Titan Medical CEO Cary Vance discusses the Enos robotic surgery platform, deals with Medtronic and supply chain silver linings.
Titan Medical President and CEO Cary Vance said he knew what he was getting into when he was approached about leading the robotic surgery company.
“The challenges, I knew what they were,” said Vance, who had served on the company’s board for two years when he became CEO of Titan in July. “I knew the opportunity we had to meet those challenges and knew the people I’d be working with … could make sure whatever strategy we have is executed.”
Vance sees “a unique opportunity” ahead of Toronto-based Titan, which is manufacturing the Enos surgical robot platform with plans to enter into clinical use next year.
In June, Titan delayed its FDA investigational device exemption (IDE) submission timeline for the robotic single-access surgery system, pushing back from the first quarter of 2023 to mid-year. The company said supplies of certain key components and materials delayed production and verification and validation testing.
Titan still has commercialization earmarked for early 2025 if all goes according to plan throughout the regulatory process.
“You have to not only go through that process and execute on it, but you need to be able to think ahead,” said Vance. “Think ahead to pricing, reimbursement, commercial strategy. You also need to think about innovations that need to occur post-launch. Just because you’re competitive in 2025 when you go to market, doesn’t mean you’ll still be competitive with that exact product in 2027.
“You need to be able to add additional features that address certain needs that the market has,” he continued. “We intend to do that.”
About Titan’s Enos surgical robot
Enos has a light, camera and multiple arms that drive instruments by the tableside. Instead of multiple arms coming from multiple directions and through multiple incisions, the arms, instruments and camera enter the patient’s body through a single 25 mm insertion tube.
Because the arms come through one insertion, they must be dexterous. Vance described them like snakes in terms of their flexibility. They have reach and flexibility, but also stability for grasping and moving tissue.
With an open procedure, though, surgeons must be able to see what’s happening, Vance said. Titan’s Enos has cameras allowing for visualization. That includes a steerable 3D HD camera for physicians to focus on the surgical site while remaining present in the room.
Vance said Titan’s platform offers intuitive hand controls and comfortability for the physician. Physician comfort ensures they don’t get fatigued to the point that they rush processes or make poor decisions.
The single incision has benefits for the patient: reduced pain and less opportunity for infection and scarring. That means less need for opioids and pain medication, shorter recovery time and faster discharges.
“We try to make sure we’re addressing all the stakeholders,” said Vance. “When you think about a surgery like that, you’re thinking about the physician, their level of comfort, their ergonomics, their ability to see and do what they need to do. … We believe that when we go to market, if we want people to care, [the system] needs to address the real value drivers that are out there.”
Titan’s work with Medtronic
Titan has a longstanding relationship with medtech giant Medtronic, including a range of purchase orders, milestone payments and more.
In September, Titan and Medtronic entered into a development deal on surgical robots. The agreement built on a 2020 development and license deal. Titan achieved all three milestones laid out in the agreement, including raising $18 million in capital in October 2020. In May, Titan signed a $2.6 million purchase order from Medtronic to provide instruments and cameras for preclinical activities.
“Medtronic’s interest has been in Titan’s ability to innovate,” said Vance. “That was the genesis of the arrangement we had about two-and-a-half years ago when we were asked to develop some technology for them.”
Vance said the arrangements with Medtronic provided a bit of a culture change at Titan. It shifted what he considered an “execution culture” to an “accountability culture.”
There’s an additional benefit in the purchase agreement. Titan manufactures instruments and cameras for Medtronic’s preclinical use. In doing that, Titan increases its own know-how around that process by being able to “look over their shoulder” a bit, Vance said. Witnessing Medtronic’s preclinical work can help Titan as it moves to use that same technology with its own system.
“We’re really proud of our team,” said Vance. “Just like any small company, you really need to learn how to execute well on milestones. I think we were able to do that really well for them, both on-time and at the level of technology they were looking for. They were very pleased with us and they paid us. They wouldn’t have paid us if they weren’t pleased with it.”
Navigating supply chain conditions
The supply chain problems that delayed Titan’s regulatory timeline had some silver linings.
Vance said the effort to work through those issues brought Titan closer to its manufacturing partners. For example, while Titan manufactures its own instruments and cameras, it contracts the physician workstation and patient cart manufacturing to a company called Benchmark.
“It’s a difficult macro environment in the supply chain,” Vance said. “Because of that, it’s not like we could just say, ‘Here’s the design. Here’s what we have. Build it.’ It was us, working daily on the phone and going to their facilities with them coming to ours to help creatively solve how to overcome it.”
Vance put it simply: time is money, and money is survival in Titan’s business. The company can’t waste a day or even a minute. Those supply chain constraints forced companies to get creative and fostered a strong response from Titan and a better relationship with its contract manufacturers.
“We’re very pleased with our ability to address that issue,” said Vance. “We have really smart people on our board who are dealing with this issue at a much larger scale. They have given some really good advice as to different avenues we can take to solve it. That’s been very helpful.”
The future of surgical robotics
Is the surgical robot space getting too crowded? Intuitive Surgical remains a leader, while Medtronic and Johnson & Johnson are making their plays. Smith+Nephew, Stryker, Zimmer Biomet and more are also competing.
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But competition can be a good thing, with rival companies pushing each other and together helping take robotic surgery mainstream.
“It’s good for companies to push the envelope,” said Vance. “Small, large, multi-arm, single-arm, endoluminal, disposable, it’s all out there. … I think the rising tide of companies will lift all the boats in robotics.”
The challenge remains to provide the best solution economically, clinically and logistically. Even with all the companies around, Vance believes Titan will still be second to market in the single-access space, following Intuitive.
Even in the competitive environment, Vance believes a share of the market is there for Titan’s taking.
“Can we take some of that market share? We believe we can but with the market share that [Intuitive has], they’re still in the single digits of the number of surgeries that are performed,” Vance said. “The bigger picture is moving from laparoscopic and manual surgeries to robotic surgeries. We’ve barely scratched the surface there.