Interview with Verb Surgical's CEO
"Late last year, Verb Surgical,
a joint venture between Verily (formerly Google Life Sciences) and
Johnson & Johnson’s Ethicon division was formed with the intent to
change the paradigm of robotic surgery established by pioneers like
Intuitive Surgical.
The entrance
of Google (now Alphabet) into any industry is noteworthy, and since
March 2015, when the initial announcement was made, a flurry of articles
has tried to divine from press releases, J&J’s earnings calls, and interviews with former Google scientists, what exactly Verb Surgical has set out to do.
The name, by
the way, very deliberately plays on the idea of action. Or actions that
matter and empower surgeons, to be more precise.
Now, in a
phone interview with Verb Surgical’s CEO Scott Huennekens, previously
the CEO of Volcano Corp., a picture begins to emerge about the Mountain
View, CA, company. Although many details are missing, it's clear that
Verb is seeking not only to rewrite the rules of robotic surgery, but
also alter the very definition of what surgery has come to mean.
The Q&A below has been edited for readability and clarity.
MD+DI:
We’ve heard a lot of buzzwords about Verb Surgical - machine learning,
analytics and advanced imaging. If I am a surgeon, what can I get from a
Verb Surgical robot in the future that I am not getting today?
Huennekens: First of all, we think of us not as a
robotics company but as a surgical platform company. If you think of
open surgery as Surgery 1.0, minimally invasive surgery and laparoscopic
surgery as Surgery 2.0, robotics surgery as 3.0, we really think that
the next era is 4.0. We call it digital surgery and physicians call it
digital surgery as well.
Instead of
having robotics that is used in just 5% of procedures and it’s like a
mainframe computer, we’re thinking of robotics like it’s a PC. It’s
always there, it’s always on.
So, it’s
lower cost, it’s more accessible to you. And then in combination with
that, there is advanced visualization and next generation technologies
that start to give you differentiation of tissue. It could be the
anatomy of the tissue, the tissue state or tissue type and surgeons
start having information to inform their decision-making.
They can
also have that co-registered with current live imaging - whether its
ultrasound, X-rays, or pre-operative imaging – and can start thinking
about planning surgeries and executing them based upon this information.
Surgeons
will also have advanced tools and instrumentation. So what you would
have is all that information but not in its individual silos where
Medtronic/ Covidien has these instruments and Karl Storze has this
visualization and somebody else has a table and somebody else has
robotics arms.
We want to
eliminate silos and bring all these together in a seamless solution and
then also have algorithms for decision-making.
I don’t want
to get into too many of the details that we are working on for
competitive reasons, but the integration of all those components
together and the solutions around procedures, is what we are looking to
do.
You’ve heard of Moneyball
and you may have even seen the movie. There’s moneyball for baseball
players. You may think of us as developing algorithms and information,
so it’s moneyball for surgeons.
In surgery,
it’s been a cottage industry so to speak where you had an apprentice who
learned from a master and that’s the way things evolved. So there is a
lot of disparity of performance in surgeons. There’s a lot of disparity
in the way procedures are done. What we believe is you can use
information and more standardized processes in surgery, just like any
manufacturing process, to increase quality, lower cost and make the
outcomes more uniform.
It’s a long-winded answer but it kind of gives you the context of what we are looking to accomplish at Verb.
MD+DI:
Can you give an example of what kind of decision-making is possible
with your advanced imaging and visualization capabilities when surgeons
are using your robot?
Huennekens: It
doesn’t have to be with a robot. It can be an open surgery case, it can
be a minimally-invasive surgery case with laparoscopic instruments or
it can be robotic. You are going to be able to just look at an anatomy
and it will tell you what the anatomy is.
You could
tell perfusion versus non-perfusion. You can tell cancer cells versus
non-cancer cells. Those are the things that we are working on and moving
forward with whether it’s just the visualization techniques or
injectables that enhance the image as well. I don’t want to get into too
much detail in what we are doing there, but it’s where things are
headed.
MD+DI: You
said these techniques can be used in open or minimally-invasive
surgery, so are you saying that Verb could offer up a solution where
hospitals might not need to buy a robot to get some of these other
advantages?
Huennekens: I
am saying it is a surgical platform, so if you have advanced imaging
capability, you don’t have to use robotic arms. The robotic arms are
just tools. You can stick your endoscope in there and get visualization.
You may want to do these things with laparoscopic instruments that are
cheaper.
There are reasons you use robotics - dexterity and reach are among some. You
may want to use them in an open case, where you have a deep region that
you want to suture for which you want to use robotic arms than to reach
in there and do by hand. We are saying why not?
Today
robotics is a defined destination. It’s not a tool. In our world, there
are no robotic cases. There’s open cases and minimally-invasive cases.
You use what you need to do surgeries most effectively. Robotic
instruments should be used in open cases or minimally-invasive cases.
MD+DI: I
wanted to draw this distinction because so far, whenever people have
talked about robotic surgery, it’s always been minimally-invasive
robotic surgery. You are broadening that term a little bit because you
are saying robotic assistance can be easily used in open procedures too.
Correct?
Huennekens: That’s
why we call it digital surgery. It’s going to the future where all
these procedures are digitized and computer-assisted. I think of it as
computer-assisted surgery versus robotic. Robotics is one element of
computer-assisted surgery or digital surgery.
MD+DI: But if a surgeon wanted to use a robot, Verb Surgical will have a robotic system in addition to all these other capabilities?
Huennekens: Absolutely.
It’s one of the key pillars. The pillars are: robotics, always there,
always on; advanced imaging; machine learning, Big Data; and advanced
instrumentation.
Ethicon Endo
Surgery is a big leader in instrumentation and has a $6 to $7 billion
sales franchise. Google is a world leader in Big Data and machine
learning. They are also a world leader in optics, video and data
analytics, and then you have robotics which is something that Verb is
working on separately, but in a different form so that it’s always
available.
And then put
an umbrella over all of that and we are saying we will be open
platform. Intuitive Surgical’s systems are closed. You have to buy the
instruments from them. You have to buy the visualization.
We are
saying if you pick up your cell phone and download an app, and you can
use your app on your phone, we’re willing to give people access to our
platform under the right circumstances obviously. We have to respect
regulatory requirements and such, but if someone has a set of pediatric
instruments that would work, we’d be willing to grant them access under
the right business relationship to our platform, as an example.
MD+DI:
Maybe this is stretching it a little, but it’s like you are building an
App store for surgery like what Apple did with iPhone where other
people can sort of plug and play?
Huennekens: That’s right. It’s not a stretch at all. What we are saying is that we want to have a broad open platform with multiple apps.
You asked,
what’s the physician going to have? Well, the physician will have
choice. As long as there’s an instrument that they want to use and that
company is willing to work with us, they’re going to be able to use it
on our platform.
MD+DI: How big are your robots going to be in term of footprint? Can you give a percentage?
Huennekens:
There’s no percentage I can provide, but I can say it’s not going to be
this thousands-of-pounds system. It’s going to be more between a
mainframe and a PC, so it’ll be much smaller and always on.
The surgeon
console that allows surgeons to interface with the robot will be
different as we move forward. I don’t want to move into specifics, but
Intuitive’s surgeon console is a large system as well, and ours will be
much different in form and function.
MD+DI: TransEnterix’s
CEO has criticized current robotic systems as having no feel because
surgeons on the console don’t know if they are touching soft tissue or
bone. That company is developing robots with haptic feedback. Can you
talk about what Verb Surgical is coming up with?
Huennekens: No, we’re not touching upon that, no pun intended, at this time relative to what we are offering.
I can only
say that we’re looking at telling you what the tissue is and we think
there’s some interesting opportunities to improve on the touch and feel
as well as the way you interact with your instruments.
MD+DI: Can you talk about cost?
Huennekens:
With Intuitive, you take a piece of a capital, which is a big part of
the cost, and you amortize it. Then because the cost of the instruments
and everything else is so prohibitive, it only gets used once a day,
times 200 times a year, then your robots cost you over $1,000 every time
you use it. If you use it four times a day, it costs you $250.
Our system will cost much less than Intuitive Surgical’s.
Also, with
our system, you could use robotics in say two steps within a
laparoscopic procedure where it makes sense for you to use them. Our
system will be used in many more procedures, so it’s worth it.
Our vision would be that it’s less than $100 to use it. Maybe
there will be a premium on a couple of instruments but you are talking
about a couple of hundred dollars, not couple of thousand dollars.
We are
leveraging J&J’s $6 to $7 billion revenue in its surgical business
and Medtronic is probably looking to do the same thing for Covidien’s equally-sized surgical instrument business.
So it’s a
little bit different business model for us than Intuitive Surgical
because you are talking about open, minimally-invasive cases and a
broader tool set.
MD+DI
An analyst recently said that Intuitive Surgical has such a head start
that even with the heft of Google and J&J, Verb Surgical and others
will not really be able to beat Intuitive. Do you agree?
Huennekens: No. Who do you think is our competitor? Now I get to ask you a question.
MD+DI: The status quo.
Huennekens:
Yes, the status quo, non-use. So 95% of the market doesn’t use a
robotic solution and the Intuitive system doesn’t address that 95%. We
said for all the reasons why: from cost, to size, to set up time. You
look at the global [Intuitive] footprint. It’s not a solution.
So no, they
are not a competitor. We want to have our system in every single OR.
Every single OR in 10 years will be a digital surgery OR in the U.S.,
Europe, and Japan, and it will be starting to have an impact on the rest
of the world as well.
There’s a
different future that exists because it’s not selling a mainframe
computer that costs $2.5 million. We’re going to be selling a PC at a
different price point.
If you look
at the other businesses of Medtronic — and I am not saying we will do
this — but they’ll give away the capital, if hospitals buy enough
instruments.
You go into Cleveland Clinic that’s doing a $100 million-a-year in business with Medtronic, you think Medtronic won’t provide 8 ORs
with equipment that cost them $500,000 for the continuation of a $100
million-a-year contract for five years. Of course they will.
J&J has
that kind of scale as well. J&J and Medtronic’s robotics business
model can be entirely different than the business model of Intuitive,
which is dependent on the robot because the instruments aren’t as big a
deal or they don’t have other businesses in open surgery and
minimally-invasive surgery.
It’s also difficult for TransEnterix and these other companies because they’ve got a chicken and an egg problem.
MD+DI: Where are you in terms of product development and when can we see a surgical platform from Verb?
That’s a
question I get asked all the time. We’re not answering that right now
for competitive reasons. I am not trying to be coy or anything like
that.
MD+DI: So you can’t even say, in two years, three years, five years or whatever?
Huennekens: It will be before five years, I can tell you that.
MD+DI: What surgical procedures are you targeting?
We are
moving forward with surgeries in urology, gynecology, general surgery
and thoracic surgery. It’s our objective to have multi-quadrant access
and have a full assortment of procedures that we satisfy in those areas.
MD+DI: How is the joint venture structured?
Huennekens: We
are consolidated in the financial statements of Alphabet, so that
basically says that they have a slightly higher interest than J&J
and there is an equity pool for employees.
MD+DI: How much money have you raised so far?
Huennekens: What we’ve said is from the money that J&J invested with SRI, [the company licensing robotic technology
to Verb], what’s been invested by J&J for instrument development
and what’s been invested by Google for development for all the other
aspects of the project, plus what’s funded, to commercialize this is a
$250 million project.
Part of that
has been spent. There’s been a two plus, almost three-year development
period during which J&J invested with SRI to develop a prototype
robot. Now you’ve got ongoing investments that Google and J&J each
company has been making. There’s money that has been put into Verb to
fully fund it to commercialization. The combination of all that is
around $250 million.
MD+DI: Is there anything else you wish to add?
Huennekens: I
would describe this as democratized surgery. We are on the verge of
revolutionizing this market by bringing advanced robotics, advanced
instruments, advanced imaging, machine learning, cloud and data
computing, so it’s a super exciting time.
Twenty-five
years ago when I graduated business school, I worked for two years in
general surgery. Then I worked 23 years in cardiac surgery and there
were no billion-dollar markets when I started, but when I left, there
were 15/16.
Coming back
to general surgery after all this time, all that has changed is that
laparoscopic surgery is a little bit further along and robots are used
for prostate surgery and a little bit of gynecology. Part of the problem
is technology costs. Now, you’ve got the sun setting on a lot of IP
from Intuitive and evolution of technology, so you’ve got new robotics
companies that are coming into the field.
I think we
are going to see a lot of change in the next five years and it’s a $10
to $20 billion opportunity. I am less concerned about the dollars. This
translates into the fact that we have the opportunity to impact 10 to 20
million surgeries.
By: Arundhati Parmar is senior editor at MD+DI. Reach her at arundhati.parmar@ubm.com and on Twitter @aparmarbb
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