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CMR Surgical

CMR Surgical

Modular Surgery Robots

Andrew Kuzemczak
March 04, 2025

Hi friend,

Welcome back to Future Human, and a massive welcome to our 12 new subscribers since last Tuesday. We are growing steadily, but something tells me we may soon get an injection of support if my bets prove fruitful. I have spent the last 5 months putting together a healthtech conference here in NYC alongside 6 other graduate and medical students from Weill Cornell. That conference happened this past weekend, so Sunday was spent running around from 7AM-6PM and MCing in front of hundreds of people.

Long story short, I am about to plug this newsletter in our Slack chat with all attendees, so wish me luck! Surely that cannot backfire!

Last week, I also had our first founder interview with a serial entrepreneur and hardware inventor tackling partial blindness. That’s another way to say next week’s edition (#5) will be amazing and hopefully a first of many with conversation backing up each detail. I am still riding the high of that interview. Such cool tech!

But before we can get to #5, we must publish #4, so here we go!

I think few images evoke the feeling of ‘the Future’ — or better yet, ‘the Future Human’ — more than robots. How much more future can you get than taking a mere mortal and enhancing nearly every capability, while also removing all ethical judgement, remorse, and self-awareness. I am joking (I hope). In all seriousness, robots are amazing but have not made tremendous ground in medicine, except in a few key areas. Amazingly, despite their god complexes, surgeons have been among the most receptive to robotic innovation.

So with that, we return to our communal car analogy, and I ask you?

If you need to repair not just your car (the Ferrari), but thousands of Ferraris globally, would you wait years on one mechanic working with their hands to get to you, or allow them to augment their abilities with robots to improve accessibility, outcomes, and even cost?

The Story

A doctor, a physicist, an engineer, and an entrepreneur walk into a bar. I’m not much of a comedian, but I do love healthtech, so that is where we will begin. A group of five successful gentlemen from different walks of life collided in Cambridge, UK in 2014:

Mark Slack, a South African gynecologist
Luke Hares, a microelectronics physicist
Keith Marshall, a product development engineer
Paul Roberts, a serial inventor
Martin Frost, a seasoned entrepreneur

Together, united by the theme of innovation, they sought to improve medicine and found their way to the surgeon community through Dr. Slack. Laparoscopic surgery, or keyhole surgery, was gaining popularity, driving the minimally invasive surgery (MIS) movement forward. Small incisions (0.5-1.5 cm) in the abdomen or pelvis allowed surgeons to perform procedures that once required large, traumatic cuts, such as a thoracotomy.

The team then asked, how can we improve minimally invasive surgery?

Robotics were already present, speeding up procedures for many, but they cost millions and therefore could only be found in the highest resourced tertiary care centers. They concluded that access to such advanced techniques was the next key step in the MIS movement. With that, Cambridge Medical Robotics was founded (later renamed CMR Surgical).

They maintain a uniquely non-US footprint, which we will discuss a bit later. They are headquartered in Cambridge with presence throughout Europe, Latin America, Asia Pacific, Middle East, Africa, and Australia. Just five years after founding, their product was in hospitals beginning with Galaxy Care in Pune, India.

CMR Surgical manufactures the Versius Surgical System, the world’s most modular and compact surgical robot. They lead a fervent charge against the incumbents to redefine how accessible these technologies can be. Despite entering the market 20 years later than the market leader, they have surpassed all but one to sit as the #2 surgical robot outside the US. Amazing work — so let’s dive in.

The Tech

Robotic surgery, internet, GPS, the microwave, velcro, and duct tape. All good things come from the US military.

I joke, but now that I’ve lost some subscribers, let me say that robotic surgery would not be where it is without the military. In 1987, the military top brass (e.g. Richard Satava, MD, a surgeon and colonel in the U.S. Army) set out to create a “telepresence surgery system” that would enable surgeons to perform operations on the injured soldier sooner and from a long distance. Together with the Defense Advanced Research Projects Agency (DARPA), Dr. Satava scoured American universities. When the Stanford Research Institute (SRI) developed a prototype of a surgeon-controlled robotic telepresence workstation and a remote surgical unit, DARPA and Stanford formed a research partnership.

The robot was initially developed for open surgery (remember the traumatic incisions), but the team rapidly realized it was perfect for laparoscopy.

A few key laparoscopy points for our non-clinicians:

Small incisions are made in the abdomen or pelvis of the patient
A laparoscope, a thin tube with a camera, is inserted through one of the incisions
Other instruments, such as forceps or scissors, can be inserted through the other incisions
Surgeon can view the organs on a monitor and perform biopsies, removals, or repairs

The DARPA and SRI collaboration, however, moved exactly how fast you would imagine a public sector + academic collaboration would — snail-like. Realizing this, laparoscopic pioneer, Dr. Frederic Moll, and two partners would form Intuitive Surgical and acquire SRI’s IP in 1995. Two years later, the first robotic-assisted operation — a cholecystectomy (removal of the gallbladder) — was performed on a living patient using the Mona robot.

Intuitive would grow and even acquire its sole competitor, Computer Motion, in 2003. Computer Motion was unique in that it had funding from NASA’s Jet Propulsion Laboratory to develop a remote-controlled robot for astronaut training and remote operations. In 2001, a transatlantic cholecystectomy was even performed using their robot, Zeus. But like with all things in business, to the victor go the spoils, so nobody talks about Computer Motion (sad, but true).

It was not entirely smooth sailing for Intuitive from there, though. For example, cardiac cases were among the first to use robots based on the assumption that it would be easier to sew bypass grafts. The early robots, however, were cumbersome and collided with the critical heart-lung machines (cardiopulmonary bypass (CPB)). Many tried robotic surgery, but abandoned it soon after. To add to the early challenges, latency time issues would prevent remote operations for years.

It looked like robotic surgery would disappear, but unsurprisingly…I knew you were all thinking it.

“The prostate saved robotics!”

Dr. T. Sloane Guy, Director of Minimally Invasive + Robotic Cardiac Surgery at the Georgia Heart Institute

Urologists and general surgeons began using the robots regularly for radical prostatectomies (prostate removal) in the US. Compared to open techniques, the robotic approach decreased hospital stay and blood loss among patients. The credibility was growing.

Okay, back to CMR’s tech.

The team at CMR Surgical is now taking on Intuitive (read above, scary incumbent with 20 year head start). They are doing this with their Versius Surgical System. Versius is a single arm system, able to be configured into any combination of arms a surgeon wants. The small and modular system allows the company to offer the most versatile solution I could find on the market at a fraction (1/4) of the price. Versius is designed to biomimic the human arm, giving surgeons the choice of optimized port placement, 3D HD vision, a 710° range of motion, and the dexterity, precision, and accuracy of small fully-wristed instruments. I frankly never knew “fully-wristed” was an adjective, but hey when you are leading a market revolution you live by your own dang rules.

For those in medicine, you have probably seen or heard of the market leader Intuitive’s da Vinci robot. This $2 million, multi-arm platform looks like the device every evil villain uses to torture the protagonist in a promising superhero film. For those who are not in medicine, you might also have heard of it. If not, look it up. You’ll agree.

Just looking at it you can imagine the amazing work it can do, but also the barriers that it poses. First, $2 million is outrageous. Second, 1200lbs is outrageous. Third, four arms is outrageous (at times). What if I need just two arms? What if I need to move it to another floor? What if I only have $500,000 burning a hole in my pocket?

Life’s most pressing questions.

CMR Surgical, Versius Surgical System

CMR is tackling all of this and more. Versius is designed to be adaptable:

Single arm units allowing variable combinations and diverse port (incision) placements depending on surgeon preference
Compact footprint allowing usage in small ORs, rapid movement to where it is needed, and storage with ease
Open surgeon console (instead of the competitor’s heads-in system) allows visual on patient, clear communication with team, and reduced fatigue from cramped seating
Smaller size weighing just 400lb (still a challenging lift for us mortals, but better) allows more rapid OR movement

Put simply, CMR was inspired by laparoscopy and built their platform in the same style to reduce the learning curve and get surgeons to proficiency sooner. Spoiler, it is working. Surgeons are not wasting time converting to full robotic operators. They are remaining surgeons, but with augmented skills thanks to Versius.

In their own 2023 study, CMR demonstrated across 100 robotic cholecystectomy (goodbye gallbladder), total operation and set up time decreased markedly from the first 50 to the final 50. For added context, 50 procedures is a small amount for a surgeon to see the level of improvement they recorded. Operative time went from 29 minutes to 22 (-24%). Set up time went from 8 minutes to 5 (-37.5%). Small numbers in absolute terms, but proportionally massive, demonstrating the effective platform and impact of the laparoscopic origin.³

Long tech section this week, but what do you expect when a medical student tries to understand a literal human-cutting robot!

The Market

The global surgical robot market is doing exactly what we all thought…taking off like a billionaire’s rocket ship.

The total global market is around $10B, but it records a CAGR anywhere from 9.5-16.5%. This is the highest range of any product or market we have evaluated. Unsurprisingly, 78% of US surgeons are interested in embracing robots. As seen in the figure below, regardless of specialty, the percent using robots is always a ways away from the percent who want to (read — room for growth).

Bain & Company, Future of Robotics survey (2022)

The use of robotic surgery for all general surgery procedures in US increased from 1.8% to 15.1% from 2012 to 2018. Interestingly, use of laparoscopy, which had increased by 1.3% per year prior to the adoption of robotics, afterwards declined by 0.3% per year.¹² So is there room for both? Prior to this study, I would have said yes, but I will leave it to the markets to decide.

For surgeons, robotic assistance provides what you would expect: enhanced performance/precision, ability to reach new regions with minimal invasion, comfort by permitting surgeons to sit down.

For hospital systems, robotic surgery can reduce costs through shorter hospital stays and fewer complications, and may even offset strain from workforce shortages.⁸

Adoption of the techniques are not universally balanced, however. Only 2% of surgeries in Europe are done robotically, while 22% in the US (as of 2022) are done this way. This has me thinking, is CMR betting on the promising untouched market in non-US regions or did they select the slow and resistant ecosystem? Only time will tell.¹¹

The industry growth can also be understood with all the new competitors pushing for a top spot. Stryker is building the Mako, Zimmer Biomet has ROSA, Johnson&Johnson has the Monarch, and Medtronic has Hugo. Intuitive continues to dominate 2/3 of the market (see above, 20 year head start), but it may not be that way for long — let’s compare.

Versius vs. da Vinci:

Versius offers a modular and portable design, whereas da Vinci has a more stationary, unified structure
Versius emphasizes ergonomic control with handheld controllers and haptic feedback, while Da Vinci provides an immersive console experience
Versius's flexibility allows for rapid setup compared to the larger da Vinci
Versius is $500K-$1M compared to da Vinci Xi’s $2.5M pricetag
Versius has ease of use in mind, so the console is simpler and more intuitive (haha) to allow for rapid scaling across institutions
da Vinci remains the industry leader with more approved surgical applications and associated clinical data

As mentioned in my final point, da Vinci comes with many more surgical approvals. In October of 2024, Versius was granted its first marketing authorization through FDA’s De Novo process which established the initial indication for adults undergoing cholecystectomy. Although Versius has already completed 30,000 procedures globally (da Vinci has done 14 million), it is just now breaking into the US.

“Ultimately we will compete in all operations, but there will be areas where we really do shine, like the chest, or in children, where the anatomical spaces are smaller, which actually favors the smaller robot.”

Dr. Mark Slack, co-founder CMR Surgical

We have ourselves a David and Goliath to watch.

The Sick

Coming to an OR near you! CMR Surgical!

As mentioned above, Versius is beginning with just cholecystectomy in the US. For the sake of not boring you, I am not going to fixate on patients who need cholecystectomy as ‘The Sick’, since CMR intends to expand outside of this ASAP. I will focus more generally on patients who need any robotic procedure and the impact of the tech on them.

Now that CMR has broken into the US through the most challenging approval route (FDA’s De Novo process), they will accelerate approvals with the easier route that is afforded to them (510(k) application). With the 510(k), the company just needs to demonstrate that the device for the new procedure is substantially equivalent to a legally marketed device (say…its own Versius for cholecystectomy) to get the next indication. They have already said they are targeting colorectal and thoracic procedures before expanding to most others.

“The real achievement was getting the system past a full FDA approval for the system and for all our instruments, because then doing the 510(k) is altogether much easier. So we do small, limited clinical trials and expand it across to the other specialties here.”

-Dr. Mark Slack, co-founder CMR Surgical

We have spoken about the value to surgeons and health systems, but only touched on the benefit for patients. So let’s ask, is robotic surgery really better for the sick?

Fittingly, we shall consult the AMA Journal of Ethics.

In 1985, Erich Mühe performed the first laparoscopic cholecystectomy in Germany. By 1992, about 80% of cholecystectomies were being performed laparoscopically. It is now the gold standard. The explosion of interest in this novel technique, however, is not always because of improved outcomes. Overwhelmingly, patients demanded the surgery because incisions could be covered with band-aids.

Upon further research, thankfully, we find more significant benefits.¹³

Shorter hospitalization
Reduced pain and discomfort
Faster recovery time and return to normal activities
Reduced risk of infection
Reduced blood loss and transfusions

Not only are outcomes often better, the learning curve is normally shorter (fewer cases needed to reach proficiency) compared to laparoscopy. In a 2021 systematic review, Flynn et al found that operating times for robotic colectomies (colon removal) were shorter than for laparoscopic colectomies when the surgeons were unfamiliar with both platforms. If we are trying to improve access and use the robots to develop the skills of these surgeons, the answer is becoming more clear. Go robotic.¹⁷

Like with anything in medicine, though, it is not that simple. In another systematic review, Lauka et al showed operative times were longer with the robot when the surgeon had a diverse laparoscopic background, often times leading to frustration with the robotic functionality. So if you have entrenched surgical skills, learning the robot may take more time.¹⁹

To recap, patients want what is new and popular. Surgeons must be cognizant of this fact and remember robotics is normally a terrific option, but not 100% of the time. A healthy balance must be found between enthusiasm for innovation and healthy pause to ensure best outcomes.

The Economy

Over 14 million robotic procedures are performed annually — surely we have some economic data on this. We do, but it is fragmented, so allow me to attack the puzzle.

Versius, like with other surgical robots, comes with high initial investment. Thankfully, at 25-50% the price of the da Vinci, it is more manageable for smaller and less resourced hospitals, but certainly not cheap.

With improved outcomes that we have mentioned above, we would see lower overall costs. Think reduced hospital readmissions, follow-up treatments, prescription drug needs, etcetera. So while the upfront costs are higher, the lifetime treatment costs can be massively reduced through robotic surgery.

One study estimated that adoption of robotic surgery across the US could lead to annual savings between $1.5-$6.5 billion by helping avoid costs related to surgical complications and follow-up treatments. A UK-based study evaluated just robotic prostate removal surgeries and calculated potential cost savings of over $350 million for the National Health Service (NHS) over 20 years after accounting for the upfront technology costs. The savings stemmed from reduced length of stay, fewer longterm treatments, and faster recovery times.

Between 2000 and 2018 (before CMR Surgical and its affordable options), robotic adoption helped the NHS reduce length of stay by 50% and decrease postoperative vists after 1 and 2 years by 44% and 46% respectively. The robotics increased total production at the hospital level between 21% and 26%, coupled with a 29% improvement in labor productivity.¹⁶

It is important to note that I noticed across papers cost savings improved when you could share the robotic platform across specialties. CMR’s Versius is of course better for this. I know that here at NY Presbyterian we have the protected cardiothoracic da Vinci (she is gorgeous but very guarded by the CT surgeons)

I am not going to necessarily say robotic surgery is a net cost saver for everyone. The economics are complex and depend on the type of procedure, the volume of procedures performed, and the patient's outcomes. With that said, I think we can agree that if we were to build the most economically viable option for most hospitals, it would be closer to Versius than da Vinci.

My Thoughts

This is my longest piece yet, so thank you for staying with me. Nearly 3,000 words later, I adore robots.

I had the privilege of witnessing this tech first hand recently when working with a cardiothoracic surgeon at NY Presbyterian. Walking in to see the lights turned low and just the blue glow of the robot (it was a da Vinci, but hopefully soon a Versius) working over the patient was truly spiritual. Eventually, I even escaped the eternal medical student corner and was invited to sit on the base of the machine underneath all the arms and screens to get the best view.

Truly life changing.

I wish that that level of precision could be delivered to all corners of the globe. With CMR Surgical’s Versius, it now can. Armed with a new FDA approval and over $1 billion in funding ($600 million in 2021 and $165 million in 2023), they are closer than ever to achieving this vision.

I could not be more excited for when the robots take over. 😅

To more lives saved,

Andrew

I always appreciate feedback, questions, and conversation. Feel free to reach out on LinkedIn @andrewkuzemczak.