Size, Modularity, Portability, Versatility: CMR Surgical's Vision to Scale Surgical Robotics so More Patients Can Receive Minimal Access Surgery | LSI Europe '23

Transcription

Scott Pantel  0:05  
We have a great a great session lined up this morning and some some really exciting recent news, which will just be one part of the story that I'm sure we're going to talk about this morning. So I wanted to get this teed up for us, I'd like to welcome the team from CMR Surgical here. For those that don't know, I'm sure many of you do, CMR Surgical as a surgical robotics company and they're behind the next generation, surgical robotic versus, and the company is on a mission to help get keyhole surgery to all patients who needed around the world, with versus being used in over 20 markets. Today's session will spotlight the company's founding story, and a deep discussion about what the future future of this market looks like. We're thrilled to have the entire team here today we have Luke Hares, who is a co founder, CTO and original inventor of the versus we have Mark Slack, also a co founder and their chief medical officer and their CEO, Supratim Bose, so welcome to the stage. You didn't see the press release yet. Take a look at it. We want to correct congratulate the team they had a very timely announcement that went out today, announcing that their system has now been used in over 15,000 surgical cases in more than 20 countries around the world across various specialties including General urological, gynecological and thoracic. And they also announced today that they raised they closed an additional round of $165 million, with some very impressive investors joining their journey. And so very much looking forward to not only hearing about how they got here, but where they see things going. And again, the point of this, this whole meeting, is to shine a light on the innovators that are changing the world. And no doubt they have a big mission here. And we're encouraged to see them here on stage with us today. So with that, I'm gonna turn it over to Henry, and over to you. Thank you.

Henry Peck  1:55  
Thank you, Scott. And thank you, everyone for joining us. First, please just join me in giving a short round of applause to celebrate that recent news. And as Scott mentioned, we're thrilled to have you here on such a timely fashion to talk about not just that news, but where versus has started, how CMR surgical has grown, and how this is going to fuel the next generation and that expansion. So let's jump right into it. Starting with Dr. Slack. And with Luke, tell us how CMR surgical got started the origin story of what is now 15,000 surgeries strong. 

Luke Hares  2:29  
Yes, certainly. So prior to CMR, I worked in the contract research and development businesses around Cambridge, well known there's many of them, and and the joy of those businesses and engineers, you can expose to a huge number of industries and opportunities. And some of my work was in the field of surgical robotics. That project ended as corpse or projects do and I then went on to work on handheld steam cleaners. But the but the thing we remained with me was that there was this massive unmet need. That really no one was to my mind effectively working on laparoscopic surgery, minimal access surgery had been out for and this was 10 years ago. So 30 35 years, and the penetration of it, it only really got to 50% Even though is obviously a better way for the vast majority of people to have the vast majority of procedures. Robotic Surgery been around for 1520 years had really only got to five or 6%. Depends how you count, and wasn't moving the dial on that 50% It wasn't providing the majority of surgeons a better way to give minimal access surgery to the vast majority of people, there was clearly a need for a better tool to enable everyone to have that. And I'm lazy. So I like to find the easiest way to do things. I like to invent tools. And CMR really was was founded on the assertion that actually, you could invent a surgical robot that would help the vast majority of people to have the right kind of surgery. And if you look at versus you have all the features of it and Versius I think it's fair to say still radically different to the surgical robots or the surgical robots on the market. All those features come from the questions we asked ourselves 10 years ago, how do you build a system that is physically capable of doing all sorts of surgery in the way that surgeons want to do it? So you're not physically constrained by the design of the system? How do you make it easy for surgeons to learn how to use for bedside staff to learn how to use because you've got to get the turnaround times down for to fit into existing hospital, ORs, existing hospital workflows. If you can do that you've got a system that can be used for everything. and you've got lots of people who can drive it, both surgeons and staff. If you can achieve that, you can keep it busy, you can get the utilization up four or five procedures every day, day in, day out. achieve that, and you completely transform the economics of providing it, and everyone can have one. And that was the basic premise. That was the foundation for for CMR. The belief that actually, if we put the system together like this, it will achieve that the thing that's been tremendously exciting over the last couple of years, is, as the numbers show, and actually, as you dig into the numbers even further, you'll see that we've got systems out there that prove that Versius does meet those requirements. And that's what's tremendously exciting. We've got the systems that are being kept busy. And we've got the systems that are doing just about everything you can imagine and a few things that frankly, back then we didn't imagine. So right at the beginning of that expansion right at the beginning of starting to move the dial and helping millions of people get the right kind of surgery.

Henry Peck  6:07  
Good. Well, I think we have everyone's attention now with that founding story. So rather than rather than start by doing something like intros, I want to make sure everybody's engaged understands where we're coming from, I think now's a good time, that we have their attention to introduce everybody starting on my left with superteam would love to do a quick intro, and then we'll go back into a little bit of that clinical space that you were talking about and some of the under penetration of the market.

Supratim Bose  6:30  
I am Supriya thimbles. I'm CEO of CMR. I was appointed CEO about five months ago. But I've spent more than four decades in the medtech industry, having worked for Johnson and Johnson, medtech for 30 years for Boston Scientific for over seven years. And then Convatec for around three years.

Mark Slack  6:50  
Hi, I'm Mark Slack. I'm one of the co founders. I'm a lapsed surgical academic, I was head of a department at Cambridge University. I've also interspersed my career with other inventions, some of which I've taken to global launch with Johnson and Johnson. And, you know, people make an assumption I was I ran a robotic amino laparoscopic training course in Cambridge for about 25 years, and became aware that I couldn't teach everybody how to do straight stick laparoscopy, they would spend two years with me and at the end of it still was struggling to get to grips with it. And as Luke highlighted less than 50% of people getting surgery get minimal access surgery, despite the myriad of advantages which she can come back to. So people make an assumption that Luke and I, both living in the Cambridge ecosystem met through science and innovation, but in truth, we met through antenatal classes we both our wives were attending. So am I, Luke did attend, I didn't. And my wife was asked if she had a partner. And she said, Yes, I'm married. And they said, Well, you must ask him to come along. And she said, believe me, you don't want him at these classes. So and that's where we actually met. But it was great, because she's also said, Luke also said, You know, I'm concerned about I want to get into robotics. Instead, the lunatic at home is talking about it as well. And, you know, it was I tried out the other systems. And it was interesting to me that something different was needed to try and meet the need of getting more people getting minimal access.

Luke Hares  8:21  
Luke has CTO co founder of CMR, surgical and the inventor of the idea of versus though, I always like to point out that it's the work of hundreds of other engineers as well. My background is done, the physicist, studied physics at Cambridge, and then went to go and work in the various technology development companies around Cambridge. That was good, worked on many, many different things, until eventually discovering that there was this need, and being very excited, because I thought had a way to do something about it. 

Henry Peck  8:56  
Great. Now we have the backgrounds, we have the founding story. And I think we need one more piece of information, the market and the clinical need to help really set the stage for where CMR is now. So Dr. Slack. Can you talk to us a little bit about what you had seen in the market around surgical robotics and why the market penetration, as we had talked about is had been so low. What's kind of going on in the clinical community at that time? And what was that unmet need?

Mark Slack  9:18  
Yeah, I think this is the narrative part of which Luke has already covered very fluently but but the point is, you know, you have to go back and say is minimal access surgery better than open surgery, and in every single domain that is just in general complications, reduces complications by 50%. But if you take something like surgical site infections, wound infections, if you have a big wound and gets infected, half of those people go back to hospital and 10 to 20%. Go back into theater, whereas in keyhole surgery, nobody goes back into hospital. And the European economy spends about 27 billion euros a year on wound infection. So you know, we talking about economies of scale that can have an impact on the health system, and there are so massive yet despite all of though we only get United States of America the most sophisticated health system in the world only has a penetrance of about 40%. of minimal access in most specialties. And so that's one of the things that intrigued me. And what I mentioned earlier is, from my own experience in training people, I realized, not everybody's capable of operating in two dimensions, with instruments going the opposite direction to where you move your arms, etc, etc. And so therefore, would robotics overcome that what struck me and I did look into the other robotic systems was that they'd been around 22 years and you've got a penetration of about 4%. So clearly, so we spoke to surgeons, we asked about 150 surgeons in Adelphi polled to say, why are there not adopted robotic surgery, and they spoke about cost, size, different ports, different port placement, different methodological approach to those operations, etc. And then said to us, what they wanted was a small modular robot that could be used in all specialties, portable, etc, etc. And that's what the company has set out to, to take Luke's vision of this much smaller, portable robot and put it into use. And one of the things we already see it is way easier to train a surgeon on a robotic system than it is on a straight stick, traditional laparoscopic system, just having the 3d and the fixed focal length from your screen, and the articulated instruments, I can probably teach most of you in this room to tie a knot in about 30 minutes. Whereas was traditional laparoscopy to do it fluently, it will take you about 70 to 80 hours of practice. So these are these economies of scale that and and, you know, I do believe that. And we already are showing people who've never done laparoscopy now using our system. And so I believe that robotics will drive the minimal access market after the 70 80% of surgeries, which needs to be with all the benefits for the people who received the surgery.

Luke Hares  12:06  
I think sorry, I think it's fair to say you did teach Matt Hancock, the then British health secretary to tie a knot in about 15 minutes. 

Mark Slack  12:16  
And if you see the pieces of it in the newspaper, you realize he's pretty good with his hand. But anyway,

Henry Peck  12:22  
On that topic of training, kind of add on another statistical area, if you had to take an estimate or maybe some internal research that you've done, what percentage of surgeons in training, do you think in the future will be training on robotics? I think a lot of what we've seen today has been trying to convert surgeons that came up in laparoscopy over to robotic surgeons, but for that next generation of surgeons, where do you think on the zero to 100 spectrum, how many of them what percent will be training with robotics? 

Mark Slack  12:46  
So I work very closely with the surgeons in training. In fact, we sponsored the association of surgeons in training, and did a survey of them, which is published now. And 98% of them have an expectation that they will practice surgery with robots, they do not anticipate a and that's partly because of ease of acquisition, partly because potentially better results in some areas, and also because of their knowledge of ergonomic injuries. So it was straight stick laparoscopy, where you standing in odd positions for hours on end, people get lots of cervical spine injuries, they get arm injuries, and the younger surgeons are very mindful that they don't want to get that. So there's a driver. I spoke a week ago with them at a meeting. And they are all we now have virtual reality headsets for our training, which we can come back to, and they will want one because they want to practice it's they can go to their their bosses and say, I can really do this.

Henry Peck  13:44  
Makes a lot of sense. The the founding story you talk about relates lots of the architecture of the system, the clinical need and why it's designed the way it is to be smaller modular. But Versius is more than hardware, it's software as well. And that software driven ecosystem plays a big role in why this system is set up for both immediate and long term impact. Luke, can you talk a little bit about that software driven ecosystem and enable in the future. 

Luke Hares  14:11  
So Versius is, assuming a level of familiarity with Versius, it's very different from the most surgical robots because when you look at versus you'll see immediately that it is based around small flexible robot arms. The design breakthrough that allows it to be that way, as is the wrist that gives us the range of motion with small flexible robot arms. It was also designed from the ground up to be part of a digital ecosystem. If I expand on the robot side first and then I'll talk about the digital ecosystem on the robot side, because so many of the things that in other systems aren't mechanical constraints like rails and how you move it during setup and things like that, are in Versius Software constrains their programmed behavior, it means that over the years Versius has undoubtedly got better. movements have got smoother setup times have got better. We've taken the learnings that we've had from the field, and we've incorporated them into Versius and everyone has benefited from them, because the principal way to incorporate them is by improving the software on the system. So it's its behavior is very software defined, that gives us a level of flexibility, not everyone anticipates. So that's tremendously exciting. But as I say, it was designed to be part of a digital ecosystem. And if you say that we're coming to, like maybe the end of the first chapter in terms of the introduction of the robot, when it comes to the digital ecosystem, we are just starting the book Versius streams back to base. Camp, complete information about how a surgery is performed, you've got the video, but again, the videos kind of old hat, you've also got, the way the instrument tips are moving. And the way the surgeon is moving the controls, you've got the way it was moved around during setup, you've got what buttons are pressed, we can play back procedures on virtual Versius is. And we can do it for every single one of the 15,000 procedures that first just has performed. So tremendous amount of detailed information. You know, people talk about doing image recognition to work out where the instruments are great. We know where the instruments are, they're held by robot arms, they know exactly where they are to within fractions of a millimeter. The question then is what what do you start to do with that, and we're already at the first stages of so taking that information and using it internally to inform development decisions. And to inform servicing decisions, I think you're you know, that joint is looking a bit worn, we should go and fix that before the surgery notices. And we're also starting to feed that information back to surgeons and back to surgical teams. This is the telemetry information. There's the clinical side of this, the registry that I'm sure Mark will talk about in a few minutes as well. And that's absolutely essential and part of this too. And really, that feeds into a really important question that I get asked quite regularly, which is does verse use make surgeons better surgeons? It's sometimes a trick question or reporter sends in? And the answer annoyingly, of course, is both no and yes. It's no, because the surgeon who stands up from versus is exactly the same surgeon who sat down versus. But on some levels, it's also yes, it's Yes, perhaps because they've got a much better tool to work with. So they can offer, they can operate for longer, more comfortably, they can perhaps operate more blood and do more complex procedures, the patients may feel that they're a better surgeon. But the real reason it's yes, is because every surgeon I've met, cares deeply about their patients and cares deeply about serving them better. And the thing that lets surgeons serve their patients better is information they can learn from. And that really is what the first step of the digital ecosystem is showing surgeons how their numbers are changing how they're improving, has they're using versus sports, showing them the areas where perhaps they could do a bit better. You know, here's a metric for tying knots. And actually, you're over here. And that really is just the very, very beginning. Because the other thing that you get when you've got a full telepresence, laparoscopic robot system is for the first time you're putting something between a surgeon and their patient which can if necessary, intervene. Currently Versius is very simple. You move your hands up, down, left, right, you move your wrists, the robot moves the instruments inside the patient in exactly the same way it makes no judgment as to, is that a sensible thing to do? Actually, in the not too distant future, based on these datasets, I can see Versius going and Are you sure you want to do that? I mean, let me give you a trivial example. Currently, if you try to fire an electrosurgery instrument, you can't see Versius will let you know. It makes no attempt to mediate I can't think of a single good reason to fire an electrosurgery instrument you can't see. And actually I would be much happier if Versius went (beep noise) before I let you do that. That's a simple example. But when you take those but that enormous clinical data set, the clinical outcomes stored in the registry, the exact information around how procedures are performed. I can imagine a future where actually down the line the system says hang on in five minutes time. 5% of surgeons in this situation had a problem. Now that's in the far future, we're not there yet, it's going to be a journey. It got, it's got to be a journey, but I can see it starting to happen. And that's going to be tremendously exciting.

Mark Slack  20:09  
But but using that same digital ecosystem, it's a moment to really have it in place. So for training, our training is obviously on electronic online and so on. And then we have virtual reality both for the team and for the individual surgeons. So I could potentially train a team with one surgeon in Barcelona, one in Cambridge and one in Oxford, working together over VR, you know, getting setting up the system. So by the time they come to the laboratory to learn, they really aren't proficient and also means they don't have to spend all the money flying across to, to train and so on and so forth. In the training system, we have virtual reality for the simulator. And our female surgeons complained that they could only get on the simulator when the robot wasn't being used, which is usually in the evening or weekends in theaters, which aren't quiet and dark, and not exactly friendly places to be, whereas now they can sit at home and practice in the comfort and warmth of their homes on the VR. But of course, what we put into the VR is that it is proficiency based. So I don't say that the surgeon is good enough yet. The system says the surgeon has passed certain proficiency tests. And he's now ready to go on to that next step. And already with the telemetry that Luke mentioned, our robot for the button 99% accuracy can tell the difference between a novice Surgeon and an expert surgeon by their hand movements. So you get these glimpses of stuff that we're really using in our day to day practice, in order to enhance it. Now the digital aspect of training with proficiency means that if you have a particularly talented surgeon, they may train in an hour, and then be ready to move on a less talented run make two or three hours but I very old ever you do you ensuring that they're reaching a benchmark, which makes sure that they save for the patients that they are operating on. And then also all of this is collected. So their data is all on an automatic logbook. When they train on the simulated or gets clicked into automatic into logbooks, they know exactly what they've done. And that's there to show people if there are any questions about your training. So you know, and that's just the beginning, there are a million other ideas we have in and around the digital side here to determine better outcomes.

Henry Peck  22:24  
It's a perspective shift a lot of the conversation around surgical robotics, even when I was in school, studying surgical robotics and started getting intuitive and j&j. The conversation is around hardware innovation, making better tools, better devices, better control paradigms, whereas the conversation now and what you're putting out is, hey, for the first time, we have laparoscopic surgery, zeros and ones, we have all this information that we didn't have before, what can we do with it and that I want to kind of parlay over to you, Supratim, you have an incredible career with global corporations strategics up to this point, why now to take on this role and scale up like CMR surgical what drives you to come in at this point and help bring this company into its next phase of growth?

Supratim Bose  23:06  
I think the first thing is that I've been involved in the medtech and continuously looking and studying where medtech is headed in terms of providing benefits to patients on a global basis. And when you look at it, robotic assisted surgery would probably become one of the largest segments of the medtech, industry and reach and if it is properly done reach the maximum number of patients possible yet. So when I was contacted for this, that's the reason I looked at it. And number two, the vision. And as you listen to both of them, somehow they came up with the right thinking and the vision that their goal is to make robotic assisted surgery available to most patients available. Yeah. So partly repetative. But the fact is to really think through and see why laparoscopic and robotic surgery, penetration is still so low, like this more than 20 years. And I think that's the interest that brought in. I think the first thing to look at is really understand how to access which markets to access, and how you go about creating that story. Number two is looking at and saying creating the awareness in a manner that both of them experts will listen to them. It's that message which must go across to the community, right? It is available, the training is not difficult, it will help the patient and these are the data that is and you can see it yourself. It's not somebody a professor telling you are good, not good, etc. Right? The data is available. Third part of it is the adoption and I think that's where a mark and the team are doing such a good job trying to train people at different levels in a different way. Yeah. So if you take a training program and said, This is the only way you can train you can never, right. And I think that was what is helping us. So we have a clear understanding, like Mark said, whom to approach in what way? And how to create it. I think the next one is affordability. So in some ways, the access has been limited because of that. Okay. And when we are going into markets, we have grown to 20 markets, including emerging markets not differentiated, you know, this is I think we know the right way to do it. Yeah. So I think that thought about it. And they approached in the in that manner. So if we have done this 15,000 surgeries, I think a lot of it is done in markets, where robotic may not have even been known sometimes. Yeah. And I think the last part of it is they're continuously engaged and aligned with the education system, the government's the policy makers. So when I look at it, it was an organization almost prepared for it, needed to understand how to commercialize this better, needed to do it in a very focused manner needed to find a way to like, look, explain, create the right product, portfolio strategy, and things like that. So that was the excitement. And that's what I'm here for. Find a way to continue to develop Versius into new areas, which will provide better obviously results, and also to reach more and more patients in more than one markets.

Henry Peck  26:49  
I want to come back to that commercialization strategy, but something you said about the opportunity for robotics to penetrate areas where the awareness is low. Dr. Slack, when we first met, you said that you don't think the industry or the world more broadly has an appreciation for what robotics can be in medtech beyond what we see today. Can you maybe share some of those thoughts as to the future of where this can go clinically, technologically, Luke as well. But what can robotics be that we haven't seen? 

Mark Slack  27:18  
I mean, the first thing is, is a penetration to the market. So there's a growing awareness that poor medical technology and poor delivery of decent medical systems is an economic impairment to many low and middle income countries. And they actually are where they need to up the game in terms of standards and so on. So we don't distinguish if you need a robot for a person having an operation in New York, you also need a robot for a person having an operation in Karachi. And we have followed that strategy. The other one, just to put in is safety. In the 90s, when minimal access surgery was introduced, it was almost carnage. And there were many 1000s of people injured and harmed with a pooor introduction. So that's why we invested so much in education to make absolutely certain that was safe. But in order to measure that safety, we have a registry of all comers. So when people start using the robot all their their intraoperative, and their personal details are entered into a registry, which is then delivered to them on an app on their phone. And we can actually confirm and we have published data in big journals like animals and British Medical Journal, demonstrating that we have safety equal to if not better than the published robotic and laparoscopic literature. But of course, we just starting to now prise open where can we do better. And I've always been reluctant to say robotics is better than mineral access, I just wanted to say it is good as that easier to attain, and therefore will be better for the community. But we are not going to see the glimmers of ways it's better as well. And in some small, especially with our vs robot, small cavity surgery, we think we can really do special things in pediatrics and in transoral robotic surgery and in, in thoracic surgery where where the small cavity that we're operating in, and the small effects, we have small ports makes a big advantage. And I'm now getting surgeons approaching me with ideas saying I think your robot will be good at that. And and that's the exciting point about having it in the hands of so many surgeons around the world is the feedback and we are very open to feedback is now helping us see where we should strategize and where we should go in order to really be using the robot where it is best.

Henry Peck  29:37  
And such an exciting promise. I think the some of the common pushback on robotics from those that are aware and have adopted has always been that there is potentially a cost increase without necessarily a clinical benefit to the patient. That's provable. Empirically, you're talking about the ergonomic benefits, but here you're citing areas where this robot is going to enable new approaches. his current approach has to be done better for the patients and the clinicians, which really opens up a whole new possibilities .

Mark Slack  30:05  
And things like it takes on a really common like pain. Now pain people are for pain is killing more Americans than the Vietnam War, the entire AIDS epidemic and motor vehicle crashes. Wow. So So 7% of patients put on an an opioid analgesic post op will be addicts a year later, 7%. So anything that reduces pain and obviates the need for opiates is really important. And because of the way it Luke's designed this way, the robot goes in and you can explain more, it knows exactly where it passes through the skin, it's called a virtual pivot point. So our robot puts no pressure against the skin. And we are noticing a market because of the unique architecture of the Vs, we're noticing a reduction in pain, which is fairly significant. And we've even seen it in some of our laboratories, preclinical laboratories, with poor sign models. So it's it's those are just all stuff that's really coming together, you know, as we see the excitement, and because that just excites us even more. 

Henry Peck  31:11  
And yeah, go ahead, Luke. 

Luke Hares  31:12  
From a technical perspective, and from a product perspective. at some levels, I I'm really proud of the fact that if you look back on the sketches, and the CGI we had 10 years ago, we basically got it right. So you know, Versius looks a lot now like it looked, then I think some things will continue to change and improve the range of instruments, all the boring stuff, the range of instruments, the Advanced Visualization, all of that sort of regular stuff will continue to get better. What ultimately, though I aspire to is, is people not noticing, there is a versus in the OR? And by that I mean, currently, it's like, we've got a robotic system, tada, tada, depending on which one you've got. Actually, I want people to come into an airlock. And will there be arms perhaps attached to the ceilings or on a pedestal to the side? Yes. Will there be a console? Yes. But all of that is essentially transparent. It's just part of the furniture in every OR for doing minimal access surgery, why would you do it in the extraordinarily difficult manual ways that Mark described so well, it should just be the ubiquitous tool for enabling everyone to have minimal access surgery. And when it achieves that it won't be special, you know that, that that's really where I want to end up this technology, derivatives of this technology, enabling everyone to have the right kind of surgery. Under that point, yeah, it'll just be mundane.

Henry Peck  32:48  
Amazing. Supratim. It sounds like there's a big vision here to deliver on and obviously coming into the CEO role, you're keenly aware of the market concentration that exists today and surgical robotics, other players in the space? How are you thinking about the future of commercialization of the company? With the new capital that you raised? What role does that play? Talk to us a little bit about, you know, where this is going next?

Supratim Bose  33:09  
Yeah, I think the first and foremost step is continuing to focus on how to keep providing a better and better versus in the future. So when we look at the investments, that's what the first thing we have to look at. So Luke, talked about the idea, as Mark said, What What's your should be able to do? And what would it make us to make this a part of the normal operating room, anybody builds an operating room, it should not be I need I have a robot. It's part of an any operating room, I think that vision itself is a part of the thing that we are trying to look at and how to create here. In terms of commercialization, we will continue to focus and look at markets where we think the penetrations are low, the market creation can be done. And so we have three levels of approaches to look at. But that is robotic already done, where there is no robotic done and when there is a mix of you know, bar to reach not there and concentrate in a manner that people appreciate and understand how this works. Yes, fits in the overall approach and take the path which will reach it to more and more hospitals and patients. So finally, the old commercial strategy would be what Luke explain, that everybody should appreciate and adopted. And we put it at a level and build models which will enable hospitals to adopt it. Yeah. So we have to be creative in different markets, we have to build business model which is market appropriate. We are not going to standardize and say this is the only way to approach the market. And so that's where the main focus is today. Create a market appropriate business model, which will help us to reach more patients

Mark Slack  34:59  
But also And the entire company is really behind this analogy. I'm in a very privileged position of being a chief medical officer in a company that says progressive as it is towards patient well being patient health. When I was speaking to Luke or to Supratim, I get it. We have been committed to evidence based medicine. We've done 350 categoric studies before we touched a human. But we are also committed to value based medicine. And I'm afraid the world has to actually start to embrace value based medicine, we can't just have introduction of fancy tools and tricks unless they are genuinely doing good. And at the same time, adding value to the society that we're working within the medical society. And so a lot of what we've done, and every single thing we do, we publish, so that we have this commitment to evidence based medicine, and most especially value based medicine, because otherwise, we will live in a world especially in the high income countries, we will no longer be able to afford our health systems.

Henry Peck  36:01  
Luke, it'd be to kind of start to wrap us up, and then we'll go down and hear some closing thoughts. You talked about some of the software innovation and the digital features that we'll be able to enable, you know, having multipolar bipolar energy or stapling, that's being done outside of a field of vision corrected or stopped, or at least reminded and questioned. Things like that, that are interoperative digital solutions on top of this architecture, maybe set the stage a little bit more for the future of what a next generation Versius system could either look like function like some of the features that could be present in that system will involve hardware and software, purely this architecture with a beefed up software ecosystem built on this registry. 

Luke Hares  36:41  
The hardware will always be important. I mean, you the statement you made earlier about software becoming more and more important, absolutely true. You fundamentally can't do many of these things unless you have first class hardware. So you have to have the robot. The things that I imagine will be different, though, is ever so slightly, the kind of sort of man machine interface and control during the procedure will have changed, the surgeon will both be being fed more information in terms of preoperative imaging, but also the steps of the procedure, you know, standardization of surgery, first, we do this, first we do this, then we do this, then we do this, then we do this. And the system will track as you move through those steps. So information coming in. And secondly, that guidance as well, you know, okay, we're doing this step, actually, you shouldn't be over there. You should be over here. Do you really need to be over there? Or what about this instrument you've left over there? So I think you'll find it, it'd be much like the experience of driving a modern car compared to the experience of driving a car 50 years ago, you get into a car now, first thing you do is you say, Where are you going and you put it into the sat nav. The second thing you do is you have to brake hard, the ABS cuts in and stops you skidding? Neither of those things happened 50 years ago, if you imagine in surgery, I think those the equivalent of those things will happen with surgical robots. And most of the time, actually, it will make a lot of difference, because most surgeries pretty good. But when it does make a difference, you'll be very glad it was there.

Henry Peck  38:20  
Yeah. And I appreciate that call out to to not just the interoperative digital solutions. But the preoperative imaging that you mentioned, post operative patient outcome monitoring and how that feeds back into surgery. And what we can learn, Mark maybe a couple of comments on that, as we as we close up here as to where you're thinking about not just interoperative digital solutions, but pre post and perioperative digital solutions, whether through partnerships or your own development to help continue to build this ecosystem. Yeah,

Mark Slack  38:45  
well, I mean, on a lighthearted note, Luke is very passionate about those changes in modern cars, because the car who drives is about 50 years old, and probably shouldn't be allowed on the road anymore. But anyway, that's an aside. Yes, I think, you know, surgery has to be considered in the whole, it's your preoperative phase. It's your interrupter phase in your post operative phase. And good surgery encompasses all three of those phases. And so I can see where we start to add analytics in preparation that helped us during the operation. And then like we have the registry that we way more sophisticated, looking at the use of and it's a slightly dirty word wearables with what they can do to help you with your monitoring and so on. And so I do see a much more structured environment. And also, you know, there's software excitement, where, as Luke said, where it would say, right, you got a patient is this old, and you're going to do this and the, you know, survival rate for a person with that combination is x, do you really want to do that? So I do think we're moving into a very exciting phase in medicine generally, and we're very excited to be part of a small part of it, producing a tool that rarely rarely makes a big difference. 

Henry Peck  40:01  
Fantastic and Supratim will pass it to you to end us with some closing thoughts on the market CMR surgical the story and where you're going.

Supratim Bose  40:09  
I think like we started with, it will be a very attractive market in the long term robotic, and the growth rates will continue to be high. I think for CMR itself. 15,000 procedures done launch in 2019, two and a half years in COVID. So actually, it's two and a half years. And we are not present in the world's three biggest markets yet because of regulatory US, Japan and China. So you have to look at this 15,000 In that context just yet. So the opportunity for CMR is just phenomenal. Right? Once we enter those markets, you can imagine what could be the levels of which we can gain in this business? Yeah. So I think as we are training becomes easier, doctors understand easier that this is easier to adopt. And you train all upcoming and the surgeons which we plan to do CMR will stand out as a very unique robotic system that Luke explained, that a very creative surgeon doing different things which we can talk of later, including somebody in Delhi trying to assemble is five words. So he moves with the system from one word to another. So entire prep, patient preparation time is almost already. So if you look at that it is stunning what you can do with someone, right? So you're in doing 10 procedures a day one surgeon. So that's the advantage that we want to build on. Like I said, Yeah, so once people are aware of this, adoption will be very good. So I think the future is bright both for robotic assisted surgery and for CMR. 

Henry Peck  41:49  
Fantastic. Well, Luke, Dr. Slack, Supratim. Thank you very much for joining us here at LSI. Europe 23 today and for this conversation, and thank you all for tuning in and listening. Welcome to day two. We're looking forward to seeing you all