I’ve kind of visited here before but I think that newer data and the 2024 performance of Intuitive and the da Vinci 5 sets some new benchmarks.
What I want to do in this blog post is set some expectations on the numbers that everyone is chasing - and how Intuitive sets that baseline for everyone to go against. And that may be the wrong way to think about this.
I’d like to do one of my favourite exercises with a numbers break down of installs - what it takes - support staff and the numbers behind it.
I’d then also like to dig deeper into the mechanism of a sale - install and successful use of a system.
Finally giving a little advice to senior management teams of big and small companies on expectations settings.
Let me talk about the daVinci 5 numbers for 2024
So at JP Morgan - the Intuitive team announced these numbers associated with da Vinci 5 in 2024 -
362 systems placements - that did 32,000 procedures - of over 40 procedure types - with 2500+ surgeons trained on da Vinci 5.
It sounds pretty wow right. But it is not until you dig deep into these numbers that you start to understand what this really means.
I will use March 14th 2024 date as their first commercial availability date. And I’m going to assume (badly) that shipping happened 15th March for the first “commercial” systems. This won’t be 100% accurate as some clinical systems will have remained and been converted, some newer systems will have been shipped maybe a bit later. But this is illustrative so stick with me.
So from March 14th to December 31st = (292 days or 9 months 17 days)
So that means that from day 1 - Intuitive was placing 1.24 daVinci 5s per day. (Broad average)
(As a side note they did 1068 additional Xi placements - or 2.9 daVinci Xis per day [over 365 days.] But I’ll come back to this.)
So back to DV5 - 1.24 “average” per day. But that will not look like a straight line graph. It will have started slower at first and then seen a gradual hockey stick up. I imagine an exit run rate closer to 2 per day. Which will set them up for a potential 500 - 600 Installs in 2025 BTW.
Now just to get to average 1.24 per day and to get to the 2500+ surgeons trained. Let’s start there. So that means in 292 days they managed to train 2500 surgeons on the DV5. That means an average of 8.5 surgeons trained per day - every day of the week including Saturdays and Sundays.
We need to dig deeper into that because this is where the DV5 magic happens verses every other company coming to market with a new system. The vast majority of those surgeons will have already been trained on da Vinci Xi - and it is clear that the training for the da Vinci 5 for any Xi users is a delta training. And this sort of delta training should be able to happen in the hospital - as it will be primarily Buttonology. And that opens up a few important things.
Firstly you do not need to send each of those surgeons away for an extensive 2 or 3 days in lab to learn the system - safety etc etc.
Next you don’t need to train the OR teams beyond buttonology if they are Xi OR teams. It’s a delta change not a brand new learning.
So right there - training is no longer a capacity constraint that every other robot company will face. It is only DV5 “newbies” that will need that extensive first time training. And Intuitive has tons of experience and capacity to do that.
And what does that mean - well time to be proficient with the system will be almost immediate - so that is why we see those colossal procedure numbers out of the gate. But it is also a fraction of the cost to do the training. We must remember that this is so far away from the Xi roll out a decade ago. And that explains the extraordinary numbers of placements and cases. And why people looking in the rear view mirror were caught off guard by the numbers.
So when we look at the system roll out we need to sub divide those two users groups - the Xi crowd and the newbies. Think about time to proficiency, training needs, costs needs, proctoring needs, support needs in two distinct groups. They will be quite different for anyone else coming to market.
Rapid ramp up in daVinci 5 procedure numbers
You have to step back and think that the number two robot in this space - with 160 plus systems out in the market has completed a very impressive circa 30,000 procedures.
It has taken roughly since mid 2019 to today to get there. That is coming up to 6 years of use - to get to 30k procedures. And the DV 5 alone did 32,000 procedures and surpassed them in just 9 months.
Let that sink in.
32,000 procedures by 362 systems in 9 months. Or an average (be careful here) 88 procedures per system. But that is grossly misrepresented because many of the installs will have been in less than a 3 month period - and the latest installs may have been going for just a few days or weeks.
So let’s break this into simple 120 DV5 chunks Q2, Q3, Q4 for maths sake. (This is an exercise.)
Block 3 (Q4 2024) - will have done the least - say 10% of the cases. = 3,200
Block 2 (Q3 2024) - will have done the next - say 30% of the cases. = 9,600
Block 1 (Q2 2024) - will have done the most - say 60% of the cases = 19,200
Block 1 each DV5 = 160 / 9 month = 17.7 per month
Block 2 each DV5 = 80 / 6 months = 13.3 per month
Block 3 each DV5 = 26 / 3 months = 8.6 per month
Sorry for this odd maths - but what I’m trying to determine is the uptake rate of procedures - on average - for each new block that comes on line. And it is bad math because I can only assume some averages and guesstimates of % of the case loads. But what I’m showing in my own head is that we are with a DV5 - probably getting 13 plus procedures a month quite quickly. With the block 1 starting to arrive at the Xi numbers per month. I imagine that after a full year they will be getting to the same average as the Xi.
Xi 2024 numbers - average were - 22 procedures per month across all learning curve groups with a skew to experienced users with more than 12 months install.
There’s another reason I’m looking at these sorts of numbers - it’s to understand levels of case support - and to see if there is any “strange” uptake curve. In my rudimentary maths I would say that this has a profile that will be equivalent to the Xi. So next year I’ll be looking for indicators that tell me if the promise of “better work flow” actually translates into a higher monthly usage than the Xi. It is too early to tell but these rates by my bad math gives me confidence we will approach Xi run rates. (Why wouldn’t it?)
And that is going to be vastly different from any new coming competitor.
How easy is this ramp up for other companies
DV5 has broad clearances and these numbers spill across more than 40 procedural types and that is one edge that DV5 has in the USA. Any other system will come in piecemeal. A few types of procedures here and few types of procedures there.
Now that 2500 surgeons trained will be across multiple specialties - so you have a lot of users - trained - and being able to use the system across a broad swathe of procedures. In fact as you get to 20 procedures per system per month - that’s around 1 procedure per day - and you can only get to that with multiple specialties using the system in a constant fashion.
I think it will be very very hard to get anywhere near those numbers in the early years of FDA clearance for any other company, The limited number of users, the limited procedural clearances will mean very cherry picked cases. Add to that a much longer learning curve and I will predict we will see a “Doldrums” uptake of other systems. That means we might see 1 procedure per week at most or 4 or 5 per month. And that is going to be a major issue. Why?
(I am talking about regular user sites not supported clinical sites that will be special cases for workload.)
Well the biggest issue this low use rate will create will be the economics.
Any system constrained to even 5 procedures per month - with say and average of $3000 income per case - will net $15K per month revenues. If they can maintain that over 12 months they could get $180K per year - REVENUES.
With all the cost of the robot (if given on lease) - service engineers - training - support specialists for cases - etc etc- That is going to be very thin pickings per system for the first few years. And that will primarily be driven by lack of procedural breadth and numbers of users able to use the installed systems.
I don’t want to be pessimistic - but it is going to be very hard for any other company in the next 3 years to get to the sort of ramp the DV5 did. And that is going to create a scaling issue. It will roll back to how many systems per field service engineer, how many clinical specialists, how many trainers, proctors, and all the way back to manufacturing of systems in low volumes - instruments in low volumes and therefore high costs of goods. Because models will have been made many years ago on a much bigger and faster adoption. And lower numbers hurts P&Ls in many ways.
Smart to make your new product like your old product - but new.
DV5 is a better Xi. And the main advantage of this strategy is that it smells like - looks like - runs like - works like an Xi. So it gets all the clearances of an Xi. But then delivers a ton of new goodies. Smart insufflator, hand held laparoscope, smoke extraction, better interfaces, force feedback etc etc.
The downside is - it can feel like an Xi with a paint job. (To some.)
But that approach in my book was very smart. Because if it ain’t broke don’t fix it. Just make the mousetrap a little better.
On the other hand the modular robots coming to the USA and the Bed as the robot are quite rightly attempts to be differentiated. But with that comes some of the issues of regulatory clearances, user familiarity, procedural application, “it feels different” and all the training issues and costs that pile on. But it is different so people could say “I want something that is not an Xi.”
Xi clones may get a freer ride in through FDA. Being “similar to Xi” so may get simpler regulatory and broader procedure clearances out of the gate. But then unless it’s 50% less in cost - “Why?”
When I look at the DV5 numbers - in the short term it is clear the strategy worked - and worked flipping well. But if any other company Medtronic or JNJ had come with an Xi “clone” I think there would have almost been loud booing from the floor. They have to innovate - they have to be different. But that in the short term is a major challenge as stated above. And I guarantee launch and uptake numbers will be way way way lower than all the head office spreadsheets will have hoped. The differentiation approach must be seen only as a long term play. These differentiated systems can only get to the use per month metrics of a DV5 after a few years of continued 510Ks to get more procedures cleared. And to get end effectors added to match parity.
It could pay off in the long run by offering system choice, vendor choice and if the systems bring some genuine user benefits that appeal to a big chunk of the market. But the companies must play for the long game and that’s what I want to come to next.
DV5 is not a target anyone else can achieve at launch
I have been in corporate long enough to know how those planning meetings go. How numbers, and more so, expectations roll from the top. I know what was promised to get the investments and headcount. I know how those back and forth meetings went to land on aggressive enough revenues and profits to make the project worthwhile. I’ve got a T-shirt if anyone wants one.
It can be very tempting this year for leadership to look at the DV5 roll out and set expectations that when they launch in the USA - that’s the same growth trajectory they expect.
That would be borderline delusional. No matter what your (paid) KOLs have told you in lab after lab. Because when that rubber hits the road - if you think you will do anything close to a DV5 launch you will be crushed with disappointment. DV5 is an extension of the Xi numbers that go in every year. The growth in procedures every year. It is gargantuan. But comes from a different base.
But if I was in a leadership position of a rival robotic systems within a corporation - I’d be approaching this in a completely different way. I mean a radically different way.
Firstly I would ignore 100% DV5 and even Xi and all those other growth curve comparisons that BCG and McKinsey will have spouted. Even the “let’s look when Intuitive started out…” It’s irrelevant in 2025.
In fact my KPIs and dashboards would look very very different than anything you’ve ever seen before. They would be focused for at least two years on solely leading indicators related to fundamentals of the robot function.
For two years there would be no “US commercial launch” post FDA. It would be a hyper specific market approach to gain very specific information points. I would make that clear to the markets. “Don’t look at installs and revenues for two years please."
I know that the two companies are losing Market Share to Intuitive for lap surgery. But that would be a totally parallel strategy - and not linked to the robot in any way shape or form. The big danger here is that they conflate the two problems and try and solve for both in one solution. And try and solve with the same commercial infrastructure.
Instead this is two solutions to two distinct problems. And that will be the hardest thing for both companies to come to terms with… and then resolve for.
The first question for companies entering the US market is - “What does success of the robot look like?”
Not “What does success of the commercial company for open lap and robotic look like?” - That is a different solution.
Then I would break down the challenge of the deployment of robots - and work out what does the real and right cadence of deployments look like for ten year sustainability. It is one per month? One per week?
What does an adoption curve look like? Is it one procedure per week? Two per week? What is “good for me in the long term?”
What am I saying? I’m trying to say that they DV5 launch was special due to the nature of the installed base of the Xi, the particular regulatory situation and system configuration. If a HUGO or Ottava in any way base their metrics on the DV5 (or Xi) - it is going to be a rather large delusion.
If either company is thinking in terms of “what % market share of robotics can we get year 1, 2, 3 ?” - again this is going to be a mess.
And having scoured the old Auris litigation papers - there was once (note I say once) a thinking this way.
For the smaller companies - (and some like Virtual Incision, Moon Surgical and Distal Motion are already in limited launch) setting sensible “non Intuitive” internal targets is crucial. And then communicating to the markets what “success” looks like is critical. You can’t allow external companies or investors start to judge your results in comparison to daVinci 5. Again it will look sad in comparison. Managing the “What we want to achieve at launch in the USA” will be critical.
Spelling out “Our launch is to prove X,Y,Z” is essential.
What could crush you when you launch your surgical robot?
The sheer logistics that companies have to contend with on launch will be one of the gating items. Any complex capital sales will be 12 to 18 months and over 500 call points to get the purchasing body wanting to take on your robot, get them comfortable of the risk and at a point to sign a contract.
The logistics around this for smaller companies is quite challenging - time consuming and resource intensive.
Even for bigger companies - it is not easy. Medtronic already has an experience of this in the outside USA setting. I think by now they understand this complexity around the sale, shipping, implementation, and case support of a HUGO. I think they have had a good few years of learning.
JNJ with Ottava - this will be a new challenge for them. And even with their large infrastructure, contracting departments and know how - it will throw up some challenges they have yet to experience.
The smaller companies have to build that infrastructure from scratch - and it is not “copy and paste” from outside the USA. Their biggest challenge will be having a critical mass of bodies and money to throw at this. So they have to play extremely smart in goal setting - deciding locations - first user profiles etc. And employing the right team. Old Intuitive team members that sold against open and lap cases may not be prepared to fight against a perception of a vastly superior competitor.
Your product. As obvious as this may seem - if your product is not perfect when you launch - you put yourself at risk. The benchmark is so high from Intuitive and the tolerance for disruption in hospitals so low - that any mismatch here will result in big problems.
Initial enthusiasm - dawning realisation the product has major limitations - gradual decline in cases as enthusiasm wavers - hyper case selection for your robot “This case is not quite right let’s use the daVinci or do it lap today…” - general drift away and waiting for improvements. Eventually discussions about stopping the program. Or sending the systems back.
If that happens in enough initial sites - you and your robot will struggle. You actually won’t get many bites of the cherry in the USA. The tolerance will be low to waiting for you to get your shit together and re-engaging with them.
For the big companies - demonstrating that you can go to your premier accounts and give robots for free will be okay. But won’t impress. Going to places you already have massive contracts for endo-mechanical and more should be the first sites where you can get traction. I hope.
Beyond that, key teaching centres - the Mayo’s - the Baylor’s etc - the big teaching centres.
And they will all want a demonstrator of your robot. But can you show it will be a “work horse?”
Due to regulatory constraints - you may be pegged to say bariatric, or colorectal or prostate. But you will need to demonstrate that in that specialty you can get to utility rates comparable to the ten Xis sitting next door. You’ll need to show that using Hugo or Ottava in say “prostate” you can get to the same case times, workflow, usage rates as the Xi. And you’ll need to do it fast.
You may not think benchmarking is fair - but those institutions will want to do RCTs comparing your system to the gold standard. That is why they want your system. Not because they want an alternative to the Xis they have stacked up.
If set up is more complex - nursing teams and OR teams will be disgruntled. OR managers will benchmark turn over of the OR and case loads.
Imagine going to Vip Patel with a HUGO and having him run a week of cases. If he can’t get to his 8 cases per day - that hospital will be polite, but not tolerant, and quite quickly that team will revert to the Xi or DV5.
So picking - who - where - what will be on full display for the world to see. And that data gets out - and people talk - and despite the conclusions “you will help” to get to on clinical papers…such as… (I’ve written one for you to save you some time…)
“Set up time and intra operative times were comparable. Safety profile is comparable and the system worked as well as an Xi. However this is a small RCT and larger multi centre trials will need to be undertaken.”
People will look at real world data - and real world usage. And no well engineered RCTs will replace the real world volume usage. So setting yourself up for success and managing that narrative will be a primary function of the company.
The more companies can do to distance themselves from the comparisons to the Intuitive launches and uptakes and metrics - the better. Unless you are clearly better - faster - easier - and more pleasurable to use for a user. In that case - scream it loud.
The early days will be just about showing “you work” and then adding regulatory submissions - expanded indications and end effectors over the next years. Under promise and over deliver.
Set out what “win” for you means - not “Win against Intuitive.”
But what about your laparoscopic and endo-mechanical business?
Let me put the elephant on the table. According to data both Medtronic and Ethicon (JNJ) are losing stapler share, energy device share, procedure share at an alarming rate as the world moves to robotics.
And as 98% of worldwide cases that move from lap to robotic go to Intuitive - these companies are losing the battle as Intuitive wins.
I do see some efforts to retain stapler share etc - with marketing on “hand held is better” - and data wars on advanced energy etc etc. Tech wars.
And I know that the robot is a part of the armamentarium to try and stop this decline. And I get the - should an account, or a user, want to step across to robotics - they could then step across to Hugo or Ottava. And that is a possible long term strategy.
However the numbers coming out in 2024 on stapling market share (endocutters) - DV5 uptake - Xi uptake - procedural growth in robotics - does not paint a picture where Ottava and HUGO will de-facto stop that decline. As per what I said above - the rate at which those companies will realistically be able to deploy robots will not counter the erosion as Intuitive march on. And let us not forget the other 30 companies that are nibbling away at the global laparoscopic market day in and day out. They will continue to grow and take market share as well. Small but every $ hurts right…
So I believe strongly that there is a need for a radically different decoupled strategy regarding the legacy lap and endo-mechanical business.
I won’t go into that today - but I perosnally don’t see either company doing the right things that are needed to be competitive in that space. No matter what “internal think” is happening. The fight is no longer between JNJ and MDT - it is a fight for survival of lap (endo-mech) vs the rise of the robots.
And to counter that - the answer is not 50 ottava or 50 Hugo in the next 2 years in the USA. To stop that rot you need 2000 of each deployed within 2 years. And unless you plan to deploy (starting tomorrow) 2.7 robots every day for 365 days for 2 years - never missing an install…. It ain’t going to happen.
The numbers related to DV5 and Xi should be a massive wake up call that your robot cannot fix your situation fast enough. So instead, there needs to be an orthogonal strategy related to stopping the decline of that endo-mechnical market. Because it is about rate of decline until they get enough critical mass in the robotics space to be “meaningful.” ie. in 5 to 10 years.
I’ve said this before and I’ll double down. The decade ago strategy of let’s build a robot - get on the market and own 30% of this market in three years is utter fantasy in 2025. That was a pipe dream of how you would get on the bandwagon way back when. These DV5 numbers alone should put that to bed once and for all.
Instead, it is time for the big companies to have a dual band strategy of “what is a win for us in robotics?” Separate from “How do we stop the decline in lap until we become relevant.”
(I know exactly what I would do tomorrow) And a big big big (listen to what I’m saying as someone that gets a lot of private emails) - getting the JNJ and MDT team morale back up is one of the biggest strategies you need to implement today. No team with their heads down can win.
For the small companies - your mission is to show that your differentiation is valued and fits a part of surgery where you are the preferred choice over other systems. Not going to dive deep today - but I already see a few of the companies have worked that out and are implementing. Well done.
Final thoughts
I’ve done this post today to try and add some perspective on two things. Intuitive and DV5 launch is incredibly impressive. But it has to be put in perspective of their base of installs - the similarity to the Xi - the clearances - and the pent up demand for the 5th generation DV that was there since 2023. Plus this is a decade on from the Xi launch and they have a massive robot centric infrastructure in place that can handle this scale of launch and uptake. So put it in perspective.
And for those coming to market - I hope I can convince you that trying to replicate the DV5 launch in scale or size in the USA is pure folly. Instead you need your early launch plans that determine, for your robot, what success means - and set KPIs that reflect that. And think more about leading indicators for the next 5 to 10 years and not lagging indicators of installs in the short term.
With these two perspectives the companies and their management can set more realistic expectations and align the goals and rewards to these objectives. And detach this from the primary strategy of stopping the endo-mech decline (for the big two followers.)
And my strong advice is communicate - communicate - communicate. (For all companies) own the narrative in a meaningful way and determine what good for you looks like. - Then make sure all stakeholders are aligned to your “good” and not “Did you see the DV5 launch.”
These are simply observations and thoughts by the author for educational purposes only.