Case 3:21-cv-03496-SK Document 1 Filed 05/10/21 Page 1 of 33
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`HALEY GUILIANO LLP
`JOSHUA V. VAN HOVEN (CSB No. 262815)
`E-Mail: joshua.vanhoven@hglaw.com
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`GREGORY J. LUNDELL (CSB No. 234941)
`E-Mail: greg.lundell@hglaw.com
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`111 N Market Street, Suite 900
`San Jose, California 95113
`Telephone: 669.213.1050
`Facsimile: 669.500.7375
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`RICHARD T. MCCAULLEY (applying pro hac vice)
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`E-Mail: richard.mccaulley@hglaw.com
`116 W. Hubbard, Unit 20
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`Chicago, Illinois 60654
`Telephone: 312.330.8105
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`Attorneys for Plaintiff
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`SURGICAL INSTRUMENT SERVICE COMPANY, INC.
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`UNITED STATES DISTRICT COURT
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`NORTHERN DISTRICT OF CALIFORNIA
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`SURGICAL INSTRUMENT SERVICE
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`Case No. ________________________
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`COMPANY, INC.,
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`Plaintiff,
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`vs.
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`INTUITIVE SURGICAL, INC.,
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`Defendant.
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`1. SHERMAN ACT § 1 - TYING
`2. SHERMAN ACT § 1 – EXCLUSIVE
`DEALING
`3. SHERMAN ACT § 2 - MONOPOLY
`4. SHERMAN ACT § 2 – ATTEMPTED
`MONOPOLY
`5. VIOLATION OF LANHAM ACT
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`JURY TRIAL DEMANDED
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`COMPLAINT
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`Plaintiff Surgical Instrument Service Company, Inc (“SIS”) brings this Complaint against
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`Defendant Intuitive Surgical, Inc. (“Intuitive”) for antitrust violations of tying, exclusive
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`dealing, monopolization, and attempted monopolization under the Sherman Act, and unfair
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`competition under the Lanham Act.
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`111 N. Market St.
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`San Jose, CA 95113
`United States of America
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`COMPLAINT
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`Case 3:21-cv-03496-SK Document 1 Filed 05/10/21 Page 2 of 33
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`INTRODUCTION
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`1.
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`SIS has 50 years of experience servicing surgical instruments and equipment
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`ranging from simple devices such as forceps and scalpels to complex electromechanical devices
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`such as flexible video endoscopes, powered orthopedic devices, and surgical video systems. SIS
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`employs exhaustive inspection and repair procedures to ensure that previously used surgical
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`instruments are only returned to the operating room in accordance with specifications. SIS’s
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`services save health care providers and patients millions of dollars a year, reducing the per-surgery
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`cost of procedures without compromising instrument operation or patient safety. SIS is a trusted
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`nationwide partner for hospitals, health care systems, and group purchasing organizations
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`(“GPOs”), including in this District.
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`2.
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`Since the late 1990’s, defendant Intuitive has been the leading provider of robotic
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`surgery systems for minimally invasive soft tissue surgeries. In contrast to operating directly on a
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`patient, the surgeon using Intuitive’s system remotely operates a multi-arm “da Vinci” surgical
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`robot from a console that receives video of the surgical site and includes means for precisely
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`controlling the movement and operation of surgical tools known as EndoWrists. EndoWrists
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`include traditional surgical tools such as forceps and scalpels and are attached to the robotic arms
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`based on the type of surgery to be performed. The robotic arms include motors that control cables
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`within the EndoWrist in response to the surgeon’s inputs, allowing precise multi-axis movement
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`of the “wrist” of the surgical tool that is not possible in traditional surgeries.
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`3.
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`Intuitive has monopoly power in the relevant markets of surgical robots for
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`minimally invasive surgeries, the instruments used in such surgeries, and the servicing of those
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`surgical robots, with a 99%+ market share. In the early 2000’s, Intuitive’s Form 10-K filings noted
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`a use counter to limit the number of operations performed with EndoWrist instruments, and
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`acknowledged its strategy to “sell the instrument for a fixed number of uses or hours and
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`effectively price our EndoWrist instruments on a per-procedure or per-hour basis.” As Intuitive
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`has since gained and exercised monopoly power in the relevant markets, this strategy has become
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`extremely profitable. Although revenue from the da Vinci robots initially exceeded revenue from
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`COMPLAINT
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`Case 3:21-cv-03496-SK Document 1 Filed 05/10/21 Page 3 of 33
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`instrument and accessory sales, by fiscal year 2013 Intuitive’s revenues from instruments and
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`accessories surpassed da Vinci robot revenue. By fiscal year 2019 instrument and accessories
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`revenue exceeded $2.4 billion, or more than a $1 billion more than sales of da Vinci systems.
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`Although Intuitive does not break out its gross profit for instruments alone, its gross profit on
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`instruments and da Vinci systems is over 70%.
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`4.
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`In connection with the purchase or lease of da Vinci Surgical products, Intuitive
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`requires customers to enter into a Terms and Conditions Agreement ("Sales Agreement") and a
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`Use, License and Service Agreement ("ULSA"). In connection with the agreements required to
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`purchase or lease an Intuitive robotic surgical system, Intuitive demands that customers further
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`agree to a limited license for the use of EndoWrist instruments. The limited license expires once
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`an EndoWrist instrument is used up to its maximum number of uses as specified in the
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`documentation accompanying the particular instrument. Intuitive’s ULSA prohibits customers
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`from engaging any unauthorized third party to repair, refurbish, or recondition EndoWrist
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`instruments, whether before or after the limited use license has expired. Further, if a customer has
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`or attempts to have an EndoWrist instrument repaired, refurbished or reconditioned, Intuitive has
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`threatened to terminate the entire Use, License and Service Agreement with the customer
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`immediately upon written notice, and any warranties applicable to the da Vinci robotic surgical
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`system will become void. Intuitive has advised its customers that should Intuitive or its personnel
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`determine, after having accepted a service call or a purchase order for a service call, such as after
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`an Intuitive Field Service Engineer arrives at a customer’s site for a service call, that the da Vinci
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`robotic surgical system has been used with EndoWrist instruments refurbished or modified by any
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`unauthorized third party, Intuitive will no longer provide any service for the customer’s entire
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`robotic system.
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`5.
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`Plaintiff SIS has detailed procedures for servicing used EndoWrists to original
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`specifications and returning them to service. These procedures include disassembly of the
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`EndoWrist, inspection of all components, adjustment of components as necessary, confirming all
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`movements, and setting a counter to Intuitive’s original counter value. While these procedures are
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`COMPLAINT
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`Case 3:21-cv-03496-SK Document 1 Filed 05/10/21 Page 4 of 33
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`extensive and return the EndoWrist to original performance specifications, the cost to the hospital
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`is a fraction of what Intuitive charges to buy a new EndoWrist. In 2019 and 2020, SIS entered
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`into contracts and was in discussion for other contracts to provide EndoWrist repair services to
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`numerous hospitals, health care systems, and GPOs. The cost savings were so substantial that one
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`of the nation’s largest health care systems awarded SIS’s EndoWrist repair program a prestigious
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`annual award for cost savings. Revenues for SIS, and savings to hospitals and patients, were
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`anticipated to be in the tens if not hundreds of millions of dollars.
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`6.
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`When Intuitive discovered that its customers were using SIS’s services, it
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`immediately leveraged its anti-competitive agreements and monopoly power to crush this threat
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`to its supra-competitive EndoWrist profitability. Intuitive’s agreements with hospitals include
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`numerous restrictive terms that allow Intuitive to render the da Vinci robots effectively inoperable,
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`and it threatened to exercise those terms against hospitals that used SIS’s services. Intuitive also
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`made misleading statements that use of refurbished EndoWrists would violate FDA requirements
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`and intellectual property rights.
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`7.
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`Despite the massive savings to hospitals and patients from SIS’s EndoWrist
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`program, SIS’s customers and potential customers had no choice but to capitulate to Intuitive’s
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`threats. Because of Intuitive’s monopoly power in minimally invasive surgical robots, the
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`instruments for those robots, and the servicing of those robots, there are no realistic alternative
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`suppliers in those relevant markets. Health care providers have made massive capital investments
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`in da Vinci robots, surgeons are specifically trained to perform surgery with those robots, and a
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`large number of patients choose da Vinci robotic surgeries despite a significantly higher out-of-
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`pocket cost. To lose access to existing da Vinci robots would not only waste an expensive capital
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`investment, but would effectively foreclose hospitals and surgeons from performing certain types
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`of surgeries.
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`8.
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`Intuitive’s anti-competitive conduct cannot be justified by any purported safety or
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`regulatory requirements. All components of the EndoWrists are medical-grade materials that are
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`capable of many times more uses than permitted by Intuitive’s unilaterally programmed counter.
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`COMPLAINT
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`Case 3:21-cv-03496-SK Document 1 Filed 05/10/21 Page 5 of 33
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`SIS’s services ensure that the inspected or repaired EndoWrists meet all original specifications,
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`and SIS sets the instrument counter to the original value provided by Intuitive. In sum, the only
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`purpose of Intuitive’s anti-competitive conduct is to maintain supra-competitive “per-procedure”
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`EndoWrist pricing. By leveraging its monopoly power and anti-competitive agreements in this
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`manner, Intuitive has violated the Sherman Act’s prohibitions on monopoly, attempted monopoly,
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`exclusive dealing and tying, and the Lanham Act’s prohibition on unfair competition.
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`9.
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`Intuitive is the dominant supplier of robotic surgical systems for minimally invasive
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`soft tissue surgeries. Intuitive essentially has no competition in this market. Additionally, Intuitive
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`is the dominant supplier of instruments used with minimally invasive soft tissue robots and the
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`dominant supplier of servicing for the robots -- essentially having no competition in either of these
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`markets as well.
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`10.
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`Intuitive has used its monopoly power in the EndoWrist instrument replacement
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`aftermarket, as well as in the servicing of surgical robots, to engage in a variety of anticompetitive
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`practices. These exclusionary practices essentially prevent hospitals, health care systems, and
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`GPO’s from having access to competitors that offer to repair and refurbish EndoWrist instruments
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`which have been previously used.
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`11.
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`Intuitive wields its monopoly power in the market for robotic soft tissue surgery
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`systems to coerce hospitals, health care systems, and GPO’s to act in ways that have
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`anticompetitive effects thus harming competition. Such coercion is backed up by Intuitive’s
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`threats to withhold technical support and servicing for the robotic surgery systems purchased by
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`hospitals, health care systems, and GPO’s and to deny those customers access to additional and/or
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`replacement EndoWrist instruments.
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`PARTIES
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`12.
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`Plaintiff Surgical Instrument Service Company, Inc. is an Illinois corporation with
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`a principal place of business at 151 N. Brandon Drive, Glendale Heights, Illinois.
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`13.
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`Defendant Intuitive Surgical, Inc. is a Delaware corporation with a principal place
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`of business at 1020 Kifer Road, Sunnyvale, California.
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`San Jose, CA 95113
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`COMPLAINT
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`Case 3:21-cv-03496-SK Document 1 Filed 05/10/21 Page 6 of 33
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`JURISDICTION AND VENUE
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`14.
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`Jurisdiction - This Court has subject matter jurisdiction over this action pursuant to
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`28 U.S.C. §§ 1331 and 1337(a) and 15 U.S.C. §§ 15, 22, and 1121. Defendant has been engaged
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`in interstate commerce during all relevant times of the Complaint.
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`15.
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`Jurisdiction - This Court has personal jurisdiction over Defendant due to its
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`business activities in this District, including Defendant being headquartered in this District.
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`16.
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`Venue is proper under 15 U.S.C. § 22 and 28 U.S.C. § 1391(b) and (c). Intuitive is
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`headquartered in this District and a substantial part of the events giving rise to all claims occurred
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`in this District.
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`17.
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`Intradistrict Assignment – Pursuant to Civil L.R. 3-2(c), the present action is an
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`antitrust action that is assigned on a district-wide basis.
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`GENERAL ALLEGATIONS
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`I.
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`SIS’S SURGICAL INSTRUMENT REPAIR BUSINESS
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`18.
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`Founded in 1971, SIS has been a leader in surgical instrument and equipment
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`service and repair for 50 years. During this time, SIS has safely and effectively serviced millions
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`of surgical instruments for health care providers. SIS’s best-in-class team, equipment, and
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`processes are trusted by hundreds of hospitals throughout the country, including hospitals in this
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`District. SIS does not merely inspect and repair surgical instruments, but also functions as an
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`operational partner for its client hospitals, improving their operations and processes.
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`19.
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`SIS services a wide variety of instruments, ranging from relatively simple
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`mechanical devices such as traditional standard and laparoscopic instruments to complex
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`instruments such as electrical and pneumatic saws and drills, a wide range of optical and video
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`endoscopes, and surgical video equipment. Based on the FDA’s Quality Systems Regulation
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`(QSR) and current Good Manufacturing Practices (cGMP), SIS develops inspection and repair
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`processes that ensure that any equipment returned to the hospital or surgical field will function
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`properly.
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`COMPLAINT
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`Case 3:21-cv-03496-SK Document 1 Filed 05/10/21 Page 7 of 33
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`20.
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`Based on this extensive experience with a wide range of surgical instruments, SIS
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`is intimately familiar with the capabilities and lifespan of medical grade materials and components
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`such as stainless steel, composites, and tungsten used in such devices. SIS technicians employ
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`industry-leading procedures for inspection, alignment, sharpening, electrical insulation test, and
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`additional necessary steps to return instruments to the field with confidence. Instruments that are
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`regularly serviced by SIS are capable of dozens, hundreds, or thousands of uses over their lifetime,
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`depending on the type of equipment and materials.
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`21.
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`SIS’s services, and those like it, are essential to the safe and cost-effective operation
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`of hospitals throughout the country. SIS’s preventative maintenance and inspection services
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`ensure that instruments used in medical procedures and surgeries are safe. Its repair services
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`substantially extend the life of surgical instruments, resulting in substantial savings for health care
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`providers and patients.
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`II.
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`INTUITIVE’S DA VINCI SURGICAL ROBOTS AND ENDOWRISTS
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`22.
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`For over 20 years, Intuitive has developed and sold the “da Vinci” line of minimally
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`invasive surgical robot systems. A previous generation of da Vinci surgical robots that is currently
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`being phased out is called the “Si,” while the most recent “Xi” version was launched in 2014.
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`Additional versions of these systems also exist under the X and SP monikers. Collectively, there are
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`over 3,500 da Vinci robotic surgery systems employed by United States hospitals and surgery
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`centers, and over 5,500 worldwide.
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`23.
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`The da Vinci system generally includes a multi-arm surgical robot (left), surgeon’s
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`console (center), and a vision cart (right):
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`COMPLAINT
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`Case 3:21-cv-03496-SK Document 1 Filed 05/10/21 Page 8 of 33
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`24.
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`A new da Vinci system, including the surgical robot vision cart, typically costs
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`more than $2.0 million. Although Intuitive has begun leasing the da Vinci system to some
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`customers, the vast majority (> 85%) of active da Vinci systems are purchased by hospitals as
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`capital equipment.
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`25.
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`The instruments used in the surgical procedure are attached to the arms of the
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`surgical robot, and the surgical robot is positioned relative to the target surgical region of the
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`patient. All of the 80+ instruments used with da Vinci robots are supplied by Intuitive under its
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`EndoWrist brand. EndoWrist instruments are the only FDA-approved instruments for use with
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`the da Vinci systems.
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`26.
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`In a typical procedure, a number of small incisions are made to provide the
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`EndoWrist surgical instruments access to the target surgical region. A camera provides high-
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`definition 3D images to the surgeon at the surgeon’s console and to other operating room personnel
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`via a large screen of the vision cart. The surgeon directs the surgery by manipulating controllers
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`on the console, which allow for precision control of the robot arms and EndoWrist instruments.
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`This allows the surgeon to specify movements on a scale that is at least an order of magnitude less
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`than the surgeon’s actual hand movements at the console.
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`27.
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`The surgical instruments located at the end of the EndoWrists, such as scalpels,
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`clamps, forceps, scissors, and needle drivers, are substantially identical to similar instruments used
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`COMPLAINT
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`Case 3:21-cv-03496-SK Document 1 Filed 05/10/21 Page 9 of 33
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`in traditional surgeries. In fact, Intuitive reported to the FDA that EndoWrists and traditional
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`surgical instruments “are essentially identical… in terms of shape, size, function, and tissue
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`effect,” “are substantially equivalent in intended use and/or method of operation,” and
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`“demonstrate substantial equivalence ... in terms of safety and effectiveness.” The FDA agreed
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`and “determined the [EndoWrist] device” is “substantially equivalent” to the traditional devices,
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`and thus granted EndoWrist 510(k) certifications based on these predicate devices. EndoWrist
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`devices are constructed from traditional medical grade materials, such as stainless steel,
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`composites, and tungsten cables.
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`28.
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`An example of the working end of an EndoWrist Force Bipolar instrument is
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`depicted in the image below:
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`29. Many of the EndoWrist instruments have a wide degree of motion at the working
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`tip of the instrument, capable of rotation in multiple planes, and providing an extra level of
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`dexterity that is not available in traditional surgical instruments. The movement at the instrument
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`tip is controlled by tungsten cables located within the EndoWrist. These tungsten cables are
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`actuated by internal pulleys of the EndoWrist that mechanically interface with motors within the
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`robot arms of the da Vinci system. The motors within the robot arms in turn cause the movement
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`of the instrument tip commanded by the surgeon by changing the position of the pulleys and
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`tungsten cables. For the vast majority of EndoWrist instruments, these mechanical components
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`provide for all controls of the instrument tip within the EndoWrist.
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`COMPLAINT
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`Case 3:21-cv-03496-SK Document 1 Filed 05/10/21 Page 10 of 33
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`30.
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`EndoWrists also include an internal memory chip. The internal chip does not
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`control the movement of the EndoWrist instrument tip, but instead stores certain information about
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`the particular EndoWrist, including a model number specific to the type of EndoWrist, a part ID
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`specific to the particular EndoWrist, a chip ID for the chip itself, and a counter value for the
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`particular EndoWrist.
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`31.
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`The counter counts the number of times the EndoWrist is attached to a da Vinci
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`robot arm, not an actual measure of usage such as usage time, number of movements, or actuation
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`time. The chip also does not monitor the components of the EndoWrist for conditions that would
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`be indicative of failure, such as the lack of response of the instrument tip to requested movement
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`or a motor requiring excessive force to cause a desired movement of the tungsten cables.
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`32.
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`The da Vinci robot system queries the memory chip prior to performing any
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`operations with the particular EndoWrist instrument. After a certain number of uses, usually
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`limited to ten, the EndoWrist instrument is rendered non-operational, based solely on the number
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`of times it is attached to a da Vinci robot arm, without any regard to the actual underlying physical
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`condition of the EndoWrist instrument. Without the services of providers such as SIS, the hospital
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`has no choice but to buy a brand-new replacement EndoWrist instrument from Intuitive at full
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`price.
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`III.
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`SIS’S ENDOWRIST REPAIR BUSINESS
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`33.
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`Services of the type performed by SIS are permitted by the FDA. SIS has properly
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`repaired millions of surgical devices and instruments over its 50 years in business as an
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`independent services operator. After service by SIS, the surgical device or instrument is returned
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`to the customer for its original intended use. Indications for use are not affected, and the surgical
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`device or instrument is returned to its original safety and effectiveness.
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`34.
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`SIS has created a program for the inspection and repair of EndoWrist instruments.
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`The SIS repair procedures include an initial disassembly and inspection, checking the mechanical
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`operation and integrity of all mechanical components, an electrical integrity check to confirm that
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`electrical insulation, cleaning, sharpening or alignment of the instrument tip, and a series of tests
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`COMPLAINT
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`Case 3:21-cv-03496-SK Document 1 Filed 05/10/21 Page 11 of 33
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`to confirm that all the movements of the instrument tip are within original specifications. SIS also
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`sets the counter to a value corresponding to the initial setting of a new EndoWrist instrument.
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`35.
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`These procedures are similar to procedures that SIS has performed for decades on
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`dozens of types of surgical instruments and medical devices of similar or greater complexity. The
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`materials of the EndoWrist instruments are the same medical grade materials that typically last
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`through hundreds of surgeries and autoclave cycles in other surgical instruments and in medical
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`devices. Particularly after completion of SIS’s rigorous set of procedures, the EndoWrist
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`instruments are suitable for many more uses, and at least a number of uses equivalent to Intuitive’s
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`originally specified usage limit. In fact, independent testing has shown that EndoWrist instruments
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`serviced by SIS are suitable for 50 or more uses. Nonetheless, SIS returns the counter value to the
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`original value specified by Intuitive.
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`36.
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`Throughout 2019 and 2020, SIS spoke with numerous hospitals, health care
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`systems, and GPOs regarding its EndoWrist repair and refurbishment offering. These health care
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`providers universally conveyed their frustration with Intuitive and its abusive business practices.
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`In sum, Intuitive’s aggressive and ever-changing tactics for extracting an exorbitant per-surgery
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`fee for EndoWrists is financially damaging for hospitals and results in excessive costs for patients.
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`37.
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`Accordingly, SIS entered into service contracts with a number of health care
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`providers, including health care providers in this District and a nationwide GPO. Many of these
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`health care providers were existing SIS customers, such that the ramp up for performing
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`incremental services on EndoWrist instruments would be minimal. SIS was also in late-stage
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`negotiations with numerous additional health care providers, including a number of large health
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`care systems. These agreements and other likely customers would have been worth millions in
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`annual revenue to SIS.
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`38.
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`SIS has the experience, facilities, equipment, and personnel to perform inspection
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`and repair for EndoWrist instruments nationwide. Just based on its initial contracts, SIS was
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`prepared to service at least 1,500 EndoWrists a month. Based on potential agreements and SIS’s
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`COMPLAINT
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`Case 3:21-cv-03496-SK Document 1 Filed 05/10/21 Page 12 of 33
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`existing experience and capacity, SIS could have easily ramped up these services to service
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`thousands of additional EndoWrist instruments a month.
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`39.
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`SIS charges approximately 30-45% less per EndoWrist than what a hospital would
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`have to pay to buy a replacement EndoWrist from Intuitive.
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`40. While this is a substantial revenue source for SIS, these revenues pale in
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`comparison to the cost savings to hospitals by using SIS to service EndoWrist instruments rather
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`than throwing away and purchasing new EndoWrist instruments from Intuitive. The vast majority
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`of Intuitive’s $2.4 billion in annual instrument sales is for replacement EndoWrists, a large
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`proportion or majority of which would not be needed under SIS’s competitive offering. Indeed,
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`even at its inception the cost savings for SIS’s EndoWrist repair program were so substantial that
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`one of the health care systems awarded the program its prestigious annual award for health care
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`cost savings.
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`41.
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`Unfortunately for health care providers and patients, Intuitive became aware of
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`SIS’s repair program and its relationships with certain health care providers. Intuitive immediately
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`embarked on a scorched-earth pressure campaign to put SIS out of the EndoWrist repair business.
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`And it worked. Faced with coercive threats from the monopoly provider of robotic surgical
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`systems to effectively disable their expensive surgical robots, all of the health care providers
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`backed out of SIS’s EndoWrist repair program.
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`42.
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`In just the last year, health care providers and patients have had to pay hundreds of
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`millions of dollars for unnecessary replacement EndoWrist instruments based on Intuitive’s anti-
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`competitive conduct. Intuitive’s monopoly power and its anti-competitive use of that power are
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`detailed in the following sections.
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`IV.
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`INTUITIVE’S MONOPOLY POWER IN THE RELEVANT MARKETS
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`43.
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`There are three relevant markets for purposes of this action: (1) the worldwide and
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`domestic market for surgical robots used in minimally invasive soft tissue surgery; (2) the
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`worldwide and domestic market for repair and maintenance for surgical robots used in minimally
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`COMPLAINT
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`Case 3:21-cv-03496-SK Document 1 Filed 05/10/21 Page 13 of 33
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`invasive soft tissue surgery; and (3) the worldwide and domestic market for replacement or repair
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`of instruments for use with surgical robots used in minimally invasive soft tissue surgery.
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`44.
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`Intuitive has monopoly power in (1) the worldwide and domestic market for
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`surgical robots used in minimally invasive soft tissue surgery, (2) the worldwide and domestic
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`market for repair and maintenance for surgical robots used in minimally invasive soft tissue
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`surgery, and (3) the worldwide and domestic market for replacement or repair of instruments for
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`use with surgical robots used in minimally invasive soft tissue surgery, such that Intuitive is able
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`to exclude virtually all competition and charge supra-competitive prices in those markets. With
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`respect to the “repair” aspect of (3), Intuitive has leveraged its monopoly power in robots and
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`instruments, and service of those robots, to prevent any repair services from existing and
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`competing within the EndoWrist instrument aftermarket.
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`(1) The Market for Surgical Robots Used in Minimally Invasive Soft Tissue Surgery
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`45.
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`Intuitive’s da Vinci surgical robots are primarily used in minimally invasive soft
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`tissue surgery. Initially cleared by the FDA in 1999, the da Vinci robot was the only FDA-cleared
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`surgical robot until 2015. As of 2015, Intuitive had over 3,500 active da Vinci surgical robots at
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`hospitals worldwide.
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`46.
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`The market for minimally invasive soft tissue surgery using surgical robots is
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`distinct from minimally invasive procedures performed without surgical robots, primarily
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`due to the advantages that robotic surgery provides and the public perception which comes with
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`those advantages.
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`47.
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`In a traditional laparoscopic surgery performed without a da Vinci robot, a number
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`of trocars are placed through the skin in the target area, and function as placeholders for the surgical
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`instruments or other devices subsequently used to perform the surgery. The surgical instruments
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`and a 2-dimensional camera are then manipulated through a number of small incisions in the target
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`area of the patient, while being manipulated or held by the surgeon(s), nurse(s), surgical
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`assistant(s), and physical supports. More complex laparoscopic surgeries typically require more
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`trocars.
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`COMPLAINT
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`Case 3:21-cv-03496-SK Document 1 Filed 05/10/21 Page 14 of 33
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`48.
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`Like laparoscopic surgery, minimally invasive robotic surgeries are advantageous
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`over traditional open surgeries, in that the surgery is performed through a number of small incisions
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`rather than a large incision of open surgery, resulting in decreased infection rates, faster recovery,
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`and better patient outcomes. But da Vinci robot surgeries also have substantial advantages over
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`laparoscopic surgeries. Rather than physically holding surgical instruments or attaching them to
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`physical supports, the da Vinci robotic surgeries have precision robot arms that accurately hold
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`instrument working tips in position without causing physical strain. The surgeon is seated at an
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`ergonomic console viewing a 3D image of the surgical region. The surgeon is not limited by his or
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`her own physical dexterity in manipulating surgical instruments, but can instead make large scale
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`movements at the console that are translated to precision microscopic movements of surgical
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`instruments. Most of the EndoWrist surgical instruments have a precision-controlled full range of
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`motion about multiple axes at the working end of the instrument, as compared to the limi