At the end of 2019, a robot controlled by an engineer is dancing its robotic arm cleverly at the site of the Shanghai Expo.

On the console of this behemoth, there is a flower, and between the arms flying, the fine stamens are skillfully plucked and turned.

The surgical robot, called Leonardo da Vinci, has been unveiled at the Expo for the second time, allowing doctors to perform more accurate operations with less damage and less bleeding.

Just a year ago, the first batch of patent protection for Leonardo da Vinci's surgical robot expired one after another, and the market worth hundreds of billions of dollars quickly flooded into many famous medical giants: Medtronic PLC, Johnson & Johnson, Siemens, Stryker Corp and other companies to spend a lot of money, trying to get a ticket to the surgical robot.

What is the sanctity of "Leonardo da Vinci" that attracted international medical giants, and what kind of mysterious sea is behind it?

A cutting-edge medical device worth 60, 000 yuan at a time for Part.1.

In the late 1980s, a group of scientists began the development of field surgery robots at the Stanford Research Institute, hoping to improve medical care on complex battlefields so that doctors could operate on soldiers remotely.

The surgical system attracted the attention of the U.S. Department of Defense, and soon the project team received investment from the National Institutes of Health in the hope that they could develop a prototype for practical use as soon as possible.

At that time, some people keenly captured the business opportunities behind this sophisticated technology. A company called intuitive surgery was set up to quickly commercialize the technology, giving birth to the Leonardo da Vinci robot, which has monopolized the surgical robot market for nearly three decades.

This product, under the name of Leonardo da Vinci, pays tribute to the sages at the beginning. Leonardo da Vinci sketched the first robot on the drawing 500 years ago, which later generations named not only to create a precedent, but also to turn surgery into an exquisite art.

Leonardo da Vinci's surgical robot consists of three parts:

1. Surgeon console: the surgeon sits in the console, outside the sterile area of the operating room, using his hands and feet to control the instrument and a three-dimensional high-definition endoscope. The tip of the surgical instrument moves synchronously with the surgeon's hands, like an extension of the doctor's hands.

two。 Bedside manipulator system: bedside manipulator system is the operating component of surgical robot, and its main function is to provide support for instrument arm and camera arm. The assistant doctor works next to the bedside robotic arm system in the sterile area, is responsible for replacing instruments and endoscopes, and assists the chief surgeon in completing the operation.

3. Imaging system: the imaging system is equipped with the core processor of the surgical robot and image processing equipment, which is located outside the aseptic area during the operation, can be operated by itinerant nurses, and can place all kinds of auxiliary surgical equipment.

Many people intuitively believe that the surgical robot is to operate on human beings instead of the doctor. In fact, the surgical robot is far from being able to replace the doctor to sit on professional judgment. Its significance is more to help doctors achieve fine, minimally invasive operations that are difficult to accomplish with conventional human arms.

Compared with conventional methods, the Leonardo da Vinci robot first provides a 10-15-fold magnification of the field of vision, and then increases the hand defibrillation function, which can solve the problem of doctors shaking hands for a long time. In other words, the surgical robot is a more elaborate pair of artificial hands.

For patients, when there are a large number of nerve endings in the surgical area or when the situation is complex, the robot can perform more complex operations than traditional surgery, the wound is small, and the rate of adverse reactions will be greatly reduced.

This is why the Leonardo da Vinci robot starts up as high as 40,000 yuan to 60,000 yuan at a time, but the demand for robot surgery is still endless.

For example, open cardiothoracic surgery usually requires thoracotomy, sternum separation, free ribs, and often with the help of cardiopulmonary bypass, which has the advantages of great trauma, high risk and long recovery time.

The use of Leonardo da Vinci robot is different, only need to make a few small incisions between the ribs, can successfully complete the operation. Of course, limited by minimally invasive and the range of operation that the robot itself can achieve, only some uncomplicated surgeries can be performed.

Another example is prostate surgery, because there are many tiny nerves around the prostate in the depths of the inner cavity, if you do traditional surgery, not only the wound is large, but also the operation during the operation is not convenient, "the hand has to be twisted all the time." The usual prostate surgery not only increases the difficulty of the operation, but also consumes more energy of the doctor. The use of Leonardo da Vinci robot can not only successfully reach the depths of the cavity which is difficult to reach by hand, but also complete the difficult and high-precision operation manually.

The mode of operation will change after the use of robots. The application of robots has greatly reduced the difficulty of some operations, doctors only need to sit in front of the console to operate, reducing the degree of hard work of doctors.

Because the wound is small and the operation is relatively simple, in addition to the necessary chief surgeons and assistants, the number of medical staff needed in an operation will also be reduced. Especially in this epidemic, contactless medical care has been paid more attention, allowing robots to complete contact tasks more instead of manual, but also the protection of high-risk health care personnel.

At present, the main application field of medical surgical robot is in urology and gynecological surgery, the third in general surgery, but the fastest growing rate. In the United States, the use of Leonardo da Vinci robot for prostate surgery and hysterectomy has become a "standard procedure."

However, this cutting-edge medical device, which can be called the "hand of God" in the medical industry, has been firmly controlled by a company for 30 years.

The myth of Part.2 creating wealth, the "hand of God" has been monopolized for 30 years.

In 2015, on the occasion of Alphabet Inc-CL C's 11th anniversary, Wall Street counted that the returns of only 13 listed companies exceeded Alphabet Inc-CL C, and intuitive surgery, which specializes in Leonardo da Vinci robots, was one of them. With the rapid growth for more than a decade, intuitive surgery and his surgical robot have become the king of money and the myth of getting rich.

Intuitive Surgical (ISRG) had a market capitalization of as much as $22 billion. The company was listed in June 2000. at the initial stage of listing, due to the technical foresight and low market awareness, the stock price was once mediocre, and the PS (price-to-sales ratio) of the company was 12 times. From 2001 to 2004, the PS was kept below 10 times.

When the turning point came in 2005, Leonardo da Vinci robot was approved by FDA510k for minimally invasive gynecological surgery, which made Leonardo da Vinci surgery robot burst into a great application scene. This year, Intuitive Surgical's revenue increased by 60% compared with the same period last year, while its net profit increased to $94 million from $23 million the previous year, while its share price tripled to more than $100 for the first time.

Intuitive surgery's gross profit margin of up to 70% is a repeated reminder of an industry reality that as long as your technical moat is deeper, you will continue to reap profits. Intuitive surgery is not only a major behind the FDA certification, but also from Leonardo da Vinci robot in the field of medical robots, is a truly outstanding.

The whole research and development of surgical robot involves many disciplines, such as medicine, biomechanics, mechanical mechanics, material science, computer graphics, computer vision, artificial intelligence, mathematical analysis, robot and so on. It is impossible to enter the industry without decades of technical accumulation and a strong financial base.

Intuitive Surgical rises abruptly based on its accumulated strength. According to the analysis of its annual report, its R & D investment has remained high for many years, accounting for about 8% of its revenue. Intuitive surgery has completely monopolized the market for surgical robots with more than 4000 patents.

Taking the mechanical arm, the core component of the surgical robot, as an example, the robotic arm, as a high-value consumable material, is not only the embodiment of the scientific research power of intuitive surgery, but also the source of its rich profits.

The robotic arm of Leonardo da Vinci robot can reach 7 degrees of freedom, which is a perfect simulation of the human arm. These manipulators have different tools such as needle holding, grippers and scissors, and their positions are interchangeable. But at the same time, the manipulator has extremely high precision and can complete all kinds of complex actions that can not be done by hand sometimes.

Each Leonardo da Vinci manipulator can be used for a limited number of times, and its built-in counting device can no longer be used after 10 times. According to the research of the East-West think tank, this is because the high-precision instruments are easy to damage and must be replaced in order to ensure the safety of the operation. Intuitive Surgical is also a quite stable cash cow. The price of the robotic arm is about 100000 each, and each operation requires at least four arms on average, so the startup cost of 40, 000 to 60, 000 probably comes from here.

In addition, due to the lack of tactile perception caused by the use of robots, coupled with the ingenuity of performing surgery with robots, Leonardo da Vinci robots have to be trained by Intuitive Surgical for 150 hours. The time paid by doctors is the cost of switching to other robots. Using Intuitive Surgical's Leonardo da Vinci robot has become a kind of inertia, and Leonardo da Vinci's market barrier has been set up.

Intuitive surgery and its Leonardo da Vinci robot were not plain sailing from the start. In the early days of its listing in 2000, intuitive surgery had a long-running patent battle with ComputerMotion, another surgical robotics company.

When it comes to it, Computer Motion is the pioneer of surgical robots. The AESOP robot, which was launched in 1994, is the first robot specially built for surgery in the world. The reason why ComputerMotion starter did not win is that it has not been recognized by FDA.

By 2003, intuitive Surgical Corner overtook Computer Motion, a competitor and predecessor, and transplanted its technology to Leonardo da Vinci Robot. Intuitive Surgical eliminated the biggest competitor through mergers and acquisitions.

Since then, Leonardo da Vinci robot can be said to be the vertical and horizontal market for more than a decade, without a rival, domineering in the minimally invasive surgical robot market. After all, the patent advantage of others is thick and high enough to keep all competitors out.

The world's major medical equipment giants have been greedy for surgical robots for many years, and the first batch of patents for intuitive surgery in the past two years have just expired, and the major medical device giants have been surging. Other problems covered up by the rapid growth of intuitive surgery have also been exposed.

On the one hand, the global promotion of Leonardo da Vinci robot is not fast, from the regional distribution, we can see that the main market of Leonardo da Vinci robot is still in the United States. With the implementation of Obamacare in the United States, hospitals will be more cautious about the purchase of high-value equipment.

Intuitive Surgical will face more and more complex challenges if he wants to continue to sit on the altar of the myth of getting rich.

The medical concept of "the hand of God" has taken root in China, and it has also set off an exploration and innovation in the field of medical devices.

Part.3 competes in multiple dimensions to extend the medical robot arm further.

Only more than 50 Leonardo da Vinci surgical robots have been imported in China. In part, because Leonardo da Vinci's surgical robot belongs to Class A large equipment by 2018, hospitals have to wait for the direct approval of the National Health and Family Planning Commission before they can buy it. There are clear regulations on what kind of hospital can be configured and how many.

On the other hand, Leonardo da Vinci sells at a high price in China. According to the Shanghai Science and Technology News, Leonardo da Vinci robots that sell for about 14 million yuan overseas can be sold at home for as much as 20 million yuan. From this point of view, the development of domestic self-owned surgical robots is not only a measure to enter the blue ocean market, but also the mission to realize the autonomy of high-end manufacturing in our country.

But the technological gap in front of self-developed surgical robots is also quite realistic. Leonardo da Vinci robot specializes in laparoscopic surgery, facing the soft tissue of the human body, each patient varies greatly, and doctors pay attention to the priority of surgery.

Therefore, compared with orthopaedics and neurosurgery, celiac surgery requires the highest precision of robots. If you can't achieve this precision, you won't be able to deal with accidents. How do you get this precision? Only rely on a large number of clinical summary, repeated improvement.

At present, the "wonderful hand" of China's independent property rights has also completed many experimental surgeries, but it is still a thorny challenge for engineers to catch up with the Leonardo da Vinci robot, which has been running wild for 30 years.

But Chinese surgical robots are trying to find another way around the abdominal cavity that Leonardo da Vinci is good at.

In China, some medical device companies that turn to orthopaedics, neurosurgery and interventional surgery have made a lot of gains in the field of surgical robots. Tianji orthopaedic robot of Tianzhihang and "Ruimi" neurosurgical robot of Bai Huikang have all successfully passed the examination of the third type of medical devices, and have gone further and further in broadening the functional boundaries of surgical robots.

But 5G technology is also needed to add catalyst to China's surgical machine industry.

In June last year, Tian Wei, director of Beijing Jishuitan Hospital, remotely controlled two Tianji orthopedic surgery robots alternately through 5G technology, and performed three-dimensional spinal screw fixation for two patients with spinal fractures in Yantai, Shandong Province and Jiaxing, Zhejiang Province. a total of 12 screws were inserted, and the positioning was accurate.

This is the first remote orthopedic surgery performed through 5G in the world, and it is a milestone in the history of surgery and medicine. It not only means that the dream of real remote surgery comes true, but also means that technology has found the answer to the inequality of medical resources.

Especially in the current epidemic situation, telemedicine has gradually become a rigid demand. Remote consultation and remote guidance have gradually matured, and now telemedicine is becoming a new trend with the blessing of 5G.

With the development of Internet technology, people can consult online. Doctor Chunyu can minimize the asymmetry of medical resources in consultation, and realize the sinking of medical resources and non-contact consultation. Portable wearable devices also allow healthcare doctors to remotely monitor the status of patients and give health advice.

But the operation is different, the operation is one of the most professional medical links, which is greatly influenced by the chief surgeon. Excellent medical resources tend to gather in the region, and most of the excellent doctors gather in big cities.

Remote surgery is the most important part of telemedicine and the shortest deficiency. The Leonardo da Vinci robot originally had a remote surgery module, but most of them did not have this module when they were introduced to China.

Even so, China is facing up to the technological gap between Leonardo da Vinci and Leonardo da Vinci, and the current national policy focuses on supporting medical robots as an important part of China's industrial 4.0 strategy. The volume of China's medical market expands rapidly with the arrival of the aging society, and the promotion of graded diagnosis and treatment and the huge gap of grass-roots doctors have also become a strong driving force for robot research and development.

If Chinese robots want to catch up with Leonardo da Vinci, following the imitation of cats and tigers is not the way out, and the most appropriate way may be to find another way to overtake.

This chase and competition around surgical robots has long gone beyond the medical field and is related to the scientific and technological game between the great powers.