The minimally invasive surgery market, and associated Danish ...

The minimally invasive surgery market, 

and associated Danish opportunities 

a brief by aquilo 

Copenhagen - January 2012 

aquilo I www.aquilo.info

aquilo I www.aquilo.info 

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1) INTRODUCTION, PURPOSE AND SCOPE: ......................................................................................................... 2 

2) EXECUTIVE SUMMARY: ................................................................................................................................ 2 

3) SURGICAL DEVICE INDUSTRY DYNAMICS – THE WAY IT IS/USED TO BE: .............................................................. 3 

3.1.1 Opoly: ............................................................................................................................................ 3 

3.1.2 Approval: ........................................................................................................................................ 5 

3.1.3 Pharma/Biotech: ............................................................................................................................ 5 

4) FUTURE SURGICAL DEVICE INDUSTRY DYNAMICS - THE WAY IT IS (POTENTIALLY) GOING TO BE: ............................ 7 

4.1.1 Western healthcare systems: ......................................................................................................... 7 

4.1.2 Reduced price willingness: ............................................................................................................ 8 

4.2 Globalization & commoditization: ..................................................................................................... 9 

4.2.1 Expiring patents: .......................................................................................................................... 10 

4.2.2 EU approval process & IP prosecution: ....................................................................................... 10 

4.2.3 Demographics: ............................................................................................................................. 10 

4.2.4 What will globalization look like?: ................................................................................................ 10 

4.2.5 What will happen to the multinationals?: ..................................................................................... 11 

4.3 Innovation: ...................................................................................................................................... 12 

5) MIS INDUSTRY PERSPECTIVE: .................................................................................................................... 13 

5.1.1 MIS definition: .............................................................................................................................. 13 

5.1.2 MIS capabilities?: ........................................................................................................................ 13 

6) VIABLE MIS STRATEGIES: .......................................................................................................................... 14 

6.1 Leapfrog innovation: ....................................................................................................................... 14 

6.2 Sub-leapfrog (yet far above “face-lifting”) innovation: .................................................................... 14 

6.3 Reverse engineering: ...................................................................................................................... 15 

6.3.1 R&D cost and overhead: .............................................................................................................. 16 

6.3.2 Price point: ................................................................................................................................... 16 

6.3.3 The “made in Switzerland” twist: ................................................................................................. 16 

6.4 Emerging market strategy: .............................................................................................................. 17 

6.5 Niche indication strategy: ............................................................................................................... 19 

7) THE DANISH ANGLE: ................................................................................................................................. 19 

8) APPENDICIES: .......................................................................................................................................... 21 

* Appendix #1: Top-level analysis of Danish players ............................................................................ 21 

* Appendix #2: Competency fit, surgical disciplines, Danish players. .................................................. 28 

* Appendix #3: Collaboration matrix, Danish players. .......................................................................... 29 

* Appendix #4: Global surgical market matrix & Danish opportunities. ................................................ 30 

Appendix #5: Intuitive surgical, “Da Vinci” ........................................................................................... 31 

* For insight into these appendicies please contact Medico Innovation


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1) INTRODUCTION, PURPOSE AND SCOPE: 

Medico Innovation has rewarded aquilo with the task of producing a brief on the surgical device 

industry, and more specifically the minimally invasive surgical (MIS) segment of that sector. 

The purpose of this brief is to provide Medico Innovation with: 

a) an overview of the dynamics driving the surgical device industry. 

b) an overview of the surgical device industry with a specific focus on the MIS segment. 

c) an overview of the future viable strategies a Danish based MIS device initiative 

or company could pursue. 

d) link these global trends and strategies to specific Danish companies, institutions or initiatives. 

Ideally the above overview will enable Medico Innovation to: 

e) understand the future trends and viable strategies in the MIS segment of the surgical device 

industry. 

f) match innovative companies with physicians and/or researchers in Denmark to develop new, 

competitive MIS devices. 

It is out of scope for this brief to produce suggestions that are specifically describing new potential 

innovations - this is for the parties in (f) to examine. Nor will this brief contain calculations on revenue 

potential for the described strategies in (c). 

In (d) we shall focus mainly on delivering food for thought on which small to mid-sized Danish 

companies, institutions and initiatives that could, single-handedly or in collaboration pursue one or 

more of the strategies in (c). 

As Medico Innovation has already launched initiatives in the fascinating med-tech areas of “diagnosis & 

imaging” this brief shall exclude that part of the industry. 

2) EXECUTIVE SUMMARY: 

This brief argues that the innovation level in the surgical device industry, including the MIS segment of 

the industry, has historically produced rather modest levels of innovation when compared with other 

industries. Further, the authors present the case that the industry stands at a crossroad similar to that of 

the pharmaceutical industry a decade ago. Regardless of how swiftly the industry reacts, it is expected 

to see the industry dynamics change significantly in the coming decade. This change will be driven by: 

(a) an increasing cost pressure on western healthcare systems, (b) globalization and commoditization, 

and (c) innovation. 

For Danish MIS initiatives this could offer opportunities in most of the surgical segments. The brief 

further identifies five viable MIS strategies. 

It is recommended not to apply traditional analysis focusing on market size when determining which 

Danish initiatives could be created, but rather focus on where Danish companies, researchers and 

physicians possess know-how, and find out in which of the five viable strategies this know-how could 

yield maximum impact.


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Of the five viable strategies the brief favors: Reverse engineering strategy, Leapfrog strategy and Niche 

indication strategy. 

Finally, 20 Danish companies, research institutions and initiatives that could potentially contribute in 

creating a viable Danish MIS initiative is located, top-level research on capabilities is carried out and 

compiled in appendices 1-4. 

For insight into these appendicies please contact Medico Innovation. 

3) SURGICAL DEVICE INDUSTRY DYNAMICS – THE WAY IT IS/USED TO BE: 

When taking a closer look at the innovation that has taken place in the world of surgical devices over 

the past decades, one has little reason to be impressed. If this level of innovation (or lack of same) was 

to be transferred to the world of cars, most of us would still be driving a face-lifted version of Henry 

Ford's famous T-model. Or expressed slightly more diplomatic: One will have to search long and hard 

to find an industry where the word “innovation” occurs at such high frequency in company logos and 

tag-lines, yet, delivers so modest real innovation as in the surgical device industry. 

As a matter of fact the authors of this brief would go even further, and state that the only true innovation 

that has taken place in many of the surgical device disciplines, over the past decades, is the 

development of minimally invasive techniques and devices. Having said this one must also relativize the 

term “minimal invasive”, as it is also a marketing term that has been used and misused ever since its 

inception by device companies and doctors alike. The correct term should of course be: “Less invasive 

and potentially better for you if your surgeon has passed the point of critical mass on the learning 

curve”. We may only speculate why marketeers and doctors have chosen not to call this term by its 

correct name. 

Now, lets start with taking a closer look at the forces behind the unfolded potential for real innovation in 

an otherwise very interesting industry. As with all explanations in life, the full and complete explanation 

is multifaceted, however, when the wheat is separated from the chaff we are fortunately left with only 

three facets: 

1) “Opoly” 

2) Approval 

3) Pharma/Biotech 

3.1.1 Opoly: 

The term “opoly” refers to the ending of the competitive definition known from microeconomics in 

markets where only few companies compete. As the fast minded reader might have guessed the 

explanation “opoly” is applied here to illustrate the fact that players in the surgical device industry are 

often competing in what could be classified as duopoly-like environments.

To illustrate this point we have constructed the below Q&A: 

Q1: Who are dominating the world of orthopedic implants? 

A1: Stryker, Depuy, Zimmer. 

Q2: Who are dominating the world of interventional cardiology? 

A2: Boston Scientific, St. Jude, Cordis. 

Q3: Who are dominating the world of abdominal surgery? 

A3: Covidien, Ethicon Endo-Surgery. 

Q4: Who are dominating the world of sutures (needed for almost any kind of 

surgical intervention)? 

A4: Ethicon, (Covidien). 


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Q5: How big is the actual clinical difference between e.g. a Boston Scientific stent and 

a Cordis stent? And between Covidien stapler and an Ethicon Endo-Surgery stapler? 

A5: Small to insignificant. 

Q6: How many of the above listed companies are legally related? 

A6: Of the nine multinationals listed in the above, four are children of the same parents 

- Johnson & Johnson Medical. 

Now, you might have already figured it out, but lets spell it out now that we are at it: When looking at 

four of the major surgical/interventional disciplines (including suturing) each discipline is dominated by 

two to three multinationals, hence, the “opoly” reference. This is as close as one gets to a duopoly in a 

globalized market economy comprised of democracies with antitrust laws and cross-border 

competition authorities, who hold the honorable mandate of serving and protecting their citizens against 

big businesses becoming too big, which in-turn leads to limited innovation and high prices . . . . 

“Limited innovation and high prices”, what does that remind you of? 

When one builds on, this 21 st century duopoly-like market situation, the fact that in our little quiz above 

four of the nine listed multinationals are basically one company and further adds that the clinical 

difference between the few dominating players is insignificant, how would you think that might affect 

innovation? 

The critical reader might object that the above quiz is overly simplified and does not include all players 

and sub-specialties etc. - a criticism that is perfectly correct. One should, however, bear in mind that 

this section is not about the “full and complete industry picture”, but about the main factors driving the 

perplexing combination of modest innovation and high prices in a very profitable industry. 

Nevertheless, to add some global market statistics, that should silence potential critics of the above 

Q&A. See Figure 1 and please consider that of total global medical devices revenue in 2009, the top-30 

multinationals covered 80% of revenue generated. When isolating the top-ten multinationals, we see 

that their overall dominance equals 50%. And by further narrowing that down to the top-five, the 

dominance amounts to 33% of all medical device revenue generated worldwide 1 . Further, it is worth 

noticing that if the top-five device companies control 33% of the global device market their market 

1 Medical Markets Fact Book, 2009 and aquilo analysis


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share, in the surgical specialties where they are active (none of the top-five cover all specialties), must 

for simple mathematical reasons on average exceed 33% by far. 

Figure 1: Global top 30 medtech companies 2 

3.1.2 Approval: 

So how does the approval process affect the level of innovation? Well, the US has in the past been and 

still is the largest device market in the world making up 41% of global revenue 3 . So if you are going to 

make it big you better make it there. Obtaining a FDA approval for a surgical device can, hence, result in 

that device's revenue curve taking on exponential proportions. It is, however, even for multinationals 

with deep pockets an extremely costly and time consuming exercise to obtain the much sought after 

FDA approval. 

The argument here is that tapping into the largest and most profitable market in the world, is highly 

correlated with making or breaking it as a business. The question is, whether one can procure the cash 

and time to “sit it out”, answering question after question, going through round after round with FDA 

reviewers, hence, prolonging the process by 90 days between each round. In the world of business 

school linger this is labeled “entry barriers”. This is the second reason why we have seen a lack of 

innovation in this industry. 

To avoid any misinterpretation of the above it might be appropriate to stress that a governmental 

approval body for surgical devices naturally has it place. However, when a surgical device that has 

obtained approval by the European authorities, is required to go through a second approval process 

(FDA), that is very costly and time intensive in order to obtain access to the world's largest and most 

profitable market (the US), one has to accept that this significantly reduces the investment into new and 

innovative surgical device companies, which in turn has a negative effect on the long term innovation 

level for the entire industry. 

This leads us to the third main explanation - pharma and/or biotech. 

3.1.3 Pharma/Biotech: 

Let's start by looking at what surgery really is - with a humorist simplified twist It could be expressed as: 

Cutting bad stuff out of people with the aid of various instruments or putting some sort of functional 

implant into them so that they may live better and/or longer post operatively. 

2 Frost & Sullivan, ”Medical Device Industry: Recovering from Recession”, 2011 

3 Frost & Sullivan, ”Medical Device Industry: Recovering from Recession”, 2011


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Immediately following the above humorously twisted simplification one must on a more serious note 

express the greatest respect for the various surgical disciplines, and the men and women dedicating 

their lives to mastering them. 

The somewhat camouflaged point from the above is that due to the very nature of surgery i.e. it being a 

highly specialized craft it remains exactly that – a craft. This in turn renders surgery and thereby the 

devices used for surgery subject to a set of “natural limitations”. By “natural limitations" we understand 

the laws of mechanical physics and gravity. Now, one could argue that we are all subject to the laws of 

physics and gravity and certainly all medical treatments and natural sciences must respect these laws. 

A claim that is correct, however, this is why we specify the limitation as mechanical physics and gravity 

– a definition and limitation that is not as predominant/need not be respected in other fields like 

electronics, computing and pharmaceutics. 

Surgery has always been a mechanically driven craft and it is, hence, subject to the fact that there is 

only x number of ways in which a liver can be resected, a knee or hip can be replaced. Therefore, when 

true extraordinary innovation in the surgical field takes place one of two events often unfold: 

1) a disease that previously had no successful treatment path can now be treated surgically. Examples 

of this could cover teeth implantology, knee and hip replacements. Please note that the first generation 

of the mentioned therapies all dates decades or more back. A more recent example could be illustrated 

by Danish based Sonion Medical, who has recently developed a surgical device to treat cancer in the 

brain (human trials is currently ongoing). 

2) a disease that was previously treated surgically is now treated pharmaceutically. Examples of this 

could be schizophrenia and other mental illnesses, which were still surgical indications in the first 

quarter of the 20 th century. Other examples include GERD (Gastro-Esophageal Reflux Disease), a 

disease that was surgically treated and increased significantly throughout the 80-90's. However, in this 

day and age surgically treated GERD is facing a sharp decline, as an increasing number of GERD 

patients are treated pharmaceutically. 

As a residual of duopoly-like market 

environments, a costly path of access 

to the world's largest market and the 

role of pharmaceuticals reducing 

surgical indications, the surgical 

device market has been characterized 

by marginal innovation at the cost of 

real game-changing innovations. 

By taking “baby steps” in terms of 

innovation, the industry has actually 

been able to reshape the traditional 

Figure 2: PLC curve, with med-tech reshape 4 Product Life Cycle (PLC) as 

graphically illustrated in figure 2. 

When developing modestly improved versions of existing devices a product line is kept alive for much 

longer than it would otherwise be possible in a truly competitive market like that of cell phones, where 

product lines become obsolete in 12- 24 months. 

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The effect on the PLC curve is a quite flat decline after a device has reached maturity. This represents 

the main explanation why this industry has been able to maintain gross margins of over 80% for 

decades - many devices simply turn into true cash cows through marginal innovations, thus, moving 

along the reshaped PLC curve. 

Enough about the past and present - what will the future bring? 

4) FUTURE SURGICAL DEVICE INDUSTRY DYNAMICS - THE WAY IT IS (POTENTIALLY) GOING TO BE: 

The good news for patients, healthcare systems and in the long run probably also for the surgical 

device industry is that the future need not be an extrapolation of the past. 

When looking ahead in the surgical device industry, a few important factors seem to determine the 

future drivers in this industry: 

1) Western healthcare systems 

2) Globalization & commoditization 

3) Innovation 

4.1.1 Western healthcare systems: 

When analyzing the Western World economies, one will as expected find that dating back to the end of 

the Second World War these economies have experienced significant GDP growth decade upon 

decade 5 . Despite the fact that the Western World has become richer in real terms, we are now at a point 

where the social benefits hereunder the public healthcare systems are about to “break the bank”. 

Though this “casino terminology” might at first seem slightly inappropriate, it is nevertheless quite 

telling of the forces currently at play in all the “Old” European Countries and the Euro Zone as such. 

Admittedly, there are differences in the degree of severity in a country-by-country comparison; 

nevertheless, we are merely discussing the “degree of severity”. The variation in severity does not alter 

the fact that all the economies of the “Old” European countries are facing the challenge on how to avoid 

their social and healthcare systems becoming the “player” that “breaks the bank”. 

On a more humorous note, one could 

squeeze in that considering the current 

financial mess and bail-out issues the Euro 

Zone is facing, if it is not the social- and 

healthcare systems that “breaks the bank”, 

it will be because the private and central 

banking system will “break the bank” first. 

The “breaking the bank” issue, in the former 

Figure 3: Demographic development, Western World 6 _ ___ perspective, is indeed a two-sided coin – the 

cost side and the income side. From a cost 

perspective more people in the “Old World” will be tapping into services that are currently publicly 

funded, as the generations aged 50 and above, currently represent as much as 40% of the population 

5 OECD, National accounts of OECD countries, 2010. 

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in e.g. Germany 7 . Whereas on the income side fewer people are left to fund the publicly financed social- 

and healthcare systems. The macroeconomists label this “the challenge of the inverted demographic 

pyramid” as visualized in illustration 3. This in turn leaves the “Old World” with three main options if the 

level of publicly funded healthcare is to be maintained: 

a) Do more with less: 

The explanation lies in the heading. This option means year-on-year increases in public sector 

healthcare output combined with decreasing real budgets – not a cocktail likely to go down well with 

healthcare systems and citizens alike. 

b) Increase factor input or factor output: 

Create a biotope for new jobs creation, preferably in the private sector. This will affect the income side 

of the equation positively as more private sector employment will help fund the publicly financed 

systems via corporate and personal taxes. This will naturally not just benefit the healthcare system, but 

the entire economy in nations that are successful in navigating this path. 

or 

By replacing tasks that in today’s healthcare systems are carried out by humans with robots. This will 

potentially have a positive effect on the cost side of the healthcare system equation i.e. increase factor 

output significantly. Anecdotal evidence of such a model comes from Japan, where nurses have been 

relieved from feeding patients as this is handled by machines/robots, and overseen by a nurse 8 . 

c) Privatize: 

Finally the countries “diagnosed” with an inverted demographic pyramid will have to privatize large 

parts of their healthcare systems to achieve the much sought after efficiencies through an absolute 

advantage selection process. 

So which is it going to be? 

Well, though the way nations are likely to deal with the challenge of the inverted demographic pyramid 

in the decades to come, will include measures from all three options described above, the specific mix 

of the above measures is difficult to estimate precisely. 

The only thing we know with a high degree of certainty is that the “do more with less strategy” will be 

central to all developed countries' healthcare systems going forward, as this is the option that for 

politicians and hospital executives demands the least amount of effort and creativity to dictate 

implemented. 

4.1.2 Reduced price willingness: 

We believe that in an environment where the “do more with less strategy” dominates the scenery, the 

main challenge facing existing device companies will be what we refer to as price willingness. Price 

willingness is a measure for how much a surgeon or purchaser is willing to pay for the combination of 

device capability and perceived device innovation. 

The first sign surgical device companies come across when encountering the “do more with less 

strategy”, is the shift in power from surgeon to purchaser. Though the surgeon still has influence her/his 

power is significantly diluted, as the surgeon now has to justify her/his preference in terms of clinical 

7 OECD, Statistics Directory extract and aquilo analysis. 

8 Institut for Fremtidsforskning, Copenhagen, Denmark


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outcome to the purchaser. In a competitive environment where the real clinical difference between 

competing devices is minimal to nonexistent, such justification might prove challenging. Thus, in a 

duopoly-like environment with modest device differentiation and where the subjectivity of surgeon 

relationship and history with a specific company is taken out of the equation, or at least strongly 

reduced, which decision factor is left? 

If you whispered “price” when reading the end of the previous paragraph, you are perfectly right. Due to 

the low level of real product differentiation among the few companies dominating each surgical 

specialty, one will, in a hospital system where purchasing has been centralized and empowered, expect 

to see price becoming the main factor determining which company wins the business. 

With the combination of increased price sensitivity and centralized hospital purchasing we will also see 

more frequent tender rounds where purchasers will have the “duopoly” companies fight the price war 

against each other to win tenders that continuously become less and less profitable. As a derivative of 

the shift in decision power from surgeon to purchaser we also expect to see little or no allowance for 

price premiums on “face-lifted” devices. 

There are two main factors that have allowed the industry to stay as profitable and generate as many 

cash cows as it has: 

1) Price increases 

2) “Face-lifting” or line extensions 

It is important to understand that price increases have had a double role in generating profit to device 

companies. One is the year-on-year upward price correction to reflect or compensate for the general 

inflation in society at large. The other is the price increase that companies have been able to impose on 

what we classify as “face-lifted” devices (marginal device changes, where basic device concept is 

unchanged and clinical benefit versus original concept is statistically undocumented). In the later 

example, device companies have been able to impose “innovation” price increases of as much as 25% 

on what is, clinically seen, the same device. 

As hospitals are swiftly moving towards centralized purchasing and no longer allowing surgeons to 

decide independently on device, and thereby device company, these two important profit-drivers will 

erode and potentially disappear completely. 

4.2 Globalization & commoditization: 

The second mega trend in surgical devices is globalization. One might argue that globalization is taking 

place and based on facts from other industries already yesterday's news. This is correct when looking 

towards many consumer goods such as electronics or cars, where not only production but also 

innovation is coming out of China. However, in the surgical device industry this development has hardly 

begun yet. Some surgical device companies have invested in production facilities in China, however, 

globalization has not reached the level where a majority of devices are no longer developed and 

produced by US-based multinationals but by Chinese companies. 

Hence, the question remains: When will the surgical device industry get hit at full force by globalization, 

and what and how will that affect the market situation? 

A quite interesting question, as globalization alone would have had less of an impact on this profitable 

industry had the social and healthcare systems of the “Old World” not been under such pressure. Or 

put differently: Were we looking at a demographic situation in Europe equal to that of the 1960's,


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globalization would not be playing first violin in the symphony that depicts the future of the surgical 

industry. 

As it is not the demographic situation of the 1960’s, which prevails today, we will instead see Chinese 

low-cost versions of the surgical devices used today, flood the “Old World”. This will happen for the 

following reasons: 

1) Expiring patents 

2) EU approval process & IP prosecution 

3) Demographics 

4.2.1 Expiring patents: 

First of all, many surgical devices in the duopoly-like environments described earlier, are based on 

patents that have expired or will soon expire. This fact alone should justify our relative harsh 

introductory comments on the innovation level in the surgical device industry. This is, however, not the 

point – the point is that the combination of expiring patents and globalization most likely will spearhead 

the influx of “copy & paste” devices from China over the next decade. 

4.2.2 EU approval process & IP prosecution: 

Secondly the ease of approval for surgical devices in the EU, relatively to the US, will further assist the 

influx of Chinese “copy & paste” devices. 

The ability of European nations to follow through an effective IP prosecution towards Chinese “copy & 

paste” device manufactures who might not be eager to “sit-it-out” for 20 years is questionable, and that 

for two reasons. One being that though the EU represents a significant geographic area and economic 

power; it is comprised of 27 independent nations whose individual determination to push for change in 

China is questionable. Even as a collective (European Union) the maneuverability seems subject to 

many conflicting interests and agendas, and though on paper more powerful than the individual nations 

in the end probably also challenged in carrying through change in China. 

4.2.3 Demographics: 

Finally, the demographic reality bites again - as it is the above factors in combination with the 

demographic situation in Europe that will leave politicians and hospital executives with the dilemma of 

acting against the low-cost “copy & paste” Chinese manufactures, thus, protecting big business' (often 

US based) IP - or accepting the much needed extended hand that the “copy & paste” solutions offer in 

the battle against exploding healthcare costs. The authors of this brief are betting on the latter. 

4.2.4 What will globalization look like?: 

We believe that with globalization entering on the surgical device market at full force over the next 

decade or so we will see many of today's technologies that are non-novel, yet, still “alive and kicking” 

and attached with labels as: “highly innovative, premium devices, preferred by surgeons, best in-class 

outcomes” etc., become commodities. 

How that exactly will unfold is not easy to predict, yet, our estimate is that premium priced devices like 

DES (drug eluted stents) for interventional cardiology, stapling devices for laparoscopic surgery, 

mobility implants (knee, hip, spine) and many more will become low priced technologies developed, 

produced and marketed from China or another low cost production region.


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Today most US, Japanese and European (top three medical device markets) cardiologists would 

probably find it inconceivable to work with a DES developed and produced by a Chinese low cost 

manufacturer and back this with the importance of patient safety, company track record etc. All very 

reasonable objections, however, when looking closer at what a DES really is, then one could claim that 

it is nothing more than a stent, which by the way was invented decades ago, coated with a drug that 

further reduces the probability of narrowing of the blood stream. Admittedly, this feature represents a 

significant benefit in terms of improved patient outcomes. However, with the current and especially 

future sophistication level of Chinese manufacturing, and reverse engineering, is this really a device that 

we cannot trust the Chinese to manufacture? Must such an important and life saving device be 

marketed by a US multinational, who has its own production sites in China, for doctors, healthcare 

systems and patients to trust in it? Today yes. But in five to ten years the answer will probably be no, if 

having a low-cost Chinese manufacturer produce and market a DES, translates into price reductions of 

50% or more. 

In short, globalization will lead to a commoditization of what we today consider highly specialized and 

premium prized “technologies”, which in turn will affect the current multinationals' portfolios by turning 

many of their highly profitable cash cows into dogs. 

The reason why it is a relatively simple task for a cash rich investor (or country) to commoditize the 

surgical device industry is not only globalization, it is naturally also a residual of the strategy chosen by 

the industry decades ago. The decision we are referring to, is the choice to follow the very profitable 

“marginal innovation strategy”. As with all profitable strategies, this one will eventually outlive itself, 

which is probably what the industry will experience over the coming decade. 

4.2.5 What will happen to the multinationals?: 

An interesting question indeed. Interesting as the combination of globalization and commoditization will 

lead to a range of different outcomes for today's leaders in the surgical device industry. Some will come 

out stronger than ever before, others will be marginalized compared to their current position in the 

market and some might fold completely. 

Those who will take the legal path against the low cost “copy & paste” device companies, will most 

likely be fighting a battle already lost, and hence be the companies that will benefit the least from these 

new market dynamics. And even if they win a legal case or via an army of lobbyists succeed in having 

the US Congress and/or the European Parliament impose sanctions against the “copy & paste” 

companies or countries harboring these “profit busters”, they will most likely loose the battle of the 

public opinion in their traditional markets, leaving behind an image of profit-hungering multinationals 

that prevent tax payers access to affordable surgery. 

The other group, who has already read and understood the writing on the wall, will be re-inventing their 

innovation strategy and in some cases find their way back to what they originally were – truly innovative 

surgical device companies. 

In between these two scenarios lies a variety of strategies and outcomes of which the most interesting 

probably is the strategy of “cannibalization in due time”. This strategy builds on current market leaders 

tapping into a commoditized market by producing their own low-cost versions of their existing product 

lines or alternatively entering into some sort of legal relationship with the “copy & paste” companies 

(joint venture, majority or minority stakes etc.) and thereby gaining a foothold in this strong future 

segment.


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4.3 Innovation: 

As briefly mentioned the third and final derived dynamic from the combination of inverted demographic 

pyramid and the following cost pressure on healthcare systems, globalization and commoditization, is 

innovation. 

How does an industry that has been globalized and commoditized develop further? Well the answer is 

simple: Through real and significant innovation. 

Critics might object that after an industry has been commoditized follows a period with no or limited 

innovation. This might be correct for commodities like coffee - originally a luxury and premium priced 

product that after hundreds of years of premium status, became a commodity during the 20th century. 

Yet, one must not forget that the commodity status was not maintained for long as true innovators 

marched in and re-invented the coffee industry both in terms of machines and end products (drinks 

containing coffee). When looking at the history and development of coffee, it seems fair to state that it 

went from being a pure luxury product to being a pure commodity product. Yet, revived into the 21st 

century with two main product lines: a commodity- and a luxury line to the benefit of a broader range of 

consumers. 

The mindful reader will recall that, we earlier on stated that the change in market dynamics which we 

stand before embodies the good news for patients, healthcare professionals, public healthcare systems 

and the surgical industry at large. No doubt cheaper mobility implants and stents are beneficial to 

public healthcare systems and privately funded patients, but how can this change be beneficial to the 

surgical industry? Is it not, from a purely financial perspective, the almost beautiful symphony of high 

unit prices, marginal innovation strategy and thus extended PLC-curves, spiced up with a natural and 

anti-cyclical procedure growth averaging 3-5% per year that have led to significant wealth creation 

among the top-10 device companies? 

The reason why we argue that this change can be beneficial to the industry is that the “survivors” will 

come out leaner, meaner and more innovative, which in it self is positive. On top of this the survivors will 

also avoid going through the unfortunate mix of public embarrassment and self torture that the 

pharmaceutical industry has/is going through. The pharmaceutical industry had for years been at the 

stage where the surgical device industry is today. Incapable of understanding, embracing and acting on 

the fact that it had become complacent and thought to have earned a right to maintain abnormally high 

profit levels. Hand-in-hand with this lack of understanding came a lack in capabilities to address this 

matter with appropriate measures, resulting in an embarrassing fight to cling on to “the way it used to 

be” through various lobbyists, infomercials etc. – a battle that was clearly lost on several fronts and if 

nothing else it was certainly lost to the public opinion, and more importantly to the producers of generic 

pharmaceuticals. 

If you feel like countering that statement then think about what springs to mind when thinking about the 

pharmaceutical industry. Or even better ask a handful of people that same question. Answers will, if 

your “sample group” is not biased, most likely contain vocabulary like: ”greedy, un-trustworthy, i am 

skeptical of stuffing myself with chemicals, they are pushing indications to sell more”. 

One may also want to consider how the, by Danes perceived, best behaved kid in class – Novo Nordisk 

– has recently been questioned in relation to allegations of pushing off-label usage of its Novo-Seven 

product. Another recent Danish case is Lundbeck's anti-depressive – Cipramil – which was allegedly 

prescribed to teenagers with fatal results.


13 



The point is that if no change were to come to the surgical device industry it would travel down the 

same torturous road as the pharmaceutical industry did. The surgical device industry now stands at a 

crossroad, which depending on which path is chosen has the potential to revive an entire industry. Even 

if the entire industry should choose to go down the “pharmaceutical” path, significant change in the 

industry can be expected – the much needed change will, however, be longer on its way and instead of 

a swift, deliberate and profitable change, look more like that of the commoditization and later 

rejuvenation of coffee. 

Having discussed the main trends in the surgical device industry, we can now add the discussion of 

how these mega trends will influence the market for MIS devices. 

5) MIS INDUSTRY PERSPECTIVE: 

Most MIS devices are developed and produced by the very companies also producing non-MIS surgical 

devices, hence, the MIS innovation trends are, to a large extend, victims of the same limitations and 

trends described above. 

5.1.1 MIS definition: 

Lets first look at the definition of the term MIS. As mentioned in the introduction the MIS definition has 

been used and mis-used by companies and doctors alike. In this brief we shall however work with a 

definition as follows: Minimally Invasive Surgery are devices or methods leading to significantly: 

- Reduced pain levels 

- Reduced hospital stay 

- Reduced healthcare cost 

- Improved patient outcome 

- Improved patient quality of life 

One could object that this is a somewhat wide definition - which it is. Nevertheless, we deem it 

reasonable to look at MIS in a broad perspective, in order not to corner Medico Innovation's efforts this 

early in the process. 

5.1.2 MIS capabilities?: 

Having settled this, lets get practical about what this means by starting out with looking at a MIS 

technology which is not directly related to the “old” multinationals, yet, potentially offers MIS 

capabilities across a wide range of surgical interventions: Robotic Surgery embodied in Intuitive 

Surgical's Da Vinci Robot (appendix 5) - a great piece of technology that allows for precise dissection, 

3D capabilities, remote surgery and much more. When examining Intuitive Surgical's list of areas and 

procedures where the Da Vinci Robot's MIS capabilities can be utilized, it is difficult to imagine a MIS 

technology available today that surpasses the Da Vinci Robot. 

Does this technological wonder fall under the above interpretation of MIS? The answer to this simple 

question is less simple, wherefore; this discussion is carried out in appendix 5 (a), where we share two 

anecdotes. 

We hope that these two anecdotes and discussion around the Da Vinci Robot, in appendix 5 (b), 

illustrates well the challenges in evaluating true MIS capabilities and, thus, the challenges of developing 

true MIS devices. 

Regardless of the authors critical, yet, hopefully objective assessment of Da Vinci as a true MIS 

technology across a broad range of procedures, it remains clear that with this technology surgery has


14 



taken a step towards a potential revolutionizing future. It remains to be seen if it will be in the form of a 

robotic console or whether some of these new features developed by Intuitive Surgical, will be further 

enhanced and applied in the traditional laparoscopic devices, and to which extend Intuitive Surgical will 

be able to financially benefit long-term from the innovations it has become a first mover within. 

6) VIABLE MIS STRATEGIES: 

It is in these difficult and stormy waters of expiring patents, questionable IP protection, inverted 

demographics, globalization and challenges of documenting real MIS capabilities, we must define the 

strategies of the new MIS initiatives Denmark is to produce and thereby decide which battle fields we 

want our MIS companies to conquer. Understanding the main trends and triggers in the surgical device 

market we can now start defining the strategies most likely to be successful over the next decades. 

Lets begin with confirming that the MIS market looks attractive - from abdominal surgery we know that 

this market is growing at 10-15% annually where as the non-MIS abdominal surgical market averages 

3-5% annual growth 9 . It seems fair to assume a similar growth pattern in the other surgical specialties. 

6.1 Leapfrog innovation: 

At this level of innovation one needs not worry about the degree of surgical invasiveness – because 

here we are talking about surgical innovation that makes the blind see, the deaf hear or the paraplegic 

walk. This level of innovation is what everyone be it nurses, doctors, engineers or business people in the 

surgical industry dares only dream about in a quiet and private moment, before we are brutally taken 

back to reality by our own common sense. This is a shame - not only would a (partial) reconstruction of 

a broken spinal cord or reconnection of nerves represent an unimaginable positive to patients affected 

by paralyzation. It also makes sense that the described impairments could be improved through 

electromechanical innovation, as they are all results of damages that lead to some sort of 

“electromechanical circuit shutdown”. To cure or improve these impairments, it is probable that one will 

have to look towards sophisticated electromechanical techniques and devices. Further down this line of 

thinking we find the “joker” of stem cell research, where one day some human “spare parts” might be 

available in an injectable substance that will regenerate damaged tissue and organs. It could prove 

“less of a challenge” or “faster” to produce improved outcomes via electromechanical 

techniques/devices/implants, than via stem cell research. 

Needless, to say that if one can produce innovation that makes the blind see, the deaf hear or the 

paraplegic walk - one has a pretty strong concept by all measures. At these only too rare levels of 

innovation one would even expect to see a swift FDA approval process. 

6.2 Sub-leapfrog (yet far above “face-lifting”) innovation: 

This strategy involves significant improvements in terms of one or more of the MIS definitions above 

(significantly reduced: pain, hospital stay, costs, and/or improved: patient outcomes, patient quality of 

life) but does not necessarily change the intervention as such. A good example of this would be 

prostatectomy by laparoscopic Da Vinci technique, here the surgical procedure is not really changed, 

yet, the application of enhanced vision capabilities and thus more precise dissection capabilities lead to 

better outcomes. The previously discussed DES (Drug Eluted Stent), would likewise be an example of 

what we would label as “sub-leapfrog” innovation. 

The main challenge with this kind of innovation, apart from developing the idea, is to actually finance 

the clinical study that proves the concept: (a) safe and (b) significantly beneficial to patients. 

9 aquilo analysis based on industry interviews


15 



6.3 Reverse engineering: 

This strategy carries a low degree of real innovation and is rather a question of being innovative or 

creative in manufacturing and sales force excellence, thereby beating the multinationals in the coming 

tenders and thus becoming a profit- and “opoly” buster. 

Though, one has to acknowledge that this strategy is neither glorious nor honorable in terms of 

innovation, we will argue that this strategy from an investor perspective is quite exciting indeed. The 

answer to this somewhat counterintuitive argument lies in recalling that it is the stormy waters depicted 

above on which western healthcare systems are to navigate in the coming decades. Hence, by 

identifying the highly profitable existing MIS devices where the core of the technology has not evolved 

significantly over the past decades, and bringing “copy & paste” versions of these devices to market, 

one can cater to a new and upcoming demand pattern. A demand pattern that is dominated by publicly 

financed hospital executives that need to deliver more treatments with reduced real term budgets. 

Some readers might produce a slight frowning when reading about this strategy, thinking, “well is that 

not what some Chinese companies are already doing – so why would we go down that path”? 

Yes, there are some Chinese manufactures that have gone down this path with mixed results. Much of 

the reverse engineering that is established, is based around the segment where unit prices could be 

described as low to medium. What we have seen in the “copy & paste” MIS segment are devices like 

the laparoscopic access ports, which from a market leader like Johnson & Johnson are priced around 

USD 80-150 per unit (average usage per procedure = approximately USD 300). What we are still to see 

are “copy & paste” versions of the Zimmer knee implant, the Covidien endoscopic stapler or the Boston 

Scientific drug eluted stent – where each of these implants or MIS devices are priced in thousands of 

dollars per procedure. 

The explanation why these higher priced devices have not yet seen much competition from the Far East 

is probably multifaceted. However, one reasonable and significant explanation would appear to be a 

reluctance among surgeons and healthcare professionals towards using Chinese produced devices that 

are to last for 20 years or more. Whether this reluctancy is justified or not is of less interest for this 

strategy - as with many other aspects of the 21st century we have to accept the fact that “perception is 

reality”. 

What we are proposing is indeed to create “copy & paste” devices in the segment where a combination 

of high unit prices and high volumes are flourishing and where the core technology patent protection 

has expired or dates a decade back. 

How would a Danish based initiative be able to take up the “copy & paste” battle with all mighty China? 

And how should one go about the challenge of delivering devices that offer significant cost reductions 

yet a similar quality to that of the established multinationals? Naturally, beating the Chinese at their own 

game requires a certain degree of savvy. Lets begin by looking at why a Danish based initiative could 

fair better than a Chinese based solution. 

In today's world we possess equal portions of admiration and fear for the Chinese industrial and 

technological express train coming at us. We appreciate the cheap consumer products coming out of 

China, yet, we are less appreciative of the jobs that “has gone and will continue to go east”. But we are 

outright fearsome of what the Chinese are going to do with all that excess cash – a pile of cash that 

seems only to increase by the hour. Will they “buy” your country or a country close to you next year? 

This “fear factor” combined with the quality perception of “made in China” comprises two important 

pillars in beating the Chinese at their own game so to speak.


16 



We are thus arguing that there exists an increasing animosity towards Chinese produced goods, an 

animosity that is unlikely to decrease over the next decade, as the European recession is likely to 

worsen and potentially lead to a breakup or reduction of the Euro Zone, which in turn will increase 

national debt levels to China. Should this situation progress it is probable that even 7th grade school 

kids will understand that what drove European nations into Chinese “ownership” was the combination 

of (a) fiscal negligence and (b) an artificially maintained low Yuan which has fueled the Chinese export 

Eldorado – or expressed with an extra portion of sarcasm: The artificially maintained low Yuan is the 

reason China can “buy your country with your money”. 

In order to be successful at this strategy, one would have to apply consumer look-a-like marketing 

techniques towards hospital executives playing the “based in and produced in Europe card”. 

If a Danish based company cannot produce its “copy & paste” MIS devices in China, how is one to run 

a profitable business? There are many reasons why such a solution might be as profitable or even more 

profitable than the multinationals currently marketing such MIS devices and also more successful than 

the Chinese based devices. We shall discuss the top two reasons in the below and add a little twist as a 

third option: 

1) R&D cost and overhead 

2) Price point 

3) The “made in Switzerland” twist 

6.3.1 R&D cost and overhead: 

First of all when one implements a “copy & paste” strategy the R&D cost should by definition represent 

only a fraction of the original R&D cost (carried by the multinationals). Secondly, when competing 

against the multinationals with copies of their own portfolio in a hospital environment as described 

above, one needs less sales people trying to sell marginal and insignificant device differentiation. In this 

kind of environment quality relative to price will, ceteris paribus, be the main sales driver. 

6.3.2 Price point: 

What this also translates into is that the “copy & paste” MIS device need not be of the exact same 

quality as the original – it merely needs to be “close enough”. Likewise the price point need not be one 

tenth of the originals - a 25-40% price reduction will suffice as long as the quality is “close enough”. To 

draw an analogy from the world of European commercial airliners, one could state that to be successful 

with this strategy one need not become the Easy Jet or Ryan Air of MIS companies – becoming the Air 

Berlin will not only do – it might be the more successful strategy. 

A real life example of a company that has successfully implemented this strategy could be represented 

by UK based Purple Surgical, founded in year 2000, it has taken basic MIS devices (low to medium unit 

priced devices) in the field of laparoscopy, applied the “reverse engineering” or “copy & paste” strategy 

into a new, less expensive, yet, good enough quality product range. 

A US-based example that has gone down that same route is Applied Medical, which allegedly, has 

surpassed Covidien in terms of market share for laparoscopic access ports in the US. 

6.3.3 The “made in Switzerland” twist: 

Having covered the basics of R&D, overhead and quality versus price point, we are left with the last 

interesting factor – we call it the “made in Switzerland” twist. It is hard to think of a label that by 

consumers across the globe is regarded as highly as the “made in Switzerland” label. If “made in


17 



China” is attached with a certain association, the “made in Switzerland” automatically provokes the 

exact opposite association in our minds. Though “made in Germany” also scores high on the quality 

perception score it does not match that of the Swiss. Now, this is truly peculiar as we all know that 

German build “stuff” embodies “best in class” quality and engineering precision second to none. In fact, 

Swiss manufacturing DNA is based on German engineering. Hence, the “made in Switzerland” label is 

certainly among one of the largest marketing victories carried out by a single nation (consisting of only 

seven million people). 

The interesting point is that nowadays an increasing number of Swiss made consumer goods are 

produced in China, so the “made in Switzerland” would now at best relate to “designed by a Swiss 

based company”. Obviously this is not as quality catchy as “made in Switzerland”. So, how do some 

consumer goods companies get around this? They leave the little legally obliged label “made in China”, 

however, they put the good old Swiss flag on the product – which is probably even stronger than the 

“made in Switzerland” tag as the flag represents a visualization, a symbol of “made in Switzerland”. 

How does this little consumer anecdote relate to our business-to-business reality of MIS devices? Well, 

one can indeed be a European based MIS “copy & paste” device company and outsource device 

production to China – one must, however, assure to use the “flag” appropriately in the marketing of the 

company and the company's product line. 

Should one decide to go down this path it is important to recall that there are also low cost production 

countries inside the EU. Admittedly China is still outperforming low cost European countries by a factor 

of about 1:5-8. However, this does not include the “cultural” challenges of outsourcing production to 

China, increased transportation cost etc. 

The authors of this brief strongly believes in this strategy and have little doubt that a decade from now 

we will see quite a few “opoly” & “profit-buster” MIS companies thriving, creating employment and 

becoming an integral and respected part of the industry. The question that remains is who in Denmark 

will have the guts to go down this path? If Danish device companies can muster the courage to follow 

through on this strategy, we could see some relative quick wins and fast growing companies to the 

benefit of Denmark, healthcare systems, patients and eventually also to the benefit of the industry as 

this will force the multinationals to reinvent themselves. 

6.4 Emerging market strategy: 

This strategy shares many traits with the “reverse engineering strategy”. One could argue that the two 

strategies are indeed siblings - not twins, just siblings. 

Whereas the “reverse engineering strategy” focuses on producing “copy & paste” versions of top of the 

line MIS devices and market these at more reasonable prices than currently, the “emerging market 

strategy” focuses on producing outright inexpensive devices. 

The rationale supporting this strategy naturally has its offspring in the growth rates of countries like 

Brazil, Russia, India, and China (BRIC). Countries that on a GDP per capita basis might be considered 

relatively under privileged when compared with the “Old World”, nevertheless, these countries and this 

category of countries have undergone significant economic development over the past decade. This 

development has also led to an increase in healthcare availability in these countries. 

As it is common knowledge that several emerging markets have enjoyed impressive GDP growth rates 

and are likely to continue to present GDP growth above the six percent mark in the coming years, we


18 



shall not dwell further in justifying the attractiveness of these markets 10 . Instead we shall discuss further 

the factors driving the need for inexpensive MIS solutions and the potential reward to companies that 

can deliver such solutions. 

The combination of relatively modest GDP per capita levels and the variability in healthcare systems in 

emerging markets are the factors driving the need for inexpensive MIS devices. The word “variability” in 

this context could be replaced with “creative payment models”. First of all, surgery is rarely hundred 

percent publicly funded – not even in publicly run hospitals. As a minimum some kind of unofficial 

payment to the surgeon and often also to the anesthesiologist has to take place prior to surgery. In 

some emerging markets, it is even common practice that patients wishing to have their procedure 

carried out by MIS-technique are equipped with a “shopping list” of which devices to buy directly from 

the company/distributor and asked to bring the devices to the hospital on the day of surgery. 

When considering the current price level of MIS devices and especially the scenario above it is no 

wonder that the penetration rate of MIS techniques is faltering in emerging markets. However, the low 

penetration rate of existing MIS techniques in emerging markets and the GDP growth rates, see figure 

4, are also the factors fertilizing the future possible success for companies that can produce 

inexpensive MIS devices. 

To further illustrate this point, a Chinese university hospital or regional hospital carries out as many 

surgical procedures within one specialty as is carried out by all surgical units in Denmark in one year. 

Any MIS device company might very well be content having established a market share of say 50% in 

Denmark for a specific procedure, which in turn would translate into a range of surgeons working with 

the specific device in about ten of the country's largest hospitals. The point is that, could the same 

company produce an inexpensive version of an existing MIS device, it could by getting this into one 

Chinese hospital sell twice as many devices as it sells in the Danish market. 

China 

India 

Russia 

Brazil 

GDP, projection vs. actual, USD trn 

0 1 2 3 4 5 6 

USD trn 

Figure 4: 2010 GDP projections vs. actual 11 

In the last section we used Air 

Berlin as a consumer product that 

could well reflect the “reverse 

engineering strategy”, if we were to 

apply a similar consumer analogy 

in summarizing the “emerging 

market strategy” it would be to 

develop MIS devices, reflecting the 

cost level and philosophy of the 

Nano Car from Indian based TATA, 

a USD 3.000 modern city car. 

From figure 5 one should be able to derive one simple message: Forget about importing cheep “stuff” 

from India and China, if one can sell “stuff” to the Chinese and/or Indians, one need not worry much 

about the US. Hence, Mr. Sinatra's “if I can make it there, I can make it anywhere” might relate better to 

Shanghai or Delhi than New York. 

10 Medical Markets Fact Book, 2009 

11 Goldman Sachs, Economist, December 2011 

2010 actual 

2010 projection (2003)

USD m 


12000 

10000 

8000 

6000 

4000 

2000 

Figure 5: BRIC medical market value forecast 12 

19 



6.5 Niche indication strategy: 

This strategy is, as indicated by the headline, a rather narrow strategy both in terms of volume and 

geography. The multinationals is of course mostly interested in developing devices for indications that 

are characterized by being crucial and frequent. The “niche indication strategy” aims at a different 

combination: Crucial indication but low volume. The main business reason why Danish MIS companies 

should consider such a strategy is that the competition in this field in most cases will be modest to 

nonexistent, which in turn is explained by low incident rates. Such a dynamic can be extremely 

profitable for a, seen in a global perspective, small device company. 

An example of a Danish based company that has pursued this strategy is Aalborg based Neurodan, 

who produces a, compared to other technologies, minimally invasive implant treating the relatively low 

incident disease “foot drop syndrome”. 

Companies that pursue this strategy might find themselves in a monopoly-like market situation, due to 

the combination of addressing crucial indications and low incident rates, which in turn is a warranty for 

abnormal price and profitability levels 13 . 

7) THE DANISH ANGLE: 

Having thoroughly discussed viable future strategies and trends, this final section can be sliced sharply. 

Traditional analysis would start out by determining which therapeutic area that should be addressed. 

When glancing at appendix 4 it is evident that the largest therapeutic area is cardiology and thoracic 

surgery which, with an annual global revenue of USD 56bn, comprises about one fifth of the global 

medical device market. Taking a closer look at this huge market might be relevant for multinationals, 

however, considering that this brief is meant as food for thought for existing and up and coming Danish 

device companies, applying market size as the main selection criteria seems to make little sense. 

Instead we would argue that it would, as a first step, make more sense to estimate which Danish 

companies could independently or in collaboration successfully pursue one or more of the future viable 

strategies discussed above. 

This has been summarized in appendices 1 - 4. 

0 

BRIC, medical market value forecast 

2009 2010 2011 2012 2013 2014 

For insight into these appendicies please contact Medico Innovation. 

12 Medical Market Fact Book 2009 

13 Neurodan charges EUR 20.000 per implant, which is 3-5 times that of a knee implant. 

China 

Russia 

Brazil 

India


20 



In these appendices we have identified companies, institutions and initiatives in Denmark, ranging from 

current MIS manufacturers over stem cell technology to non-medical device material experts, that 

include one or more of the following characteristics: 

a) poses technology that if commercialized into a MIS device would match one or more of the 

___five viable strategies, discussed above. 

b) poses capabilities that if paired with other Danish companies, institutions or initiatives could 

___develop MIS devices that would fall into one or more of the five viable strategies, discussed 

___above. 

Based on our top-level research of the current Danish capabilities, appendix 1-3, It is our preliminary 

recommendation that Denmark should focus on bringing companies and researchers together to create 

initiatives that can pursue opportunites with in the: 

1) Reverse engineering strategy 

2) Leap frog strategy 

3) Niche indication strategy 

It is with in these strategies that we believe Denmark will be able to create significant results and 

position itself in the world economy of MIS devices. 

The in-dept discussion of why exactly these three strategies are most likely to deliver export successes, 

new jobs and help improve health economic outcomes for health care systems across the globe, we 

shall be pleased to discuss during a personal meeting.

Appendix #5: 

Intui/ve Surgical, “Da Vinci” (a) 

Appendix MIS capabili/es?: 

Does this technological wonder fall under the above interpreta6on of MIS? Well, yes and no – no doubt that this MIS technology has, a?er 

more than ten years in the market, finally found some true jus6fica6on. Based on surgeon interviews conducted by aquilo there seem to exist 

consensus among surgeons that beHer pa6ent outcomes are achieved for e.g. prostatectomy due to the possibility of more precise dissec6on, 

hence significantly reducing trauma to vital structures. 

But that is about it. From here there seem to be as many opinions about the technology as there are surgeons. Hence Intui6ve Surgical's claim 

that the Da Vinci Robot is also fantas6c for: Bariatric, colorectal, cardiac and many more procedures, could not be supported through the 

interviews carried out with different surgeons. 

Bariatric surgery (also known as obesity surgery) is at the top of Intui6ve Surgical's “General Surgery” list of interven6ons where the device 

offers significant benefits. This might be, if your surgeon has passed the learning curve and one is not among the pa6ents that are included in 

the learning curve. Well, the learning curve aspect is always present when implemen6ng a new technique, should technologies like the Da Vinci 

Robot not be allowed to have that learning curve? 

Indeed it should. 

However, through the below anecdotes we will illustrate the challenges of dis6nguishing between true MIS and marke6ng or perceived MIS: 

In the first anecdote a bariatric clinic was adver6sing for “the safest surgery in town” as the clinic was offering Robo6c Surgical Implanta6on of 

a gastric band to obese pa6ents – so what? Is it wrong to adver6se for Da Vinci surgery? Well, in an experienced bariatric surgeon's hands an 

implanted gastric band by tradi6onal laparoscopy, also a MIS technique, will take on average 30 minutes (the really experienced o?en go as low 

as 20 minutes). Because of the complexity of opera6ng the Da Vinci robot and changing instrumenta6on during surgery, gastric band 

implementa6on in this clinic averaged three (3) hours. Even an unexperienced bariatric surgeon will be able to implant a gastric band 

laparoscopically in about one and half (1,5) hours. 

Another Da Vinci case related to the more invasive bariatric procedure, gastric bypass, paints a similar picture. In this case a clinic decided, for 

scien6fic and research purposes, to operate with the Da Vinci Robot. The average opera6ng 6me for this group of surgeons by tradi6onal 

laparoscopic technique was around two and a half hours. When first switching to perform the gastric bypass with Da Vinci, the opera6ng 6me 

exploded to around five to six hours. It was only a?er more than three years of experience and 300 Da Vinci gastric bypass procedures that this 

team managed to get the average opera6ng 6me down to a level that mirrored that of their tradi6onal laparoscopic gastric bypass procedures. 

And so what? Well, 6me is always a factor and especially in pa6ents undergoing bariatric surgery. One should consider that these pa6ents are 

high risk pa6ents, due to their complex disease paHern. Though bariatric pa6ents are operated for extreme overweight (one medical 

condi6on), many of these pa6ents also show up with a variety of co-‐morbidi6es (mul6ple medical condi6ons) further complica6ng surgery. To 

give the reader, who might not be familiar with the disease picture of bariatric pa6ents, a quick overview of what we are talking about one 

should note that apart from extreme overweight, bariatric pa6ents o?en suffer from hypertension, diabetes, damaged/warn down joints, 

sleep-‐apnoea and more. 

On top of this, one must add that during a tradi6onal laparoscopic or Da Vinci laparoscopic opera6on the pa6ent is on her/his back, 

anesthe6zed, ven6lated and “tossed around” from side to side – from extreme an6-‐trendenelburg to extreme trendenelburg posi6ons (from 

siang upright to having the upper-‐body in 35 degree ver6cally inversed angel). How do you think opera6ng 6me maHers to this kind of 

pa6ents? Well, some bariatric surgeons' rule of thumb is that if a laparoscopic procedure in bariatric pa6ents cannot be carried out in less than 

three hours conver6on to open technique should be standard opera6ng procedure, hence assuring that the opera6on is terminated within the 

3,5-‐4,0 hour mark. 

Knowing this, how would you appreciate being among the first 300 pa6ents in the above anecdote? And we have not even discussed the 

monetary cost factor yet. 

The monetary part of the anecdote comes in two parts: First there is the extra 6me consump6on where the same team of surgeons, 

anesthesiologists, nurses etc. could have carried out more opera6ons, then there is the amor6za6on of the DKK 10-‐12 million Da Vinci Robot 

price-‐tag (instrumenta6on excluded). 

The authors of this brief hold conflic6ng views on technologies like Da Vinci in rela6on to MIS capabili6es. On one side it is inarguably a great 

piece of technology that in e.g. prostatectomy procedures offers MIS capabili6es beyond what is achieved by tradi6onal laparoscopy. However, 

considering the examples of gastric bypass or the horrendous example of gastric banding one must ques6on the true and broad level MIS 

capabili6es of this technology. 

Regardless of the authors cri6cal, yet, hopefully objec6ve assessment of Da Vinci as a true MIS technology across a broad range of procedures, 

it remains clear that with this technology surgery has taken a step towards a poten6al revolu6onizing future. It remains to be seen if it will be in 

the form of a robo6c console or whether some of these new features developed by Intui6ve Surgical, will be further enhanced and applied in 

the tradi6onal laparoscopic devices, and to which extend Intui6ve Surgical will be able to financially benefit longterm from the innova6ons it 

has become a first mover within. 

We hope that these two anecdotes and discussion around the Da Vinci Robot illustrates well the challenges in evalua6ng true MIS capabili6es 

and, thus, the challenges of developing true MIS devices. 

aquilo Ι www.aquilo.info 31

Appendix #5: 

Intui/ve Surgical, “Da Vinci” (b) 

Source: Intui-ve Surgical 

aquilo Ι www.aquilo.info 32

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