Intuitive Surgical, Inc.

Intuitive Surgical sells robotic surgical consoles to hospitals, but the actual business runs on the single-use EndoWrist instruments that surgeons must buy for every procedure — the console is effectively the entry point, and the instruments are where the recurring revenue comes from. The instruments work by routing control signals from a surgeon's console through a patient-side cart to a disposable tip, giving the instrument seven degrees of freedom at the surgical site, and the patents covering that three-node loop mean a competitor cannot replicate the dexterity without infringing them. Because each procedure type — urology, gynecology, general surgery — requires its own FDA clearance, the company must maintain active clinical programs just to keep each revenue pathway open, so the width of its clearance portfolio sets the ceiling on how many instrument sales it can generate. The one thing that cannot be engineered around is surgeon training: every surgical team must complete hands-on instruction at a certified physical training center before any instruments are consumed at all, so the number of certified instructors and available consoles at those centers is the hard limit on how fast the installed base turns into paying customers — and if a competing platform ever achieves equivalent dexterity through a non-infringing design, hospitals with da Vinci consoles would have a substitute instrument source and the per-procedure repurchase obligation that the whole model depends on would disappear.