Robots in the operating room: How deep tech is revolutionizing medicine

The groundbreaking step started with a small incision near the belly button. At the beginning of April 2021, Professor Lutz Mirow, Chief Physician at Chemnitz Hospital in Germany, sat in front of a control console and reached for his scalpel with a robotic hand. For the experienced surgeon, this gallbladder operation was both routine and completely new: it was the first time that a machine assisted him in such an operation.

Normally, the specialist in minimally invasive surgery would have had to stand in the operating room for hours to perform a series of complex steps with long, rod-shaped instruments. Now he could leave the physically demanding work to the machine and control the instruments remotely with absolute precision."The robot is really the next step"” says the 51-year-old. "We now have the ability to work even more precisely, even more effectively."

The Versius system, made by the UK-based CMR Surgical, has four arms. It was purchased by his hospital in Chemnitz, and is the first such system in Germany. One arm is used to guide the camera, which provides a close-up of what is going on in the patient's body. The other arms can be used for various tasks and moved around freely – an enormous advantage over conventional minimally invasive surgery: "With these instruments, you can reach areas of the body that are otherwise difficult or impossible to reach in keyhole surgery," Mirow explains. "That expands the possibilities tremendously."

A booming business: Robotically assisted systems

Mirow is not the only one who is enthusiastic about medical robots. Business with these high-tech systems that promise to make even complex operations less invasive and more efficient is booming around the world. Market researcher Informa estimates that in just five years, global sales of robotic assistance systems could more than double: in 2020, they amounted to 5.6 billion US dollars, and this figure is expected to rise to 11.5 billion US dollars by 2025.

For many years, this market was dominated by the Californian company Intuitive Surgical. Founded in 1995, it did pioneering work – both technically and economically – with its Da Vinci system: after receiving approval for the medical robot from the US Food and Drug Administration (FDA) in 2000, the California-based company convinced more and more new customers that the investment was worthwhile – despite its hefty price tag of around two million US dollars and ongoing costs for maintenance and associated materials.

More than 6500 Da Vinci systems are now in use in almost 70 countries, and Intuitive Surgical’s robot has assisted human surgeons in more than ten million procedures. These systems enjoy a market share of roughly 80 percent, and have also given investors a reason to rejoice: since 2017, the company’s market value has increased almost fivefold to roughly 120 billion US dollars.

Experts are not surprised by this success. Compared to conventional keyhole surgery, the Da Vinci system offers many advantages, explains Professor Stefanie Speidel, a computer scientist.

She conducts research on intelligent systems for cancer surgery at the National Center for Tumor Diseases Dresden (NCT/UCC) and in the Cluster of Excellence CeTI at the Technical University of Dresden. "The surgeon sits at the console, they have improved hand-eye coordination and 3D visualization, which enables them to see the area in question very precisely.

The device translates larger hand movements, which the surgeon executes via two joystick-like controls, into tiny tremor-free cuts. Overall, operating this system is very intuitive," she says.

Good prospects for competitors?

However, there are signs that its dominance is coming to an end. More and more competitors are entering the market – including large players such as Johnson & Johnson, Stryker and Medtronic, as well as smaller companies that often specialize in specific procedures: NuVasive in spine surgery, for example, and Zimmer Biomet for knees and hips. Newcomer Vicarius Surgical, whose investors include Bill Gates, aims to start with repairing hernias.

Despite what the term "robot" might suggest, none of the systems are intended to replace humans. They are primarily designed to support surgeons, explains Stefanie Speidel. "I believe that you can automate partial steps, such as tying knots or the movement of the camera, but not an entire operation," says the scientist. “The process is far too dynamic and complex for that."

There are several reasons that explain the sudden boom. On the one hand, patents that Intuitive Surgical filed in the 1990s are expiring; that allows other companies to use and further develop their inventions. On the other hand, medical robots are becoming increasingly attractive to potential customers, explains Umur Hürsever, a partner at the venture capital company Lightrock. For example, patients recover more quickly after minimally invasive procedures, which reduces the burden on hospitals and lowers costs for the healthcare system. Medical robots also relieve humans of many strenuous tasks – a major advantage, even if studies have so far only found measurable advantages in terms of the outcome of operations in isolated cases.

"The assistance systems provide major support for surgeons," says Hürsever. "They allow them to work more efficiently and practice their profession longer." Even just a few years ago, he says, there was still a lot of skepticism among potential customers. "We have reached a turning point. We no longer have to bring supply to the market. Instead, there is huge demand for robotically assisted systems."

Hürsever, with Lightrock, was among the first investors in CMR Surgical in 2016. The start-up, founded in Cambridge in 2014, aimed to develop a medical robot that would be more flexible but also more affordable than the incumbent Intuitive Robotics’ Da Vinci. The developers designed their Versius system to be modular so that it can adapt to different requirements, and the founders came up with a special marketing concept to reduce costs: hospitals interested in Versius do not have to fork over millions, but can finance the purchase through a service package, the price of which is also based on the number of procedures.

"This possibility is very well received," reports CEO Per Vegard Nerseth, a native of Norway who assumed his role at CMR Surgical at the beginning of 2020. Typically, he says, the contract is for seven years, and the more intensively customers use the system, the greater the financial benefits.

"The costs per procedure drops significantly, reaching levels close to reimbursement through the health system in most countries," Nerseth says. Overall, he continues, the financial benefits to customers are so great "that many clinics are now able to acquire a robotic system sooner than would have been possible in the past."

Ambitious plans for expansion

The British start-up is being rewarded for its efforts with rapid growth. Last year, the number of systems sold more than tripled, says Nerseth. He doesn’t give more specific details, in order not to give competitors insights into how the business is developing – although two big competitors are currently struggling with set-backs: both Medtronic and Johnson & Johnson have reported multiple delays for their systems. CMR Surgical, meanwhile, is focusing on expansion: armed with more than 1 billion US dollars in capital, the company, which has 800 employees, is looking to expand quickly. "We’re currently active in about 20 markets," Nerseth says, "and we’re working hard to scale the business."

But their goals are more than just geographic in nature; CMR Surgical also aims to set technical milestones: by linking hardware and software and leveraging the interplay of robotics and artificial intelligence, the Brits want to open up entirely new possibilities in medicine. After all, every operation generates data that – if aggregated and anonymized – can provide information on how to avoid complications, which procedures promise the greatest success and what surgeons should pay most attention to.

"We are gathering a lot of information that was not available to physicians before," Nerseth explains. Using data analytics, videos and visualizations, surgeons around the world can learn from each other, work together to identify best practices and implement these in a standardized manner to provide better care for patients," says the CEO. “Of course, it helps clinics when sick people heal faster, but it also helps society as a whole because it lowers healthcare costs".

Computer scientist Stefanie Speidel also sees linking robotics and data analysis as the logical next step in high-tech healthcare. Assistance systems such as Da Vinci and Versius are already "very good telemanipulators," she says. "But the big opportunity is to use them not only as mechanical aids, but to also combine them with AI methods."

Speidel is herself working on a digital navigation system that will help surgeons during tumor removals by superimposing tissue structures and vessels that must not be injured “on the endoscope image that the surgeon sees in the console.” The system has practiced this task on thousands of sample images and uses various sensors to capture more information than the human eye or an optical camera can do alone. "To indicate where the target and risk structures are, where to cut, where there might be complications" - a close interplay between AI and robotics could bring enormous benefits in all of these areas, Speidel explains.

Medical robotics: An opportunity for investors

A range of technical possibilities is also something for investors to rejoice about: the more powerful the systems become, the greater the benefit for customers. “I see enormous market potential,” says Umur Hürsever, especially for an innovative company like CMR Surgical, which is blazing its own trail with its technology. "The design is unique,” says Hürsever. “It resembles an arm with the mobility of a wrist and is very well protected by patents."

For him, the robotics start-up therefore offers the perfect combination of being able to generate a return on investment and delivering on Lightrock’s mandate to make a positive contribution to society through investments. "This is a company where commercial success and impact complement each other perfectly," Hürsever says.

Lutz Mirow, the surgeon from Chemnitz, says that using the modular design of the Versius system does indeed have tangible advantages. "You can put the robotic arm wherever you were used to, and then basically just put your knowledge to use,” he explains. “That’s much more difficult to do with other systems that have five arms on one column."

The fact that the mechanical assistant is able to help to better train the next generation of surgeons is also important to him. "We have a training module on this robot and the ability to record things and to provide support with the help of 3D vision," Mirow says. According to the surgeon, the hospital is showing significant enthusiasm for the still-new high-tech system. "The robotics team has developed into something exclusive here at our hospital," he explains. "People want to be part of it, they want to be on this team because it's something new."

The surgeons in Chemnitz have now explored the possibilities offered by the Versius system in nearly 200 operations – including complex procedures on the esophagus, stomach and intestines. "We have really explored the spectrum of what is currently possible," Mirow explains. "Some of the procedures we’ve done were the first-ever such procedures to be conducted anywhere in the world."

There have been no complications with the technique; instead, he says, patients get back on their feet faster. Experience has shown that switching from open surgery to minimally invasive surgery helps the body recover faster, Mirow says. "Now we’re seeing that patients who have been operated on robotically recover even faster."

Verklären will Mirow den Roboter bei aller Begeisterung nicht. «Er bleibt eine Maschine», sagt er. Aber eben eine Maschine, «die mich in die Lage versetzt, meine Patienten in Zukunft noch besser zu behandeln». Deshalb gibt es für den Chirurgen auch keinen Zweifel: Eines Tages, glaubt er, «werden wir einen Paradigmen-Wechsel erleben, weil nur noch robotisch operiert werden wird».

For all his enthusiasm, Mirow doesn’t want to idealize the robot."“It remains a machine," he says. But it’s a machine "that enables me to treat my patients even better in the future." That’s why the surgeon has no doubt that one day, "we will experience a paradigm shift, because all surgeries will become robotic surgeries."

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