Recently I posted a few blog posts on endolumenal robotics.
And here
With very recent news I’m now going to double down on this for an exciting next few years..
And that is because of a few news items that hit the wires over the past few days.
I know a lot of people still see this as "fringe" and all eyes are on the multiarm robots. But...
News on Fortimedix and endolumenal robotics
Firstly I see the most important validation that a major company is making overtures directly into this space. It was announced last week that Medtronic were acquiring Fortimedix BV - and honestly that is very very big news.
Fortimedix is a specialist in laser cut tubes. I worked with them on stents many years ago when that was a booming business. But in parallel they were working on some vey interesting tube tech - where they could apply segmented tubes to instruments.
By running external cabling and select cutting the tube junctions they can control pitch and yaw of the tube. So what?
Well if you look at the tube tech for the da Vinci SP by Intuitive you can see this type of “flexible” wristed instruments in use.
You can also see from the Fortimedix website the various uses they envision for their tube technology.
This includes a variety of laparoscopic - trans orifice - and endolumenal applications.
Now you have to understand a few things...
Background on Medtronic and endolumenal robotics
You need to also understand the Medtronic side to this story. Medtronic has their base platform of robotics - which is HUGO. Today a straight stick laparoscopic multi arm robot. But it basically has big delivery arms that can deliver different payloads to the clinical filed.
They have been criticised as being too big for multi-arm. But interestingly they become interesting for either single port delivery or endolumenal delivery (Bronchial approaches or GI delivery.)
That big solid base actually becomes interesting when you think single arm robot delivery.
So using Fortimedix technology you could load multiple lap instruments onto a single arm with flexible tube technology - and well you end up with a da Vinci SP style approach.
Or more likely a Titan Medical Sport style device…… WAIT !! HANG ON!
Didn’t Medtronic do a deal with Titan way back when, and get access to allot of their IP in this space.
Hmmmm.
Now lets also not forget that Medtronic already has a navigation system for endoscopic approaches. Today in lung with Illumisite.
But they don’t have a robotic solution to compete with Intuitive (ION) or JNJ (Monarch). So it seems obvious to me they need technology to get there.
Fortimedix with some Titan IP and their own in house knowhow all tucked on a HUGO robotics arm (or similar) could get them a bronchial robotics system. And keep them competitive.
It’s a skip and a jump to get to urological endolumenal.
So now we have Hugo small diameter flexible instruments for lap, endolumenal instruments for bronchial and urological. And well… next it goes to an endolumenal robot for GI - either upper GI or lower GI or actually.. both.
Now again - Medtronic is a big beastie and they already have products in GI - in many ways. Including GI Genius, Pill Cam and way more. It would not be a leap of faith to see that they go in deeper with flexible GI robotics. I mean it makes no sense to be in flexible GI as it is today… but…
Why would Medtronic get into Flexible endolumenal robots
As said in my other articles the triad of competitors is moving that way. You have Intuitive with ION and SP - which combined start to look like a GI endolumenal robot match up.
JNJ and Ottava - you need to look back at Dr Fred Moll’s initial vision (see my other posts). Monarch is a stepping stone to the urological tree and then gear it up to the GI space. That was always Dr Fred’s goal to get to these advanced endolumenal procedures as that is how you disrupt and dethrone Intuitive. Who gets there first gets that first mover advantage.
I will bet you a pie and a pint - that both Intuitive and JNJ are moving at some speed to get to an endolumenal robotic solution. And if that happens and Medtronic don’t have a solution in the pipe (you see what I did there…) then they will be a third follower.
It is clear to me that this is a strategically critical space as we start to move to combined therapies, rendezvous, earlier see n treat etc. And it is the next area of arms race in this interesting space.
Other signals Endolumenal robotics is gaining pace
If Fred Moll is involved and invested then you can bet your bottom dollar there’s a reason for it. And you may or may not know that the leading robot in this space is a startup out of Houston that is backed by…. Yep Fred Moll.
Endoquest Robotics is probably the best known endolumenal GI robot. They use a combination of flexible scopes and flexible arms to be able to deliver very complex instrument control at the tip of a technically challenging flexible robot. They have been developing this for quite some time. Because it is very hard to get this work inside a lumen at distance.
But the biggest signal last week was that Endoquest submitted their IDE (most likely for ESD endoscopic submucosal dissection of sessile polyps.)
This is possibly the biggest signal that “we are entering the endolumenal GI robotics era.”
It’s a massive and important milestone that has grabbed my attention.
It should be grabbing the attention of a lot of strategics and investors as they are geinuinely "The first mover" in this space.
Endolumenal coming from the East
Just as in multiarm, multiport robotics - the Chinese companeis are not sitting still in endolumenal robotics. Microport Medbot already have a brochial endolumenal system. They have a single port version of their Toumai robot and it is a short skip to move to endolumenal. They already have the complex flexible instrument control.
Let's not forget Apollo Endosurgery
I do want to remind some of us that one of the main suppliers of tools into endolumenal surgery today is Boston Scientific. Especially after they acquired a pioneer of endolumenal therapies - Apollo Endosurgery. A non robotic approach to make endolumenal suturing easier with Overstitch.
Boston Scientific must be looking at this space - as if any of these robots gain traction then it will obsolete their Apollo technology overnight. It may also surpolantmany of their endoscopy single use items. Robotics tools can replace a lot of what yo need to do with smnares and baskets and all kinds of stuff. So this may actually be the one time when they start to think "Hmm maybe we need one of these...". I think they need to get a robotic system in this rapidly transforming space. It's a brief discussion I know - but just throwing it out there with relation to some future articles I'm planning. Watch this one.
A revolution that could sweep out the old flexible endoscopy companies.
I am going to put my neck out here - and I’m sure a lot of people will disagree with this - but hear me out.
When Intuitive launched da Vinci back in the day - senior leaders across the industry laughed and said “A robot for laparoscopy - what a joke.” Well who’s laughing now as 25 years later they dominate the world of laparoscopy in growth, story, future, excitement. And everyone else is playing catch up.
If I talk about “Robots replacing flexible GI endoscopes” then 99% of you will laugh and call bullshit. And I take that on the chin.
Companies like Endoquest are the tip of the spear. Medtronic, JNJ, Intuitive have never been in flexible endoscopy - I mean why would they….. wait wait wait.
ION?? Monarch?? GI Genius?? Oh sorry - they don’t make old school flexible and manual endoscopes like Pentax or Olympus.
You get it?
If you look back in the day Olympus (as a leader in flexible endoscopy) did have a project in NOS and NOTES called Endo Samurai. It died. But it signals even they knew “Something is afoot.”
You have to look at a ton of other emerging technology with systems like Prof Valdastri’s magnetic endoscope robot, IQ Endoscopy and disposable scopes, and a flood of new scope technology coming that threatens the status quo.
And all of this is merging with way better “smart” GI navigation systems based on real time imaging. The robot scopes hold the promise of faster, safer and more accurate navigation and diagnosis. But they are starting to offer the tantalising prospect of AI guided autonomous driving. (There’s no bikes and pedestrians to miss.)
They offer a future looking glimpse of faster - more accurate (GI Genius) diagnostics. And now with systems like Endoquest - rapid therapeutic (complex therapeutic) delivery. Meaning that even a “lower skilled” (no offence) endoscopist can do quick and accurate diagnosis. Immediate analysis - and … wow… they can switch from autonomous diagnostic modes to immediate endolumenal treatment mode. A complex ESD done through robotic assistance right there- right then - rapidly and safely by any user.
The way endoscopic sessions are booked and paid for has to change - but if health systems can save appointments and cash - the $$ will drive it like an autonomous scope.
What we are seeing today is the start of the technology stack that gets us to these single session GI endolumenal see n treat sessions - where autonomous scope driving and easier to do therapies can be done anywhere by anyone in short time frames. Faster diagnostics and faster therapies thanks to robotics and autonomy.
(It's already here folks with Ion and Monarch in lung. It's coming in GI.)
You will not use an old school flexible scope - then see the disease. Then Swap that out and drive in the robot - set it up - and then start the therapy. No - if you have the robot (to do therapies and the cost is sunk) and it’s “easy” to use it anyway to do all the diagnostic scoping as standard. Disposable scope components or multi use - or partial disposable give rapid robotic turn over - autonomous driven diagnostics (maybe by magnets). AI assisted diagnostics. All for faster, rapid turnover and easier diagnostics. Which I think will then become cost neutral for simple diagnostics.
If this happens - then the market will move across (maybe slowly at first) but it goes across to robotic endoscopy. And new companies now take over that vast market - and Olympus and Pentax get side lined. If you think JNJ, Intuitive and Medtronic will not drive this like a bus… then you have not been awake for the past 20 years.
(Hang on didn’t Storz just do a deal with an endoscope company…. Just saying.)
So me (and that other 1%) might predict that in the next 25 years we will see a slow but constant shift in the advanced endoscopy market that will flow back into the standard endoscopy market as more endolumenal robots get established.
And much of that primary “screening” flexible endoscopy will go away from manual endoscopy as Pill cams - CT technology etc starts to displace the standard flexible endoscopy. (The lower end.)
Navigation autonomous guided robotics with "see n treat" will also displace the standard “old school” manual diagnostic endoscopy systems.
The question will be… who will take this as a clinician. Will the endolumenal endoscopists become the cardiologist equivalents that disrupted the cardiac surgeons. Or will the general surgeons get into this - embrace it - and add to their arsenal of robotic skills and start to take the whole treatment pathway. From diagnostics - to see n treat - to endolumenal interventions - to complex abdominal and endolumenal hook ups with Rendezvous.
Having discussed things like this with a lot of "coin operated" endoscopists they laugh and say never. Old school - old thinking. Maybe this will be the surgeons (having learned from their cardiac colleagues) that will take on the endocsopy as a service in their departments as robotics make it easier and faster for them. (It's complex.)
This is important because we need to ask which companies have the intimate relationships with which of those customers that take on this challenge.
Hey maybe we get a newer school of clinician subspecialty which will be surgical interventionists. Hybrid ORs, hybrid specialties using advanced technology.
It’s coming… If you have any inkling of a hybrid OR being built near you. It’s coming.
Is endolumenal robotics replacing standard endoscopy just fantasy?
Well many will sit in Tokyo and think this is ten generations away. While others in California and Texas are doing what they can to make it a rapid reality. If we are already into IDEs for endolumenal GI robotics. If monsters of companies like Medtronic are buying up manufacturers of technology to enable this. If JNJ and Intuitive are expanding indications in endolumenal…. today….
I’d put the pie and a pint money down it’s not just coming. It’s here.
These are just the guesses and suggestions for educational purposes only. All companies own their trademarks.