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Surgical Robot Wars



August 01, 2013 – Comments (3) | RELATED TICKERS: ISRG , MAKO.DL

Board: MAKO Surgical

Author: gatorswamp

I actually hold ISRG.

I am a general surgeon, and work in a minimally invasive surgery fellowship training program. I have no use for the robot in any case I do, it does not make any of them better.

This is different for urologists as sewing the urethra back to the prostate is technically demanding. Most would not have the skills for this. Maybe gyn too, they don't do as much advanced laparoscopy stuff.

In general surgery, if you can sew, the robot doesn't really help.

The pain claims are nonsense- the incisions are the same (actually 8mm in robot and 5mm for laparosocpy). Often an extra port is inserted in robotic surgery for something like a stapler which they don't make.

Less bleeding is non-sense. There is no clinical difference between a few hundred cc's of blood. You have to lose a liter and a half before transfusion is an issue. These numbers look important to a layperson, but they aren't meaningful.

Why do I hold shares? I have never seen anything like the machine that this is. Not a day goes by I don't hear about it. Surgeons are literally fearful if they don't use it they will get behind. None can explain what the benefit is. They are worried about losing their patients. Maybe they are right, I don't know. The cases take longer and are way more expensive. There is no literature. They know it takes longer but don't seem to care because they are staying up with the times. This is NOT like laparoscopy from open surgery. It is not hard to prove less pain! My resident studied a pain pump we used and it took her 50 patients and a month to do it. No difference so we stopped using it. The benefits are all suggested, but not PROVEN. It is because the benefits are small and are too hard to detect, if present at all. This thing is 15 years old! Why don't we know how it is better! It is a tool searching for an application.

I get emails all the time from the rep, I will copy the last one below. My reply to him was that indeed the ISRG reps are earning their reputation for being "threatening". Notice the email contains NOTHING about what is better about it, but gently warns of the future, they are all the same (probably one every week or two). I did not hear back from him, and wonder if he will keep sending me this stuff.

So why do I hold shares?

Simply put, I see no stopping it. It's a monopoly. The hospitals are not going to buy a different robot, no way. Everyday I hear of another person training. They are fearful of missing something that is akin to the advent of laparoscopy. Maybe they are right. One day they will make a robot that hangs from the ceiling and inserts the working ports under laparoscopic guidance. Now THAT would be cool AND save time. Right now it is only cool, and our healthcare spending keeps going up. They think they make up the cost in volume, maybe they do, I don't know. I do know the patient doesn't really benefit over laparoscopy.

The recent events with ISRG are meaningless to me. The arguments are not new, just more public. The reality is both docs and patients think robotic surgery is cool and that is enough to get this company to a certain size.

I think MAKO will grow the same way. It is a perfect tool for a doc to get industry support to start a practice, hold some seminars, and be busy right away. Of course they will proclaim it's virtues, they are probably getting paid 2-3K for the dinner where they are presenting! And they aren't really lying, we just don't know. It is easy money, and it is a popular thing to support, and they may even be right! Some guys go from one company to another doing this. I once heard a guy teach Lap Bands from Inamed one week and 2 weeks later was teaching the Realize band from Ethicon! Same guy! Unreal, they may not be wrong but it is NOT science. Don't read it as such. It is marketing.

Enough for now, here is the email, notice they still talk about the start of laparoscopy. Silly, I do all these cases laparoscopically, you just need to practice. If you can't do it laparoscopically you shouldn't be doing the robot. I have fixed lots of problems from such surgeons. They make poor decisions trying to prove themselves. You guys mention this sometimes, but this is what I actually see, almost weekly:

Hi Dr. _____,
Hope this email finds you well, not sure if you saw this article in The American College of Surgeons released on July 1st addressing a dilemma for general surgeons…the future of robotics. Will robotics enhance the ability of general surgeons to broaden their scope of practice, make the practice of surgery more fulfilling, and add value to the services provided? Based on our discussions I thought you might find value in this read.

The authors commented ( The future of robotic surgery can be determined only by probing the possibilities. To ignore the potential for extending the boundaries and safety of surgical care with robotic technology seems unwise. As a paradigm, there were many naysayers during the advent of laparoscopic surgery; time has proven them wrong…Given the much shorter learning curve, a wait-and-see approach to robotic training should have fewer adverse effects. However, several factors are influencing the early pursuit of robotics, including:
• Many surgeons have already trained in robotics and are probing the possibilities.
• Hospitals are marketing robotics as evidence that they are state-of-the-art facilities.
• Residents trained in robotics are applying for robotics credentials in gradually increasing numbers.
• The number of surgeons in the training pipeline is increasing.

Conclusion: Those surgeons who are in a position to embrace robotic training will find increasing meaningful use for the technology, which will enhance the value of the care they provide and the scope of practice they enjoy.

The advancement of general surgery applications continue to evolve and develop for the benefit of the patient. The number of general surgeons training and utilizing robotics grows daily as they seek to make an informed decision on their future in minimally invasive patient care. As you read the ACS bulletin, what are your thoughts around ACS’s outlook on the future of robotics? Could we at least meet and have you do a test drive at our _____ facility to show you some of the newer technology, if for no other reason so you can continue to stay abreast to the technology?

3 Comments – Post Your Own

#1) On August 01, 2013 at 3:49 PM, tom2727 (< 20) wrote:

I'll admit I'm in love with ISRG because I feel that robotic surgery is the future of surgery (whatever "the literature' may say about its benefits just now).  And ISRG owns the robotic surgery market now and for the foreseeable future. 

 MAKO - Maybe I just don't get this company, but it seems their robot is much more specialized than the daVinci.  Basically it's only good for one thing, right?  Where's the growth in that?  And they seem to have have very real competition from big players, (though I'm not in the industry so I don't know the landscape first hand). 

Unlike MAKO's product, the daVinci seems like it can do almost any kind of surgery by adding a few new specialized instruments (like the stapler and vessel sealer they just put out).  This provides room for growth way beyond the prostatectomies and hysterectomies they have been using it for.  And of course they are probably working on a successor robot to the daVinci, which should keep them still further ahead of the competition and open up even more possibilities for growth.

I just don't see where MAKO is ever going to amount to anything, and I don't see why so many try to hype it as "the next ISRG".  It's nothing like ISRG.  I guess the hope is MAKO gets bought by a big player and the stock pays off?  It's possible I guess.

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#2) On August 01, 2013 at 9:06 PM, captainccs (35.71) wrote:


MAKO is not the next ISRG. MAKO is the next MAKO. ;)

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#3) On August 02, 2013 at 6:39 PM, obga18 (78.62) wrote:



theyre saying theres a strong possibly that a company like mako will benefit from just places that do knee/hip replacements. no other surgeries, just dr's that specialize in this.


mako really doesnt have any big competitors, MAYBE JNJ or Stryker but it just won a big patent case. Expect shares to pop at the end of the year if they hit/succeed their mark of units sold. 

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