defence and creation of new patents, however there is no guarantee that as time passes the technology is open to imitation.

Another defensive strategy Intuitive have adopted to protect the business and drive further revenue is the diversification of products with new market launches; some of the key launches being ION an Endoluminal robot specifically designed for biopsy of the lung with the aim of obtaining definitive diagnosis sooner. The Ion is Intuitive moving into new markets and applying their systems into new and more diverse therapy areas. Further to Ion, Intuitive are launching more products to the da Vinci system, da Vinci stapling and da Vinci energy. Prior to these launches surgeons would have to use devices by other organisations which meant Intuitive were missing out on revenue in their procedures. Their strategy is to become more of a one stop shop, to protect their business moving forward. By expanding the product offering, health systems are likely to get longer term contracts in place and Intuitive will be able to leverage these relationships for future success.

JnJ’s announcement has been highly anticipated after the $3.4Bn acquisition of Auris Health. Finally in November of 2020 we got the name … “Ottava”. The system is described to give unrivalled flexibility and control to surgeons in comparison to the rest of the market (a bold claim if I do say). Although the statement certainly comes from an impressive pedigree, with JnJ’s Chief Development Officer being an Intuitive Co-Founder and Auris Health Founder Dr. Frederic Moll. If anyone could be described as a specialist in surgical robotics, Moll is definitely that person. Ottava translates from Italian to mean one octave higher and their value proposition is aimed at being the best system available on the market.

Further to the acquisition of Auris health, JnJ have a rather secretive joint venture with Google which promises to leverage data, AI, machine learning and robotics to “build the future of digital surgery”. It certainly is a great example of pulling in resources from big tech and big MedTech to gain a competitive advantage. Will JnJ align Ottava with Verb Surgical projects and if so, is this all a joint venture? Or will JnJ want to protect their access to Auris’ technology?

Although JnJ do seem like they are aiming at the premium side of the market by creating the best systems, we are unlikely to see a launch before 2024, this slow introduction to market in comparison could be a sign of bureaucracy that we sometimes see in these larger organisations although be rest assured that once the systems become available, we will see a rapid commercialisation program and large-scale investment.

Medtronic and their fondly named Hugo, named as to be a familiar and approachable figure in the OR, is aiming to reduce surgical costs to match that of a traditional laparoscopic procedure. The Hugo value proposition is clear, better clinical outcomes at the same cost as traditional surgery.

One of the key areas of the Hugo which looks like a distinct advantage is the future proofing of the robot. By having a modular design, the Hugo can be upgraded as technology develops and parts become obsolete. This means instead of big capital purchases every few years, the robot can be upgraded, changed, and updated as Medtronic continue to improve and innovate on their features. Overall, this means the Hugo will be cheaper to run over a longer period of time and with an eye on costs, the Hugo could have a strong competitive advantage.

Of course, this is not the first entry Medtronic have had into robotic surgery. In 2018 they bought Mazor Robotics in a deal worth $1.7Bn which combined Medtronic’s surgical planning platform with Mazor Robotics spinal robots. It is no secret that Medtronic are investing a large amount into R&D within robotics, which is to stop growing competition in their core business segments as well as to capitalise on a growing and innovative surgical area. Medtronic are really having a strong push on an “integrated OR” which leverages big data, AI and IOT. They have been able to integrate their robots with existing technologies such as navigational systems and imaging systems. In my opinion this is where Medtronic have a distinct advantage, their level of collaboration between existing technologies within the organisation and new robotics. But, being such a large organisation, they are more likely to succumb to the whims of bureaucracy, and that mean less agility in comparison to some of the smaller more flexible organisations.

I may be biased here as I am from the UK, but a fantastic company that is growing exponentially and are a UK unicorn is, CMR surgical. Who are, as we read, hitting new gears in their commercialisation. As the titans go to war, CMR Surgical, the only other organisation to have currently commercialised their robot has a very interesting proposition. This is through a subscription model (lease) for their robots, which is inclusive of instruments which may be an interesting carrot for health systems to consider, instead of purchasing a da Vinci. With an average base model cost of $1.5Mn, not including the instruments the da Vinci is a large capital outlay for any surgeon or health system. By leasing the Robot, this could bring costs down for less economically developed nations and their health systems, where cost is an overarching factor in decision making.

Technologically CMR’s robots are very versatile, with a small footprint in the OR and are easily manoeuvrable around the hospital and the OR, their design has the freedom of movement whilst biomimicking the human arm, a huge advantage in transitioning from traditional surgery to robotic surgery. Having recently passed the 1,000 successful procedures mark, CMR are gearing up their commercialisation effort with current launches across Europe in the UK, Germany, France, Italy, and also in both the Middle East and Asia, having systems already installed in Egypt and India.

CMR also have a location-based advantage, being headquartered in the UK they have arguably better access to Europe and MEA. However, Brexit will undoubtably have a high impact on the foreseen widespread adoption throughout the EU; although, it isn’t uncommon for a company to relocate across the Irish Sea to Ireland and gain access to the EU market and then the UK, through NI. Moreover, free trade deals are continually being drawn up between the UK and overseas post Brexit, which could increase the pull factor for Health Systems to invest in the Versius robot.

Although the rapid growth and commercialisation of CMR is very impressive, we have to question what the long-term future of the organisation is. For example, with such large organisations developing their RAS systems, will CMR go down the route of IPO which usually changes the company dynamics, and may be a blocker for innovation? Or are they an open acquisition target? Being in the industry I get a lot of market information and robotics is the word on the lips of most major organisations. Organisations who have not invested in the early-stage R&D may see CMR Surgical as a perfect acquisition target to bolster their current offerings and open up this exciting and innovation driven market.

Conclusion

To conclude, I believe that in the short term Intuitive’s biggest threat is from CMR, they are the only other organisation to commercialise, and their pricing model is very attractive, meaning the accessibility of the Versius could be the initial competitive advantage. It is not looking like JnJ are even close to release of Ottava, which seems like 2025 may be the aim of release and the details are still kept very confidential. Medtronic are the closest major to completion and with their capital and accessibility to resources have the ability to rapidly commercialise and with their current entry into spine and cranial robotics they clearly have the ability to commercialise an RAS.

This sector is certainly going to be the battleground of the future and I for one can’t wait to see the innovations that are yet to come. Although these organisations are clearly kicking up a storm, robotics are becoming more accessible, and I am currently writing another article about the rising stars in robotic assisted surgery which highlights some of the newest organisations and hottest innovations who have expressed their plans to enter the market… Watch this space.