The da Vinci is a robot-assisted system for minimally invasive soft-tissue surgery. A surgeon sits at a console and controls robotic arms beside the operating table. EndoWrist instruments attached to those arms translate the surgeon’s hand movements inside the patient through small incisions.

The system combined features of open surgery with smaller incisions associated with laparoscopic procedures. The opinion recounts evidence of reduced bleeding, pain, scarring, hospital stays and recovery times compared with open or conventional laparoscopic surgery. It also notes that some cancer procedures performed with the da Vinci can’t be performed laparoscopically.

That clinical role helped make the robot difficult for hospitals to avoid. The trial record described surgeons being trained on the da Vinci in medical school and hospitals needing the system to recruit them. Intuitive had installed more than 5,000 robots in the United States, compared with only a few dozen machines from competitors.

An EndoWrist’s programmed life isn’t based on the duration or intensity of each activation. Once the counter reaches zero, the instrument becomes unusable unless its electronics are modified.

Intuitive’s sales agreement prohibits customers from using the da Vinci with an instrument that Intuitive didn’t make or approve. A separate license and service agreement says the limited license for an EndoWrist expires at its maximum number of uses and prohibits unapproved repair, refurbishment or reconditioning.

The resulting commercial chain is straightforward: hospitals acquire the dominant robot, the robot accepts only instruments made or approved by its manufacturer, and each instrument expires on a schedule programmed by that same manufacturer.

Surgical Instrument Service Company, or SIS, is a family-run business that repairs and refurbishes surgical tools for hospitals and surgery centers. In spring 2019, it learned that another company, Rebotix, could modify an EndoWrist circuit board and reset its counter.

The companies divided the work. SIS marketed the service through its hospital relationships, inspected and refurbished the instruments, and handled cleaning. Rebotix reset the counters. SIS charged 40% less than the price of a new EndoWrist from Intuitive.

Beginning in June 2019, around six hospitals used the service for approximately six months. According to the record described by the court, the refreshed instruments performed as expected and there was no evidence of patient harm during that period.

Intuitive then sent letters “strongly discourag[ing]” the hospitals from using the service. The company said using an EndoWrist past its programmed limit materially breached its agreements and warned that it might stop accepting service calls for da Vinci systems used with instruments refurbished by an unauthorized third party.

Every participating hospital dropped SIS’s EndoWrist service. The direct consequence established by the record is narrow but concrete: six hospitals lost access to that lower-priced repair option, and SIS lost those customers. The opinion doesn’t quantify what hospitals subsequently spent on replacements or connect the restriction to patient bills, insurance costs or public healthcare spending.

Rebotix tested a representative sample of EndoWrists through 29 uses and reported no degradation in performance or condition. It tested a smaller sample past 50 uses and again reported no signs of material degradation. The opinion doesn’t state how many instruments were included in either sample.

Intuitive had performed safety validation only through each instrument’s programmed number of uses. It maintained that the counter reflected engineering limitations and patient-safety considerations. The company also pointed out that neither SIS nor Rebotix responded when it later requested clinical evidence of the service’s safety and effectiveness.

Those facts don’t produce a judicial answer about how many uses are safe. Rebotix’s tests and the absence of reported harm during a limited six-month program support SIS’s position, but they aren’t the same as a court finding that indefinite reuse is safe. Nor does Intuitive’s invocation of safety establish that every contractual restriction was competitively justified.

The Ninth Circuit explicitly declined to decide whether Intuitive’s controls served patients’ best interests or whether the trial court mishandled evidence involving the Food and Drug Administration. Neither party had properly placed those issues before the appeals court.

SIS sued in May 2021. It alleged tying, exclusive dealing, monopolization and attempted monopolization under the Sherman Act. In ordinary language, SIS claimed Intuitive used its control over the robot market to require hospitals to buy replacement instruments from Intuitive and block independent repair competition.

The case reached a three-week trial in January 2025. The decisive dispute concerned the test SIS had to satisfy before a jury could consider those claims.

The trial judge ultimately required SIS to prove four factors drawn from the Supreme Court’s Kodak case and the Ninth Circuit’s Epic Games decision. Those factors are used when a company faces competition in a primary market but allegedly gains power over customers after they buy its product. They examine whether customers knew about the later restrictions, could calculate lifetime costs, faced significant switching costs and formed a legally distinct aftermarket.

SIS had presented no evidence aimed at that test. Once the judge confirmed that the jury would receive the instruction, SIS stipulated to judgment for Intuitive and appealed.

The appeals court held that the Kodak/Epic test applies when the primary, or “foremarket,” is competitive and a plaintiff instead claims that customers became trapped in a single-brand aftermarket. It doesn’t apply in the same way when the plaintiff presents evidence that the company already has market power in the primary market.

Here, SIS’s expert placed Intuitive above 99% in the foremarket for minimally invasive soft-tissue surgical robots. Trial evidence placed the company at 100% in the aftermarket for EndoWrists. The Ninth Circuit characterized SIS’s case as a conventional claim that power in one market was used to restrain competition in another.

The distinction matters because information and switching tests accomplish little if buyers lack a meaningful alternative. A hospital can understand every future EndoWrist cost and still be unable to choose another robot if Intuitive effectively controls the available market.

Intuitive alternatively asked the court to uphold the judgment because, it argued, SIS’s trial evidence was insufficient. The panel rejected that route too.

Intuitive had waived its argument that SIS failed to prove market power before 2019 by not properly raising it before the verdict. The panel added that the evidence would have been sufficient anyway. Intuitive’s own expert testified that the company was approximately the only U.S. seller of these robots from 1999 through 2018, and its president confirmed that it was the only seller until at least 2009.

The court also held that a reasonable jury could find Intuitive’s process for approving third-party EndoWrist services was illusory. SIS presented testimony that no established process existed before November 2022 and noted that earlier third-party approvals involved products such as detergents and instrument trays, not EndoWrists.

Intuitive had contrary evidence. It cited dozens of approved third-party products and services, later approvals involving modified EndoWrists, and the fact that neither SIS nor Rebotix sought approval before the business stopped. That conflict is for a factfinder; the appellate panel didn’t resolve it.

The unresolved issue is no longer whether SIS must satisfy a test designed for a competitive robot market. It is whether the contracts, programmed use limits and hospital warnings were lawful restraints in a market where the trial evidence placed Intuitive’s share near total control.