“Oh, God, please don’t let me trip over anything.”
That’s my first thought as I tiptoe around the electrical cords snaked across the operating room floor. It’s an early October morning at the Long Island Jewish Medical Center in New York. I’m decked out in a onesie-style baby blue protective suit, a hair mat, a bonnet to cover my beard, an additional mask for my mouth, and booties over my shoes.
None of this is designed for agility. It’s meant to protect the patient lying on the table less than five feet away from me. His exposed torso is peppered with small holes through which cancer surgery specialist Dr. James Sullivan and his team insert their medical instruments.
As it happens, there’s another surgeon in the room besides Sullivan—one more modestly garbed than either of us. Wrapped in plastic sleeves that cover its central boom and sprawling white arms is Intuitive Surgical’s da Vinci Xi robotic surgery system. It’s hard to tell who’s in charge.
The instruments inside the patient include three separate, interchangeable components that can slice, shift, grasp, cauterize, or otherwise manipulate human tissue, as well as a movable high-definition camera that illuminates the body’s internal landscape in stunning 3D clarity. That’s a visual advantage that Sullivan says has revolutionized how doctors perform minimally invasive surgery—the kind that doesn’t require chopping someone open to remove a body part or collect samples.
Sullivan makes his way to a console on the left side of the OR, where he takes a seat in front of a viewfinder that looks like it belongs in a futuristic video game arcade. He places his middle fingers and thumbs into two pairs of rings on two movable arms. At the console’s floor are foot pedals, which function like a clutch in a manual car. With his fingers and feet, Sullivan will navigate the four instruments now inside the patient’s body—alternating between the pincer-laden surgical extensions and a 3D endoscopic camera.
Over the next few hours, he’ll use the da Vinci to cut out a lymph node from the patient (who suffers from lymphoma) for lab testing.
Two hours later, I ask Sullivan how long it will be before the patient is discharged from the hospital.
“Where do you live?” He asks.
“Bushwick, in Brooklyn,” I reply.
Sullivan chuckles. “He’ll be home before you.”
Futurist culture has no shortage of fever dreams starring robot doctors. This story isn’t about that. While we’re still a ways from the day when androids become our go-to physicians, robotic surgery is already commonplace—and probably surprisingly so, if you don’t happen to be a surgeon. Intuitive Surgical (ISRG), headquartered in Sunnyvale, Calif., got the first-of-its-kind clearance for its robotic surgical system from the Food and Drug Administration back in 2000. But it has been largely in the past few years that its machines have exploded in popularity. Surgeons who tout the tech say it’s given them a far clearer view of what’s happening inside the body and greater control over their instruments.
Intuitive’s devices are now used at all of the top-ranked U.S. Hospitals for cancer, urology, gynecology, or gastroenterology—including venerable institutions like New York’s Memorial Sloan Kettering Cancer Center, the Mayo Clinic, Johns Hopkins, and the Cleveland Clinic. More than 4,100 da Vinci base units have been installed worldwide as of June 30, including 2,703 in the U.S., 698 in Europe, 538 in Asia, and 210 in the rest of the world.
The systems aren’t cheap: The list price for the fourth-generation da Vinci Xi is $1.9 million, and that doesn’t include the cost of various surgical appendages, which can add tens of thousands of dollars more to the price tag. Still, the robots keep selling—and surgeons are increasingly adopting them in their practices.
Intuitive Surgical is featured on our inaugural Future 50 list. Click here to see the full list.
The company says that more than 4 million minimally invasive surgeries have been performed with da Vinci systems since 2000—a new one begins every 42 seconds somewhere around the globe, Intuitive CEO Gary Guthart tells Coins2Day. The number of those procedures done worldwide spiked 15% in 2016 compared with the previous year, and Intuitive projects an additional 14% to 15% rise in the number by the end of 2017. Indeed, for certain more complicated procedures, such as radical prostate removal, robotic-assisted surgeries now account for nearly 90% of operations.
The boom has driven Intuitive to $2.7 billion in 2016 global revenue, with more than 70% of sales being recurring in nature—a fact that underscores the advantage that comes from being the first major player in a rapidly growing market.
That’s been a draw for investors too; in 2017 alone, Intuitive’s valuation has soared more than 70%, pushing its market capitalization near the $40 billion mark.
The growth has been so breakneck that it’s natural to wonder if it can continue. But those who follow the company closely say they believe it can—that there is something truly intuitive about Intuitive’s grasp of the future of surgery. The company, meanwhile, is churning out new tools that can perform more kinds of operations, expanding feverishly into Asia, and experimenting well outside its comfort zone with cancer diagnostics.
Intuitive has teamed up with China’s Fosun Pharma, for instance, in a joint venture to detect lung cancers in their earliest stages, developing a flexible robotic catheter that can navigate into the cavernous regions of the lungs. “The problem with lung cancer today is we don’t have great tools to diagnose it,” says Morgan Stanley analyst David Lewis, who has covered Intuitive for a decade. “We can’t always find it, because it’s hard to navigate something in the lung without doing damage to the patient.”
Because Intuitive’s catheter can be tracked and targeted with pinpoint accuracy, it should make it easier to identify lesions with precision, Lewis explains. “We think this procedure will revolutionize the treatment of lung cancer,” Lewis says.
“Sometimes, you just know when something’s better,” says Dr. Martin Weiser, an attending surgeon and a vice chair of education and faculty development at the Memorial Sloan Kettering Cancer Center, of robotic-assisted surgery. Such was the case when laparoscopic surgery debuted years ago. In laparoscopy, surgeons thread medical instruments and cameras by hand through small holes in the patient’s body. Surgeons, particularly older ones, were slow to adopt the new technology, largely because of the learning curve required. But eventually, it became common medical practice, says Weiser. The same has been true of robotic-assisted surgery, he says. “Whether it’s less time at the hospital for a patient or an easier time operating for a surgeon, you just know when it’s better.”
It isn’t clear whether robotic surgery uniformly leads to better outcomes. (Don’t look to the extensive medical literature for a clear-cut answer; conclusions differ from study to study.) But surgeons who swear by their robotic arms tend to return to the same words of praise: They tout the “speed of recovery” for patients, who typically don’t need to spend days or weeks in a hospital as they might after traditional open surgery. They speak of the “clarity” of its camera, the “flexibility” of its instruments.
When I get the chance to test a da Vinci Xi training module myself, the word “flexibility” is the last one that would pop to mind. At first, anyway. But after a few minutes’ practice, “operating” on a plastic torso replica filled with balloons, pennies, and other knickknacks, even my own comically uncoordinated hands seem nimble, somehow. Within 10 minutes I was able to pick up a $5 bill inside the fake chest with one of the robotic pincers, pass it to the other one, and flip it around every which way with a flick of my wrist. (“It’s like having four arms,” as Sullivan puts it.) That’s when I learned a little something about the $5 note: On the back, which prominently features an illustration of the Lincoln Memorial, there are 26 states listed across the top of the building. The lettering is so small that I’d never noticed it before; under the da Vinci’s camera, the state names were sharp and clear.
But in medicine, impressive technology is little more than a parlor trick if it doesn’t benefit patients—like James (who asked to keep his last name private), a 42-year-old colon cancer patient who had part of his large intestine removed by Sullivan a few months ago. James chose the robotic option, despite some initial apprehension, after watching some YouTube videos of the machine in action. “I figured this is either going to work out perfectly or it’s going to go really bad,” he says.
He was discharged from the hospital four days after the operation and was back at work within three weeks. It was a far different experience than the one his father had 15 years ago—for what in theory was the same operation. “They cut him from his sternum to his pubic bone, peeled him open, and took everything out and put it all back,” James says. “So his recovery time was much, much longer. Months.”
While insurance reimbursement rates for patients are the same, in most cases, whether they opt for robotic surgery or not, there is nonetheless a difference in cost, says Sullivan—to both the patient and the hospital. “What really is never factored in is the fact that you’re changing the patient’s length of stay,” he says. “In a hospital, if your average length of stay is 3.1 days and you take that down to 2.1, that is a real cost savings.”
But when it comes to the question of how quickly Intuitive can ramp up sales, particularly in less tech-hungry markets, the machine’s nearly $2 million price tag is no small factor. And while the academic debate over patient outcomes is a heated one, a rough consensus does emerge when it comes to more complicated surgeries—such as radical prostatectomy, where the prostate gland and some of its surrounding tissue is removed, usually to treat prostate cancer. Here, the verdict is in da Vinci’s favor: Robotic surgery tends to be both better for the patient and more cost-effective.
A big part of Intuitive’s playbook is to evangelize that message not just with potential hospital customers, but—more important—with young surgeons who, the company hopes, will represent the next generation of
its users.
David Lewis, the Morgan Stanley analyst, shares an anecdote about just how quickly the surgical environment is changing. Five years ago, at a prominent meeting for laparoscopic and endoscopic surgeons, he says, “the reception to Intuitive Surgical was extremely poor. In fact you could sort of sense in any given room that physicians were almost frowned upon for their use of the system.” Five years later, that same meeting had been overtaken by young surgeons presenting data from their use of Intuitive robots.
A survey by investment and research group RBC Capital last year found that American surgeons think that within five years, 35% of operations will involve robots in some form, compared with 15% today.
With an expanding market, naturally, comes competition. Both Medtronic and Verb Surgical (Johnson & Johnson’s joint robotic surgical project with Google parent Alphabet’s life sciences arm, Verily) are expected to challenge Intuitive with their own robotic surgery product lines. Those aren’t easy names to go up against; they have substantial footholds in hospitals around the world, and they may be able to leverage those long-standing relationships to elbow their devices into the OR.
Richard Newitter, a managing director of the medical supplies and devices research unit at Leerink, is largely bullish on Intuitive’s future, however. “We think the competition is a validation of the market and potentially an expansion of it,” he says.
Morgan Stanley’s Lewis agrees. He envisions three major phases of progression for Intuitive (though he’s quick to note that this is his prediction, not the company’s). The first phase, which is ongoing, is continuing to establish a presence in more hospitals in the U.S., Europe, and Asia. “European markets in many respects have lagged the U.S. Robotic markets by three to five years if not longer,” says Lewis. “So taking these kinds of technologies into the European markets, and taking them into new markets like China and Japan, is going to be important.”
But Lewis says the following two phases are more compelling—and where the greatest potential growth may emerge. First comes what he calls “platform expansion,” in which Intuitive pushes a number of new products that have either just entered the market or that are in the works. One is the da Vinci X, a system recently cleared by the FDA, which comes with a list price $600,000 cheaper than the Xi. Those units could attract hospitals that don’t have the deep pockets major cancer centers do.
Another, which Lewis calls a potential game changer, is the da Vinci SP, expected to be released in 2018. “SP” stands for “single port.” Rather than the four, spiderlike arms of the da Vinci Xi, the da Vinci SP has just one arm, inserted into one hole in the body, through which four different maneuverable tools emerge. Watch a video of the machine in action and you will likely think it’s some alien creature. The SP, for instance, could enable surgeons to treat certain oral cancers far less invasively because the port can be inserted through an existing orifice such as the mouth. (By contrast, in some cases, traditional surgical approaches require splitting open a large portion of a patient’s neck.) In a May report, Lewis and colleagues estimated that, by 2025, surgeons could perform as many as 170,000 new robotic procedures annually using the instrument.
Then comes phase three, according to the Morgan Stanley analyst: That’s where Intuitive could potentially bring together all sorts of buzzy technologies under a single platform, Lewis says. He imagines robotic systems with more advanced imaging that can highlight the body in even greater detail, enabling surgeons to instantly differentiate between individual blood vessels and nerves. Or those that incorporate a patient’s medical history right on the console. Or video that allows surgeons to replay past procedures during a current one.
All of that may sound like the stuff of science fiction. But then, 10 years ago, so did the idea of a robot surgeon.
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Catalia Health: A robo-nag for your medications.
What if a cute little yellow robot could help solve a $300 billion health care problem: people failing to properly take their prescription drugs? That’s what Catalia Health has set out to do with Mabu, an A.I.-driven robotic medical companion that makes small talk with patients—and gives them timely reminders to take their meds too.
Hololens: Using VR to train MDs.
Augmented and mixed reality aren’t just for gaming. Case Western Reserve University and the Cleveland Clinic are designing programs that use Microsoft’s HoloLens to teach med students anatomy. With holograms, students can manipulate organs and bones from every conceivable angle and get an immersive look at the body’s internal landscape.
Woebot Labs: Chatbot therapy. Couch optional
For those who can’t get an appointment with their therapist (or can’t afford one), there’s an alternative. Woebot, a chatbot developed at Stanford, will work through your issues 24/7 via Facebook Messenger. It will ask how you’re feeling, recommend ways to feel better, and even share the occasional joke. Think of it as talk therapy for the A.I. Age.
A version of this article appears in the Nov. 1, 2017 issue of Coins2Day with the headline “Coming to an O.R. Near You.”
