直覺手術 (ISRG) 2019 Q4 法說會逐字稿

Ladies and gentlemen, thank you for standing by, and welcome to Intuitive Surgical's Fourth Quarter 2019 Earnings Release. (Operator Instructions) As a reminder, today's conference is being recorded. I'd now like to turn the conference over to Senior Director of Finance, Investor Relations, Calvin Darling. Please go ahead.

女士們、先生們，感謝您的耐心等待，歡迎參加直覺外科公司2019年第四季財報發布會。 （操作說明）提醒各位，本次會議正在錄音。現在我將會議交給財務高級總監兼投資者關係主管卡爾文·達林先生。請開始發言。

Thank you. Good afternoon, and welcome to Intuitive's Fourth Quarter Earnings Call. With me today, we have Gary Guthart, our CEO; and Marshall Mohr, our Chief Financial Officer.

謝謝。下午好，歡迎參加Intuitive第四季財報電話會議。今天與我一起出席的有我們的執行長Gary Guthart和財務長Marshall Mohr。

Before we begin, I would like to inform you that comments mentioned on today's call may be deemed to contain forward-looking statements. Actual results may differ materially from those expressed or implied as a result of certain risks and uncertainties. These risks and uncertainties are described in detail in the company's Securities and Exchange Commission filings, including our most recent Form 10-K filed on February 4, 2019, and 10-Q filed on October 18, 2019. Our SEC filings can be found through our website or at the SEC's website. Investors are cautioned not to place undue reliance on such forward-looking statements.

在會議開始之前，我想告知各位，今天電話會議中提及的評論可能包含前瞻性陳述。由於某些風險和不確定性，實際結果可能與明示或暗示的結果有重大差異。這些風險和不確定性已在公司提交給美國證券交易委員會（SEC）的文件中詳細描述，包括我們於2019年2月4日提交的最新10-K表格和於2019年10月18日提交的10-Q表格。您可以透過公司網站或SEC網站查閱我們提交給SEC的文件。投資者請勿過度依賴此類前瞻性陳述。

Please note that this conference call will be available for audio replay on our website at intuitive.com on the Latest Events section under our Investor Relations page. In addition, today's press release and supplementary financial data tables have been posted to our website.

請注意，本次電話會議的音訊回放可在我們網站intuitive.com的「投資者關係」頁面下的「最新動態」欄位中找到。此外，今天的新聞稿和補充財務資料表也已發佈在我們的網站上。

Today's format will consist of providing you with highlights of our fourth quarter results as described in our press release announced earlier today, followed by a question-and-answer session. Gary will present the quarter's business and operational highlights, Marshall will provide a review of our fourth quarter financial results, then I will discuss procedures and clinical highlights and provide our financial outlook for 2020. And finally, we will host a question-and-answer session.

今天的會議形式如下：首先，我們將重點介紹今天早些時候發布的新聞稿中概述的第四季度業績；隨後進行問答環節。 Gary 將介紹本季的業務和營運亮點；Marshall 將回顧我們第四季的財務表現；之後，我將討論流程和臨床方面的亮點，並展望我們 2020 年的財務前景。最後，我們將進行問答環節。

With that, I will turn it over to Gary.

接下來，我將把麥克風交給蓋瑞。

Thank you for joining us today. At Intuitive, we measure our efforts by their ability to positively impact the quadruple aim: better outcomes, better patient experience, better care team experience and lower total cost to treat per patient episode. This fourth quarter of 2019 was another strong one for Intuitive in pursuit of these aims, capping a good year for the company. Our performance is reflected in healthy total growth and customer use of our systems, new capital installations, sustained quality service of our customers, clinical publications and the launch of new products and services.

感謝您今天蒞臨本次活動。在 Intuitive，我們衡量自身努力的標準在於其能否對四重目標產生正面影響：改善治療效果、提升病患體驗、改善醫療團隊體驗、降低每次治療的總成本。 2019 年第四季度，Intuitive 在實現這些目標方面再創佳績，為公司全年畫上了圓滿的句號。我們的業績體現在以下幾個方面：整體業務的健康成長、客戶對我們系統的使用率提升、新增資本投入、持續為客戶提供優質服務、臨床出版物的發表以及新產品和服務的推出。

For the quarter, global procedure growth was approximately 19%. Growth was led by general surgery in the United States with positive contributions to the global growth rate from Japan, China, Germany and Korea. Globally, customer utilization of systems increased again in the quarter, indicating greater productivity per installed system. Leasing and alternative placement models have also helped our customers gain access to additional procedure capacity with lower capital outlays.

本季全球手術量成長約19%。美國普通外科手術引領了成長，日本、中國、德國和韓國也對全球成長率做出了積極貢獻。在全球範圍內，客戶對系統的利用率在本季度再次提升，顯示每套已安裝系統的生產力有所提高。租賃和替代部署模式也幫助我們的客戶以更低的資本投入獲得了額外的手術能力。

In the United States, year-over-year procedure growth for the quarter was 18%. General surgery accounted for the largest increase, accompanied by stable growth in urology and gynecology. Within general surgery, hernia repair, cholecystectomy, bariatric and colorectal surgery showed strength.

在美國，該季度手術量年增18%。一般外科手術增幅最大，泌尿科和婦科手術也維持穩定成長。在一般外科手術中，疝氣修補術、膽囊切除術、減重手術和結直腸手術表現強勁。

Outside the United States, several markets are early in their transition from growth in urology to other surgical categories, including gynecology, thoracic surgery and general surgery, with growth varying by country. Calvin will take you through global procedure dynamics in more detail later in the call.

在美國以外，一些市場正處於從泌尿外科成長到其他外科領域（包括婦科、胸腔外科和普通外科）轉型初期，各國的成長情況不盡相同。稍後，Calvin 將在電話會議中更詳細地介紹全球手術動態。

With regard to our installed base, placement of new systems in the quarter was solid. We placed 336 systems in the quarter, with growth in total placements rising 16% from Q4 of 2018. Net of trade-ins and retirements, our da Vinci installed base grew to approximately 5,582. The mix of system placements this quarter continues to favor our flagship Xi System, and trade-ins were healthy. The proportion of systems placed under operating leases was 38% this quarter compared with 33% last quarter. As a reminder, total placements and the percentage of systems placed under lease or usage-based arrangements can vary substantially quarter-to-quarter.

就我們的已安裝系統而言，本季新系統的安裝情況穩健。本季我們共安裝了336套系統，總安裝量較2018年第四季成長16%。扣除以舊換新和退役系統後，我們的達文西手術系統已安裝約5,582套。本季系統安裝組合仍以我們的旗艦產品Xi系統為主，以舊換新狀況良好。本季以經營租賃方式安裝的系統比例為38%，高於上季的33%。需要注意的是，總安裝量以及採用租賃或以使用量計費方式安裝的系統比例可能有顯著的季度間波動。

Over the past several years, we've been working to enable greater access to our products and services. For example, we believe leasing and usage-based models benefit our customers by lowering barriers for them to provide high-quality computer-aided interventions. We anticipate continuing to expand access and lower cost for our customers as our business progresses into different procedures and geographies.

過去幾年，我們一直致力於讓更多人能夠方便地取得我們的產品和服務。例如，我們相信租賃和按使用量付費模式能夠降低客戶進行高品質電腦輔助介入的門檻，從而使他們從中受益。隨著業務拓展至不同的流程和地區，我們預計將持續擴大客戶的使用範圍並降低成本。

Turning to expenses. We believe we are still in the early days of computer-aided surgery and acute interventions. As a result, we are investing in building our capability in several important ways, including deepening internationally, launching our new platforms, strengthening our computational capabilities and executing projects that support future scale and provide leverage opportunities as we grow. Our spending for the quarter and for the year was within the upper end of spend guidance we shared with you in 2019. It is supported by solid procedure growth, capital placements and product cost reductions.

談到支出，我們認為電腦輔助手術和急診介入治療仍處於發展初期。因此，我們正從多個重要面向投資提升自身能力，包括深化國際業務、推出新平台、增強運算能力，以及執行支援未來規模擴張和提供成長槓桿機會的專案。本季和全年的支出均處於我們2019年與您分享的支出預期上限範圍內。這得益於穩健的手術量成長、資本投入和產品成本降低。

Financial highlights of our fourth quarter results are as follows: Procedures grew approximately 19% over the fourth quarter last year. We placed 336 da Vinci Surgical systems, up from 290 in the fourth quarter of 2018. Our installed base grew 12% from a year ago. Revenue for the quarter was approximately $1.3 billion, up 22%. Pro forma gross profit margin was 72.2% compared to 71.8% in the fourth quarter last year. Instrument and accessory revenue increased to $671 million, up 24%. Total recurring revenue in the quarter was $896 million, growing 24% over Q4 of 2018 and representing 70% of total revenue. We generated a pro forma operating profit of $506 million in the quarter, up 23% from the fourth quarter of last year, and pro forma net income was $417 million, up 18%.

我們第四季的財務亮點如下：手術量較去年同期成長約19%。我們安裝了336台達文西手術系統，高於2018年第四季的290台。我們的系統裝置量較去年同期成長12%。本季營收約13億美元，成長22%。備考毛利率為72.2%，高於去年同期的71.8%。器械及配件收入成長至6.71億美元，成長24%。本季經常性收入總額為8.96億美元，較2018年第四季成長24%，佔總營收的70%。本季按備考營業利潤為5.06億美元，較去年同期成長23%；按備考淨利為4.17億美元，成長18%。

Highlights for the full year 2019 are as follows: Procedures grew approximately 18% over 2018. We placed 1,119 systems in the year, growing the installed base 12% over 2018. Revenue for the year was approximately $4.5 billion, growing 20% over 2018. And pro forma net income was approximately $1.5 billion, up 17% over 2018.

2019年全年亮點如下：手術量較2018年成長約18%。全年共安裝1,119套系統，裝置量較2018年成長12%。全年營收約45億美元，較2018年成長20%。以備考淨利計算約15億美元，較2018年成長17%。

Turning to progress in our innovation pipeline, I'll start first with systems. We are in our Phase I launch of da Vinci SP, and we are working to expand its clinical clearances and build SP products at scale. In the quarter, we installed 6 systems to bring our installed base of SP to 44. Customer response and early clinical results using SP remain encouraging, with over 50 peer-reviewed clinical articles on SP to date. With regard to additional indications for SP, we've been in discussion with FDA regarding data requirements for a colorectal indication. We expect this to require an IDE trial that includes follow-up analysis. This implies we do not expect a third indication for SP in the U.S. in 2020. While I would like a faster launch of SP, the combination of additional indications for SP and our readiness for deployment at larger scale will pace the speed of our SP commercial expansion.

談到我們創新產品線的進展，首先是系統方面。我們正處於達文西SP系統I期上市階段，並致力於拓展其臨床審批範圍，實現SP產品的規模化生產。本季，我們安裝了6套系統，使SP系統的裝機量達到44套。客戶回饋和SP系統的早期臨床結果仍然令人鼓舞，迄今為止，已有超過50篇關於SP系統的同行評審臨床文章發表。關於SP系統的其他適應症，我們一直在與FDA討論大腸直腸癌適應症的資料需求。我們預計這將需要一項包含後續分析的IDE試驗。這意味著我們預期2020年SP系統在美國不會獲得第三個適應症。雖然我希望SP系統能更快上市，但SP系統其他適應症的拓展以及我們為大規模部署所做的準備，將決定SP系統商業擴張的速度。

In flexible diagnostics, our Ion platform is focused on the need for accurate and timely biopsies to support definitive early diagnosis of suspicious lesions. As of the end of the quarter, there are approximately 16 systems in the field, some commercial and some clinical trial sites with several hundred procedures performed. To date, the rollout is meeting our expectations, and user feedback during this initial launch period has been strong. We expect several publications reviewing the performance of Ion to be presented during 2020.

在靈活診斷領域，我們的 Ion 平台專注於提供準確及時的活檢，以支援對可疑病變進行早期確診。截至本季末，已有約 16 套系統投入使用，部分用於商業用途，部分用於臨床試驗，已完成數百例手術。迄今為止，推廣工作進展順利，符合預期，用戶在初期推廣階段的回饋也十分正面。我們預計將在 2020 年發表多篇關於 Ion 表現的評測文章。

Turning to instruments and accessories. Our team has been making great progress in building out our instrument portfolio with high-quality products. Our experience has shown that procedure adoption occurs when holistic -- when the holistic needs of the care team are met, when the right system and imaging products come together with the right instruments and accessories. Our team initiated our first phase launch in the quarter for our SynchroSeal sealing and transection device, along with our first integrated energy controller called the E-100. SynchroSeal provides surgeons with wristed, precise and fast sealing and transection ability often used in general surgery. Early feedback on its performance has been outstanding. SynchroSeal joins our portfolio of advanced instruments, stapling instruments and advanced energy instruments that customers are now adopting in their da Vinci cases.

接下來談談器械和配件。我們的團隊在建立高品質器械產品組合方面取得了顯著進展。經驗表明，只有當醫療團隊的整體需求得到滿足，合適的系統和影像產品與合適的器械和配件相結合時，手術流程才能有效推廣。本季度，我們的團隊啟動了SynchroSeal密封和切斷裝置的第一階段上市，同時推出的還有我們首款整合式能量控制器E-100。 SynchroSeal為外科醫生提供腕式、精準、快速的密封和切斷功能，常用於一般外科手術。其性能的早期回饋非常出色。 SynchroSeal的加入，進一步豐富了我們先進的器械產品組合，其中包括縫合器械和先進能量器械，這些產品目前已被客戶應用於達文西手術。

Turning to imaging and analytics. We're working on imaging, computing and real-time cloud technologies that allowed for capabilities from big data analytics to telementering, to augmented reality. Here alone, Intuitive Surgical simulators have been used for over 17,000 hours by more than 5,800 surgeons. Our IRIS augmented reality system entered clinical use in the fourth quarter of 2019, and we're pleased with our first customer responses. Over the past several years, our analytical capability has increased, and we now routinely engage our customers to help assess the performance of their robotic-assisted surgery programs relative to other surgical modalities. Armed with local comparative analysis of robotic-assisted surgery within their institutions, hospitals with active programs have been building access to da Vinci systems in growing their programs. We expect continued investment and progress in these areas in 2020.

接下來我們來談談成像和分析。我們致力於成像、運算和即時雲端技術，這些技術能夠實現從大數據分析到遠端會診再到擴增實境等多種功能。光是在這些領域，Intuitive Surgical 的模擬器就已被超過 5,800 位外科醫生使用超過 17,000 小時。我們的 IRIS 擴增實境系統於 2019 年第四季投入臨床使用，我們對首批客戶的回饋感到滿意。過去幾年，我們的分析能力不斷提升，現在我們經常與客戶合作，幫助他們評估其機器人輔助手術專​​案相對於其他手術方式的績效。憑藉對本機構機器人輔助手術的在地化對比分析，已開展相關項目的醫院正積極拓展達文西手術系統，以支持其計畫的發展。我們預計 2020 年這些領域將繼續投入資金並取得進展。

As we move into 2020, let's step back and review the da Vinci Surgery universe. In the past several years, general surgeons have increased their adoption of our offerings, underpinned by improvements in the quadruple aim and procedures they perform, from hernia repair, cholecystectomy and colorectal surgery to bariatric surgery. These surgical procedures span a broad range of complexity and economics. At the same time, Intuitive continues to deepen our capability in key countries to support the adoption of robotic-assisted surgery in their health care environments. We are flexing our company to better serve these customers with the launch of new systems, new instruments and updates to our software, along with changes to our sales and support models and pricing structures. Given the large global opportunity to pursue the quadruple aim, I believe the next few years for the company will be dynamic. We will guide the company to meet our customers' clinical and economic needs across this wide range of procedures and geographies. Doing so will involve continued investment in innovation in both technology and business models, and we see a path to do both.

展望2020年，讓我們回顧一下達文西手術系統的發展歷程。過去幾年，隨著四重目標的不斷改進以及手術技術的進步，普通外科醫生對我們產品的採用率顯著提高，涵蓋了從疝氣修補術、膽囊切除術、結直腸手術到減肥手術等多種手術類型。這些手術的複雜程度和經濟效益各不相同。同時，Intuitive 持續深化在關鍵國家的能力建設，以支持其醫療機構採用機器人輔助手術。我們正在調整公司營運模式，透過推出新系統、新器材和軟體更新，以及調整銷售和支援模式和定價結構，更好地服務這些客戶。鑑於實現四重目標在全球範圍內蘊藏著巨大的機遇，我相信公司未來幾年將充滿活力。我們將引領公司滿足客戶在各種手術和不同地域的臨床和經濟需求。為此，我們將持續投資於技術和商業模式的創新，而我們也看到了實現這兩方面目標的途徑。

Moving into 2020, we are focused on the following: first, supporting adoption of da Vinci in general surgery, including hernia repair, colorectal procedures and bariatrics; second, launching our SP Ion imaging instruments and analytics platforms; third, extending our depth in OUS markets, particularly Asia and EU, with growth beyond urology; and finally, supporting additional clinical and economic validation in our focused procedures and countries.

展望 2020 年，我們將重點關注以下幾個方面：首先，支持達文西手術系統在普通外科手術中的應用，包括疝氣修補術、結直腸手術和減肥手術；其次，推出我們的 SP Ion 成像儀器和分析平台；第三，拓展我們在海外市場（特別是亞洲和歐盟）的業務，並將增長拓展到最後的泌尿外科支持手術和經濟；

Lastly, we are pleased to publish today our inaugural quarter sustainability report which you can find on our website, outlining our multiyear efforts in these areas.

最後，我們很高興今天發布首個季度永續發展報告，您可以在我們的網站上找到該報告，其中概述了我們在這些領域多年來的努力。

I'll now turn the call over to Marshall, who will review financial highlights.

現在我將把電話交給馬歇爾，他將回顧財務要點。

Good afternoon. I would describe the highlights of our performance on a non-GAAP or pro forma basis. I will also summarize our GAAP performance later in my prepared remarks. A reconciliation between our pro forma and GAAP results is posted on our website.

午安.我會先介紹我們公司非GAAP（非GAAP）或準備績效的亮點。稍後，我將在準備好的演講稿中概述我們GAAP（GAAP）下的表現。我們網站上已公佈備考業績與GAAP業績的調節表。

Revenue and procedures are consistent with our preliminary press release of January 9. Key business metrics for the fourth quarter were as follows: Fourth quarter 2019 procedures increased approximately 19% compared with the fourth quarter of 2018 and increased approximately 11% compared with last quarter. Procedure growth continues to be driven by general surgery in the U.S. and urology worldwide. Calvin will review details of procedure growth later in this call.

收入和手術量與我們1月9日發布的初步新聞稿一致。第四季的關鍵業務指標如下：2019年第四季手術量較2018年第四季成長約19%，較上一季成長約11%。手術量的增長繼續由美國的普通外科手術和全球的泌尿外科手術推動。 Calvin將在本次電話會議稍後詳細介紹手術量增長。

Fourth quarter system placements of 336 systems increased 16% compared with 290 systems last year and increased 22% compared with 275 systems last quarter. We expanded our installed base of da Vinci systems by 12% to approximately 5,582 systems. This growth rate compares with 12% in the last quarter and 13% last year. Utilization of clinical systems in the field, measured by procedures per system, grew approximately 6%, which is the same as the 6% growth last quarter and last year.

第四季系統安裝量為336套，較去年同期的290套成長16%，較上季的275套成長22%。達文西手術系統的裝機量成長12%，達到約5,582套。這一成長率與上季度的12%和去年同期的13%基本持平。臨床系統在現場的使用率（以每套系統完成的手術例數衡量）成長約6%，與上季及去年同期的成長率相同。

Our revenue overview is as follows: Fourth quarter 2019 revenue was $1.3 billion, an increase of 22% compared with $1 billion for the fourth quarter of 2018 and an increase of 13% compared with $1.1 billion last quarter. Instrument and accessory revenue of $671 million increased 24% compared with last year, which is higher than procedure growth, primarily reflecting customer buying patterns and increased usage of our advanced instruments. Instrument and accessory revenue realized per procedure was approximately $1,980, an increase of 5% compared with the fourth quarter of 2018 and was consistent with last quarter. Instrument and accessory revenue per procedure has grown in the low single digits over the past couple of years, reflecting increased usage of our advanced instruments, partially offset by higher growth in benign procedures where revenue per procedure is lower than the overall average. While adoption of benign procedures has been a major contributor to the overall I&A revenue, to the extent benign procedures grow faster than complex procedures, I&A per procedure may decline. In addition, over time, as we achieve greater penetration of our advanced instruments in da Vinci procedures, the growth rate for advanced instruments will slow and align with the growth rate of underlying procedures of which advanced instruments are used. Systems revenue for the fourth quarter of 2019 was $416 million, an increase of 22% compared with the fourth quarter of 2018 and an increase of 23% compared with last quarter. Relative to the fourth quarter of 2018, systems revenue reflected higher system placements, higher ASPs and higher lease-related revenue.

我們的營收概況如下：2019 年第四季營收為 13 億美元，較 2018 年第四季的 10 億美元成長 22%，較上一季的 11 億美元成長 13%。器械及配件收入為 6.71 億美元，較去年同期成長 24%，高於手術量成長，主要反映了客戶購買模式的變化以及我們先進器械使用量的增加。每例手術的器械及配件收入約為 1,980 美元，較 2018 年第四季成長 5%，與上一季持平。過去幾年，每例手術的器械及配件收入一直保持個位數低增長，這反映了我們先進器械使用量的增加，但部分被良性手術的較高增長所抵消，而良性手術的每例手術收入低於整體平均水平。雖然良性手術的普及一直是器械及配件總收入的主要貢獻者，但如果良性手術的成長速度超過複雜手術，則每例手術的器械及配件收入可能會下降。此外，隨著我們先進儀器在達文西手術中的應用日益廣泛，其增長速度將逐漸放緩，並與使用這些先進儀器的基礎手術的增長速度保持一致。 2019年第四季系統營收為4.16億美元，較2018年第四季成長22%，較上一季成長23%。與2018年第四季相比，系統收入的成長反映了系統安裝量、平均售價和租賃相關收入的增加。

We completed 126 operating lease transactions representing 38% of total placements compared with 84 or 29% of total placements in the fourth quarter of 2018 and 92 or 33% of total placements last quarter. As of December 31, we have 658 operating leases outstanding and realized approximately $34 million from revenues related to these arrangements in the quarter compared with $16 million last year and $27 million last quarter.

本季我們完成了126筆經營租賃交易，佔總交易量的38%，而2018年第四季為84筆，佔總交易量的29%，上季為92筆，佔總交易量的33%。截至12月31日，我們共有658份未結清的經營租賃合同，本季度從這些合同中獲得的收入約為3400萬美元，而去年同期為1600萬美元，上季度為2700萬美元。

Operating leases create a future source of recurring revenue and reduce the volatility of system revenue, while the increased number of operating systems -- operating leases placed in the quarter dampens short-term revenue growth for the quarter in which they're placed.

經營租賃創造了未來的經常性收入來源，並降低了系統收入的波動性，但隨著經營租賃在當季投入營運系統數量的增加，會抑制該季度短期收入的成長。

Operating leases include usage-based financings that we provided to certain hospitals with advanced robotics experience. We believe that our lease financing alternatives align with customer objectives and have enabled faster market adoption. Relative to systems purchased over the lease period, we earn a small premium reflecting the time value of money, and in the case of usage-based arrangements, the risk that those systems may not achieve anticipated usage levels. The proportion of operating lease and usage-based arrangements will likely increase long term and will vary quarter-to-quarter.

經營性租賃包括我們向某些擁有先進機器人技術經驗的醫院提供的基於使用量的融資方案。我們相信，我們的租賃融資方案符合客戶目標，並有助於加速市場推廣。相對於租賃期間內購買的系統，我們可獲得少量溢價，這反映了資金的時間價值；對於基於使用量的租賃安排，還需考慮系統可能無法達到預期使用水準的風險。經營性租賃和基於使用量的租賃安排的比例可能會長期增長，並且會隨季度波動。

We recognized $34 million of lease buyout revenue in the fourth quarter compared with $20 million last quarter and $17 million last year. Lease buyout revenue has varied significantly from quarter-to-quarter and will likely continue to do so.

第四季我們確認了3,400萬美元的租賃買斷收入，而上一季為2,000萬美元，去年同期為1,700萬美元。租賃買斷收入季度間波動較大，而且這種情況可能會持續下去。

138 or 41% of current quarter system placements involved trade-ins, reflecting customer desire to access or standardize on our fourth-generation technology, contributing to an Xi installed base growth of 39% year-over-year. This is an increase compared with 81 or 28% of system placements in the fourth quarter of 2018 and 116 or 42% last quarter. Trade-in activity can fluctuate and could be difficult to predict. However, given prior product trade-in cycles, we expect the proportion of the installed base traded in, in future quarters to decrease over time.

本季系統安裝中，有138套（佔41%）為以舊換新，這反映出客戶希望體驗或採用我們的第四代技術，從而推動Xi系統裝機量年增39%。這一比例高於2018年第四季的81套（佔28%）和上一季的116套（佔42%）。以舊換新活動可能出現波動，難以預測。但根據以往的產品以舊換新周期，我們預期未來幾季以舊換新系統佔總裝機量的比例將逐漸下降。

81% of the systems placed in the quarter were da Vinci Xis and 16% were da Vinci X Systems compared with 79% da Vinci Xis and 17% da Vinci Xs last quarter. 6 of the systems placed in the quarter -- fourth quarter, were SP systems. Our rollout of SP surgical system will continue to be measured, putting systems in the hand of experienced da Vinci users while we optimize training pathways in our supply chain.

本季安裝的系統中，81%為達文西Xi系統，16%為達文西X系統；而上季度，達文西Xi系統佔比為79%，達文西X系統佔比為17%。本季（第四季）安裝的系統中，有6台為SP系統。我們將繼續穩步推進SP手術系統的推廣，優先將系統交付給經驗豐富的達文西用戶，同時優化供應鏈中的訓練路徑。

We placed 7 Ion systems in the quarter. Ion system placements are excluded from our overall systems count and will be reported separately. Procedures and other information associated with Ion are excluded from our prepared remarks and will be reported separately when they become more substantive.

本季我們安裝了7套離子治療系統。離子治療系統的安裝數量不計入系統總數，將單獨報告。與離子治療系統相關的操作流程和其他資訊不包含在我們事先準備好的報告中，待其內容更加詳實後，我們將另行報告。

Globally, our average selling price, which excludes the impact of operating lease revenue and lease buyouts, was approximately $1.61 million compared with $1.46 million last year and $1.57 million last quarter.

在全球範圍內，我們的平均售價（不包括經營租賃收入和租賃買斷的影響）約為 161 萬美元，而去年同期為 146 萬美元，上一季為 157 萬美元。

Our fourth quarter ASPs reflect a favorable geographic mix as we sold 39 systems into China and 26 into Japan where ASPs are higher, given the higher cost of doing business in those geographies. Excluding geographic mix, ASPs for the quarter declined slightly relative to the third quarter, reflecting pricing arrangements associated with a higher mix of multisystem contracts. System ASPs will fluctuate with geographic and system mix and may decline relative to the average total 2019 ASP, reflecting increased multisystem arrangements.

第四季平均售價反映了有利的地域組合，我們向中國售出39套系統，向日本售出26套系統，由於這些地區的營運成本較高，因此平均售價也較高。若不考慮地理組合，本季平均售價較第三季略有下降，這反映了多系統合約比例增加所帶來的定價安排。系統平均售價將隨地域和系統組合而波動，並可能低於2019年全年平均售價，這反映了多系統合約的增加。

Outside of the U.S., results were as follows: OUS procedures grew approximately 22% compared with the fourth quarter of 2018 and increased 9% compared with last quarter. Fourth quarter revenue outside of the U.S. of $422 million increased 37% compared with the fourth quarter of 2018 and increased 27% compared with last quarter. The increase compared with the prior year reflects increased instruments and accessories revenue of $47 million or 39% growth and increased systems revenue of $58 million or 42% growth. The increase in instrument and accessory revenue was primarily driven by procedure growth and stocking orders associated with China system sales. The increase in systems revenue is primarily the result of increased placements and increased ASPs reflecting favorable geographic and product mix.

美國以外地區的業績如下：美國以外地區的手術量較2018年第四季成長約22%，較上季成長9%。第四季美國以外地區的營收為4.22億美元，較2018年第四季成長37%，較上季成長27%。與上年同期相比，成長主要體現在器械及配件收入增加4,700萬美元（成長39%）以及系統收入增加5,800萬美元（成長42%）。器械及配件收入的成長主要得益於手術量的成長以及與中國系統銷售相關的庫存訂單。系統收入的成長主要源自於安裝量的增加和平均售價的提高，這反映了有利的地理分佈和產品組合。

Outside of the U.S., we placed 140 systems in the fourth quarter compared with 115 in the fourth quarter of 2018 and 90 systems last quarter. Current quarter system placements included 54 into Europe, 26 into Japan and 39 into China compared with 55 in Europe, 31 into Japan and 2 into China in the fourth quarter of 2018. 71% of the systems placed in the quarter were da Vinci Xis and 24% were da Vinci X Systems compared with 55% da Vinci Xis and 30% da Vinci Xs last year. 32 of the system placements in the current quarter were operating leases compared with 15 last year and 21 last quarter. The 39 systems into China included customers who had begun their tender processes and we believe expedited their purchase cycles to avoid a tariff increase that was expected on December 15. The proposed tariff was suspended on December 13. We would expect remaining purchases under the quota to be completed consistent with historical time lines, and therefore, we expect placements to be lower in the first quarter and skew more towards the end of 2020 and into 2021. While overall European system placements were relatively flat in the quarter and for 2019, shipments by country fluctuates significantly. Placements into the 4 largest European markets increased 29% in the fourth quarter and 19% for the year. Overall placements outside of the U.S. will continue to vary as some of the OUS markets are in early stages of adoption; some markets are highly seasonal, reflecting budget cycles or vacation patterns; and sales into some markets are constrained by government limitations.

除美國以外，我們第四季共安裝了140套系統，而2018年第四季為115套，上季為90套。本季安裝的系統中，有54套位於歐洲，26套位於日本，39套位於中國；而2018年第四季，歐洲為55套，日本為31套，中國為2套。本季安裝的系統中，71%為達文西Xi系統，24%為達文西X系統；而去年同期，達文西Xi系統佔比為55%，達文西X系統佔比為30%。本季安裝的系統中，有32套為經營租賃，去年同期為15套，上季為21套。銷往中國的39套系統中包含一些已啟動招標流程的客戶，我們認為他們加快了採購週期，以避免原定於12月15日生效的關稅上調。該關稅提案已於12月13日暫停。我們預計配額下的剩餘採購將按歷史時間表完成，因此，我們預計第一季的安裝量將較低，並將更多地集中在2020年底和2021年。雖然歐洲整體系統安裝量在本季和2019年全年相對平穩，但各國的出貨量波動較大。歐洲四大市場的安裝量在第四季成長了29%，全年成長了19%。美國以外地區的整體安裝量將繼續波動，因為部分美國以外市場仍處於早期應用階段；一些市場具有明顯的季節性，反映了預算週期或假期模式；而且部分市場的銷售受到政府限制。

Moving on to gross margin and operating expenses. Pro forma gross margin for the fourth quarter of 2019 was 72.2% compared with 71.8% for the fourth quarter of 2018 and 72% last quarter. The increase compared with the fourth quarter of 2018 and last quarter primarily reflects higher system ASPs and product cost reductions. Future margins will fluctuate based on the mix of our newer products, mix of systems and instrument and accessory revenue, system ASPs and our ability to further reduce product costs and improve manufacturing efficiencies.

接下來是毛利率和營運費用。 2019 年第四季的備考毛利率為 72.2%，高於 2018 年第四季的 71.8% 和上一季的 72%。與 2018 年第四季和上一季相比，毛利率的成長主要反映了系統平均售價 (ASP) 的提高和產品成本的降低。未來的毛利率將根據新產品組合、系統和儀器及配件收入的組合、系統平均售價以及我們進一步降低產品成本和提高生產效率的能力而波動。

Pro forma operating expenses increased 23% compared with the fourth quarter of 2018 and increased 19% compared with last quarter. Spending is consistent with our plan. It includes an order of magnitude of increase, costs associated with the expansion of our OUS markets, spending on our imaging and analytics capabilities and investment in our infrastructure in order to scale the business. We believe we have a unique opportunity to expand the benefits of computer-aided surgery and acute interventions around the world and have been and will continue to invest in the business accordingly.

預計營運費用較2018年第四季成長23%，較上一季成長19%。支出符合我們的計劃。其中包括數量級的成長，與拓展海外市場相關的成本、影像和分析能力方面的支出，以及為擴大業務規模而對基礎設施的投資。我們相信，我們擁有獨特的機遇，可以在全球範圍內推廣電腦輔助手術和急診介入治療的優勢，因此我們過去一直並將繼續相應地投資於這項業務。

Our pro forma tax rate for the quarter was 21.1% compared with our expectations of 19% to 20%, reflecting geographic mix. Our actual tax rate will fluctuate with changes in the geographic mix of income, changes in taxation made by local authorities and with the impact of onetime items. Our fourth quarter 2019 pro forma net income was $417 million or $3.48 per share compared with $353 million or $2.96 per share for the fourth quarter of 2018 and $409 million or $3.43 per share for last quarter.

本季備考稅率為21.1%，高於我們先前19%至20%的預期，這反映了地域組成的變化。實際稅率會隨著收入地域組成的變化、地方政府稅收政策的調整以及一次性項目的影響而波動。 2019年第四季備考淨利為4.17億美元，合每股3.48美元，而2018年第四季為3.53億美元，合每股2.96美元，上一季為4.09億美元，合每股3.43美元。

I will now summarize our GAAP results. GAAP net income was $358 million or $2.99 per share for the fourth quarter of 2019 compared with GAAP net income of $293 million or $2.45 per share for the fourth quarter of 2018 and GAAP net income of $397 million or $3.33 per share for last quarter.

現在我將總結一下我們的GAAP業績。 2019年第四季GAAP淨利為3.58億美元，即每股2.99美元，而2018年第四季GAAP淨利為2.93億美元，即每股2.45美元，上一季GAAP淨利為3.97億美元，即每股3.33美元。

The adjustments between pro forma and GAAP net income are outlined and quantified on our website. It include excess tax benefits associated with employee stock awards, employee stock-based compensation and IP charges, amortization of intangibles and acquisition-related items and legal settlements.

我們網站上詳細列出了備考淨利潤與GAAP淨利潤之間的調整項，並進行了量化說明。這些調整項目包括與員工股票獎勵、員工股票選擇權薪酬和智慧財產權費用相關的超額稅收優惠、無形資產攤提、收購相關項目以及法律和解費用。

We ended the quarter with cash and investments of $5.8 billion compared with $5.4 billion at September 30, 2019. The cash generated from operations was partially offset by investments in working capital and infrastructure during the quarter. Capital expenditures for the quarter and the year are higher than historical averages as we invest in our infrastructure. We expect investments in our infrastructure to continue into 2020.

截至本季末，我們的現金及投資總額為58億美元，而2019年9月30日為54億美元。本季經營活動產生的現金流量部分被營運資本和基礎設施投資所抵銷。由於我們對基礎設施的投資，本季和全年的資本支出均高於歷史平均值。我們預計對基礎設施的投資將持續到2020年。

In the quarter, we grew inventory by approximately $16 million to $596 million, representing approximately 142 days of inventory, which is slightly lower than at the end of the third quarter. We did not repurchase any shares in the quarter and have approximately $1.7 billion remaining under the Board buyback authorization.

本季度，我們的庫存增加了約1,600萬美元，達到5.96億美元，相當於約142天的庫存量，略低於第三季末的水準。本季我們沒有回購任何股票，根據董事會授權的股票回購額度，我們仍有約17億美元的剩餘額度。

In summary, I want to highlight certain business dynamics that may impact your models. First, as I noted, we will grow operating expenses appropriately as we see the substantial opportunity to expand the benefits of computer-aided surgery and acute interventions. Calvin will provide you with operating expense growth guidance. In addition, as we align to our -- with our customer needs, we believe the percentage of leasing and alternative financing arrangements will increase over time. We also believe the number of trade-in transactions will level off in the short term and then decline over time. System ASPs will fluctuate with geographic and system mix and may decline relative to the average total 2019 ASP, reflecting increased multisystem arrangements. While adoption of benign procedures has been a major contributor to overall I&A revenue, to the extent benign procedures grow faster than complex procedures, I&A per procedure may decline. Lastly, it's likely we will see elongated negotiation time lines and possibly price pressures as competition gets closer to launching their products. We will continue to manage the business for the long term as we believe that the fundamentals of the business are strong.

總而言之，我想重點介紹一些可能影響貴公司業務模式的動態因素。首先，正如我之前提到的，隨著我們看到電腦輔助手術和急診介入治療的巨大發展潛力，我們將適當增加營運支出。 Calvin 將為您提供營運支出成長的指導。此外，隨著我們不斷調整自身以適應客戶需求，我們相信租賃和替代融資安排的比例將隨著時間的推移而增加。我們也相信，短期內以舊換新交易的數量將趨於穩定，然後隨著時間的推移而下降。系統平均售價 (ASP) 將隨地域和系統組合而波動，並可能相對於 2019 年的平均總 ASP 有所下降，這反映了多系統組合的增加。雖然良性手術的普及一直是整體 I&A 收入的主要貢獻者，但如果良性手術的成長速度超過複雜手術，則每次 I&A 手術的收入可能會下降。最後，隨著競爭對手的產品上市日期臨近，我們可能會看到談判週期延長，並可能面臨價格壓力。我們將繼續進行長期經營，因為我們相信該業務的基本面很強勁。

And with that, I'd like to turn it over to Calvin, who'll go over procedure performance and our outlook for 2020.

接下來，我將把發言權交給卡爾文，他將介紹手術流程的執行情況以及我們對 2020 年的展望。

Thank you, Marshall. Our overall fourth quarter procedure growth was approximately 19% compared to 19% during the fourth quarter of 2018 and nearly 20% last quarter. Our Q4 procedure growth was driven by 18% growth in U.S. procedures and 22% growth in OUS markets. Overall procedure growth for the full year 2019 was approximately 18%, equal to 18% in 2018, comprised of 17% growth in the U.S. and 21% growth in OUS markets. In the U.S., Q4 procedure growth was consistent with recent trends and was largely driven by continued strength in general surgery, with substantive contributions from gynecologic and urologic procedures.

謝謝馬歇爾。我們第四季的整體手術量成長約為19%，與2018年第四季的19%持平，而上一季則接近20%。第四季手術量的成長主要得益於美國市場18%的成長和美國以外市場22%的成長。 2019年全年整體手術量成長約18%，與2018年持平，其中美國市場成長17%，美國以外市場成長21%。在美國，第四季度的手術量成長與近期趨勢一致，主要得益於一般外科手術的持續強勁成長，婦科和泌尿外科手術也做出了顯著貢獻。

In U.S. general surgery, fourth quarter growth in leading procedures, hernia repair and colorectal remains solid at rates consistent with last quarter. Cholecystectomy growth continued to accelerate in the fourth quarter and now represents a significant driver of incremental procedures. While da Vinci cholecystectomy adoption has been robust given the high level of lab penetration, it is difficult for us to predict the extent and pace of future chole adoption. Bariatric procedures also showed continued solid growth in Q4 and will become an increasing area of field focus for us in 2020. For the full year 2019, approximately 421,000 U.S. general surgery procedures were performed, up 29% from 2018, representing approximately 48% of overall U.S. da Vinci procedures. Q4 U.S. gynecology procedure growth was largely consistent with the first 3 quarters of 2019. For the full year 2019, approximately 282,000 U.S. gynecologic surgery procedures were performed, up 6% from 2018, representing approximately 32% of overall U.S. procedures.

在美國一般外科領域，第四季主要手術、疝氣修補術和大腸直腸手術的成長依然穩健，成長速度與上季持平。膽囊切除術的成長在第四季持續加速，目前已成為新增手術量的重要驅動因素。儘管達文西膽囊切除術的普及率很高，這得益於其在實驗室的高滲透率，但我們難以預測未來膽囊切除術的普及程度和速度。減重手術在第四季也持續保持穩健成長，並將成為我們2020年重點關注的領域。 2019年全年，美國共進行了約42.1萬例普通外科手術，較2018年增長29%，約占美國達文西手術總量的48%。美國第四季婦科手術量的成長與 2019 年前三個季度基本一致。 2019 年全年，美國共進行了約 282,000 例婦科手術，比 2018 年增加了 6%，約占美國整體手術量的 32%。

In U.S. urology, fourth quarter dVP growth rates continued to exceed our expectations, although growth did moderate from Q3. For the full year 2019, approximately 138,000 U.S. urologic procedures were performed, up just under 10% from 2018, representing approximately 16% of overall U.S. da Vinci procedures. As a highly penetrated procedure category, we believe that our U.S. prostatectomy volumes should track to the broader prostate surgery market and will likely grow more modestly in 2020.

在美國泌尿外科領域，第四季度達文西機器人手術（dVP）的成長率持續超出預期，儘管成長速度較第三季有所放緩。 2019年全年，美國共進行了約13.8萬例泌尿外科手術，較2018年成長近10%，約占美國達文西機器人手術總量的16%。由於前列腺切除術是一個高度普及的手術類別，我們認為其在美國的手術量將與更廣泛的前列腺手術市場保持一致，並可能在2020年實現更溫和的成長。

Fourth quarter OUS procedure volume grew approximately 22% compared with 24% for the fourth quarter of 2018 and 23% last quarter. Fourth quarter 2019 OUS procedure growth was driven by continued growth in urology procedures and earlier-stage growth in general, gynecologic and thoracic surgery.

與2018年第四季的24%和上一季的23%相比，2019年第四季的OUS手術量增加了約22%。 2019年第四季OUS手術量的成長主要得益於泌尿外科手術的持續成長以及一般外科、婦科和胸腔外科早期手術量的成長。

In China, as in Q3, procedure growth accelerated modestly as new systems installed under the latest system quota began to provide capacity for incremental growth. In Q4, the China procedure growth rate slightly exceeded the overall OUS metric. As Marshall mentioned, 39 systems were shipped into China in Q4. Note that 35 of these 39 systems went to new hospitals. Teams in these hospitals will need to move through training pathways and established da Vinci procedure processes before these new systems contribute meaningfully to procedure growth in China.

在中國，與第三季類似，隨著最新系統配額下新安裝的系統開始提供增量成長所需的容量，手術量成長略有加快。第四季度，中國的手術量成長率略高於美國其他地區的整體水準。正如馬歇爾所提到的，第四季共有39套系統運往中國。值得注意的是，這39套系統中有35套交付給了新醫院。這些醫院的團隊需要完成培訓，並熟悉達文西手術流程，這些新系統才能對中國手術量的成長做出實質貢獻。

In Japan, procedure growth was again strong at just over 40%, reflecting growth in procedures granted reimbursement status in April 2018 and continued later-stage growth in urology procedures. Our emphasis in Japan remains on surgeon and team training and building proctoring networks.

在日本，手術量再次強勁增長，增幅略高於40%，這反映了2018年4月獲得醫保報銷資格的手術量增長，以及泌尿外科手術後期階段的持續增長。我們在日本的工作重點仍然是外科醫生和團隊的培訓以及建立指導網絡。

Overall, European procedure growth was largely consistent with prior periods, with variation by country. German results were particularly strong, while results in the U.K. lagged.

整體而言，歐洲的手術量成長與以往時期基本一致，但各國之間存在差異。德國的表現尤為強勁，而英國的表現則相對落後。

Now turning to the clinical side of our business. Each quarter on these calls, we highlight certain recently published studies that we deem to be notable. However, to gain a more complete understanding of the body of evidence, we encourage all stakeholders to thoroughly review the extensive detail of scientific studies that have been published over the years. A recent article by Drs. Wexner and Emile et al in the journal of Techniques in Coloproctology provided results from a systemic review and meta-analysis of intracorporeal versus extracorporeal anastomosis in minimally invasive right colectomy. This study analyzed data from 25 studies and 4,450 patients. Intracorporeal anastomosis was associated with significantly shorter-length extraction site incisions, earlier bowel recovery, fewer complications and lower rates of conversion, anastomotic leaks, surgical site infections and incisional hernia as compared to extracorporeal anastomosis. This study highlighted the many clinical outcome advantages associated with intracorporeal anastomosis, da Vinci systems, instruments and smart stapling technology, enabling performing anastomosis of the bowel inside the body. And it is our hope that more patients can benefit from intracorporeal anastomosis with continued adoption of our technology. Intuitive investment in a prospective multicenter intracorporeal versus extracorporeal anastomosis study comparing robotic versus laparoscopic approaches called the ANCOR study is timely. And the enrollment for this study is expected to be completed this year, with results expected in 2021. The details of the ANCOR study are available online at clinicaltrials.gov.

現在我們來談談業務的臨床方面。每個季度，我們都會在這些電話會議上重點介紹一些我們認為值得關注的近期發表的研究。然而，為了更全面地了解現有證據，我們鼓勵所有利害關係人仔細查閱多年來發表的大量科學研究的詳細資訊。 Wexner 博士和 Emile 博士等人最近在《結直腸病學技術》雜誌上發表了一篇文章，提供了微創右半結腸切除術中體內吻合與體外吻合的系統評價和薈萃分析結果。這項研究分析了 25 項研究和 4450 名患者的數據。與體外吻合相比，體內吻合有切口長度顯著縮短、腸道恢復更快、併發症更少、中轉開腹率、吻合口漏、手術部位感染和切口疝發生率更低等優點。這項研究強調了體內吻合術、達文西手術系統、器械和智慧縫合技術在臨床療效方面的許多優勢，這些優勢使得在體內進行腸道吻合成為可能。我們希望隨著我們技術的不斷應用，更多患者能夠從體內吻合術中受益。目前，我們適時地啟動了一項前瞻性多中心研究——ANCOR研究，該研究旨在比較機器人輔助手術和腹腔鏡手術在體內與體外吻合術中的應用。研究的受試者招募預計今年完成，結果預計將於2021年公佈。 ANCOR研究的詳細資訊可在clinicaltrials.gov網站上查閱。

I will now turn to our financial outlook for 2020. Starting with procedures. As described in our announcement earlier this month, total 2019 da Vinci procedures grew approximately 18% to roughly 1,229,000 procedures performed worldwide. As communicated previously, during 2020, we anticipate full year procedure growth within a range of 13% to 16%. We expect 2020 procedure growth to continue to be driven by U.S. general surgery and procedures outside the United States where we are at earlier stages of adoption. We expect similar seasonal timing of procedures in 2019, as we have experienced in previous years, with Q1 being the seasonally weakest quarter as patient deductibles are reset. Q1 and full year 2020 will benefit from 1 extra working day attributable to leap year.

接下來，我將談談我們對2020年的財務展望。首先是手術量。正如我們本月稍早發布的公告所述，2019年達文西手術總量成長約18%，達到全球約122.9萬例。先前我們已溝通，預計2020年全年手術量成長率將介於13%至16%之間。我們預計2020年的手術量成長將繼續由美國普通外科手術以及我們目前仍處於早期應用階段的美國以外地區的手術量推動。我們預計2019年的手術量季節性變化與往年類似，第一季通常是淡季，因為患者的自付額會重新計算。 2020年第一季和全年將受益於閏年多出的一個工作日。

With respect to revenue, as we have mentioned previously, capital sales are ultimately driven by procedure demand, catalyzing hospitals to establish or expand robotic system capacity. Capital sales can vary substantially from period-to-period based upon many factors, including U.S. health care policy, hospital capital spending cycles, reimbursement and government quotas, product cycles, economic cycles and competitive factors. Within this framework, we'd expect 2020 capital placement seasonality to generally follow historical patterns by quarter.

關於收入方面，正如我們之前提到的，資本支出最終受手術需求驅動，促使醫院建立或擴大機器人系統。資本支出會因許多因素而顯著波動，包括美國醫療保健政策、醫院資本支出週期、報銷和政府配額、產品週期、經濟週期以及競爭因素。在此框架下，我們預計2020年的資本投入季節性將大致遵循歷史季度模式。

During the fourth quarter of 2019, 126 of the 336 systems shipped or 38% were under operating leases. We expect the proportion of systems placed via operating leases will vary from quarter-to-quarter and could trend up in the future. During Q3 and Q4, 42% and 41%, respectively, of systems placements were upgrades to our Gen 4 platform. As we mentioned last quarter, we expect the proportion of trade-in transactions to generally trend downwards in 2020.

2019年第四季，在出貨的336套系統中，有126套（佔38%）採用經營租賃方式交付。我們預期透過經營租賃方式交付的系統比例將逐季波動，未來可能呈現上升趨勢。第三季和第四季度，分別有42%和41%的系統交付是我們第四代平台的升級。正如我們上個季度所述，我們預計2020年以舊換新交易的比例整體呈下降趨勢。

Turning to gross profit. Our full year 2019 pro forma gross profit margin was 71.7%. In 2020, we expect our pro forma gross profit margin to be within a range of between 70% and 71% of net revenue. The slightly lower gross profit margin anticipated in 2020 reflects higher sales of newer products and infrastructure investments. Our actual gross profit margin will vary quarter-to-quarter depending largely on product, regional and trade-in mix and the impact of new product introductions.

接下來談談毛利。我們2019年全年的備考毛利率為71.7%。 2020年，我們預期備考毛利率將佔淨收入的70%至71%。 2020年毛利率預期略有下降，反映了新產品銷售額的成長和基礎設施投資的增加。我們的實際毛利率將因產品、地區和以舊換新組合以及新產品上市的影響而逐季波動。

Turning to operating expenses. In 2019, our pro forma operating expenses grew 27%. In 2020, we expect pro forma operating expenses to grow between 15% and 20%. We expect our noncash stock compensation expense to range between $400 million and $440 million in 2020 compared to $336 million in 2019. We expect other income, which is comprised mostly of interest income, to total between $100 million and $115 million in 2020. With regard to income tax, in 2019, our pro forma income tax rate was 19.5%. As we look forward, we estimate our 2020 pro forma tax rate to be between 20% and 21% of pretax income, with the increase primarily reflecting the anticipated geographic mix of pretax income.

接下來談談營運費用。 2019年，我們的備考營運費用成長了27%。我們預計2020年備考營運費用將成長15%至20%。我們預計2020年非現金股權激勵費用將在4億美元至4.4億美元之間，而2019年為3.36億美元。我們預計2020年其他收入（主要包括利息收入）總額將介於1億美元至1.15億美元之間。關於所得稅，2019年我們的備考所得稅率為19.5%。展望未來，我們預期2020年備考所得稅率將達到稅前利潤的20%至21%，成長主要反映了預期中的稅前利潤地理分佈變化。

That concludes our prepared comments. We will now open the call to your questions.

我們的發言到此結束。現在開始接受各位提問。

(Operator Instructions) Our first question will come from the line of David Lewis with Morgan Stanley.

（操作員說明）我們的第一個問題將來自摩根士丹利的戴維·劉易斯。

Just 2 questions for me. Gary, I want to start with you first on chole. It's probably your largest procedure set in terms of volume, 2 sequential quarters of acceleration within chole, obviously, still very low penetration. Historically, that was tied to sort of trainings. Physicians would use chole as a way of training on broader general surgery procedures. But can you just talk about the last 2 quarters' acceleration in procedure? Do you think that's simply training, a leading indicator of general surgery? Or do you think something is going on, distinct from that within broader chole? And a quick follow-up.

我只有兩個問題。 Gary，我想先問你關於膽囊切除術的問題。就手術量而言，這可能是你最大的手術類型，膽囊切除術的手術量連續兩個季度都在增長，但顯然，其普及率仍然很低。過去，這與培訓有關。醫生會利用膽囊切除術來訓練更廣泛的一般外科手術。但你能談談最近兩個季度手術量成長的原因嗎？你認為這只是訓練的結果，還是一般外科手術的領先指標？或者你認為除了膽囊切除術本身之外，還有其他因素在起作用？還有一個後續問題。

Okay. On the first one, just I'm going to put a posted note on the assumption of its size relative to everything else. I'll let Calvin come back and put it in context size-wise in terms of current run rate. But the underlying question of what are we seeing in cholecystectomy, we think there's a segment there where we're bringing differentiated clinical value, could be underlying clinical elements like obesity, comorbidities, state of disease of the gallbladder. So while it's a large category as a whole, generally well served by minimally invasive surgery today, there are segments in it that are difficult and for which we think current product sets do really well. There's also a set of training or people deepening their experience as they go through it. So there's a mix of those 2. We think there is a durable component segmenting out how big that is over time. We're still working through where we think those end points are. We have seen it both grow in the last few quarters and appear to be sticky, not to have be a transient.

好的。關於第一個問題，我先簡單說明一下它相對於其他所有問題的規模。我會讓Calvin回來，根據目前的運行速度，從規模的角度來分析。但關於膽囊切除術的根本問題，我們認為在這個細分領域，我們能夠提供差異化的臨床價值，這可能與肥胖、合併症、膽囊疾病狀態等潛在臨床因素有關。雖然膽囊切除術總體上是一個很大的類別，目前微創手術已經能夠很好地滿足需求，但其中也存在一些棘手的細分領域，我們認為目前的產品組合在這些領域表現非常出色。此外，還有一些培訓項目，或者說，一些醫生在實踐中不斷累積經驗。所以，這兩者兼具。我們認為，隨著時間的推移，這個細分領域會呈現出持久的趨勢。我們仍在研究這些趨勢的最終目標。我們看到，在過去的幾個季度裡，這個領域一直在成長，而且似乎具有很強的穩定性，而不是曇花一現。

Calvin, in terms of kind setting in context relative to other procedures.

就與其他程式相比，Calvin 在情境中的分類設定方面。

No. I mean the size of the market, you can tell from our commentary, it's gotten to the point where general surgery is a meaningful enough category. It's a more and more significant contributor to growth within the general surgery category that's growing overall. Again, as we mentioned in the commentary, it's hard for us to gauge given the high lab penetration there to what extent and what pace it may ultimately adopt.

不，我的意思是，從我們的評論中可以看出，市場規模已經發展到普通外科作為一個重要細分市場的程度。它對整體成長的普通外科領域貢獻越來越大。再次強調，正如我們在評論中提到的，鑑於實驗室滲透率很高，我們很難評估它最終會發展到什麼程度以及發展速度。

Okay. And then just curious, second question for me is just on the capital environment. Your fourth quarter U.S. net placement growth was a little lower, and Europe in 2019 was a little lower on a net placement basis. Maybe just comment on underlying demand for systems in the U.S. and the European markets. And also curious if has -- in any respect, has competitors introducing new systems or talking about their new systems more publicly? Has it, in any way, impacted demand or changed the conversation you're having with large IDNs in the U.S. or European customers?

好的。那麼，我的第二個問題是關於資本環境的。你們第四季在美國的淨部署成長率略低，2019年歐洲的淨部署成長率也略低。能否談談美國和歐洲市場對系統的潛在需求？另外，競爭對手是否推出了新系統或更公開地談論他們的新系統？這是否對需求產生了任何影響，或者改變了你們與美國或歐洲大型整合交付網路（IDN）客戶的溝通方式？

On the outline of the first question, you just sort of think about what the installed base growth was. So if you think about capital demand underneath, there's what's happening to installed base, so opening additional capacity in various places or trade-ins of older-generation systems. I'll let Marshall speak to the quantitative nature of your question with regard to the U.S. and in Europe. But I'd say there is -- it's something -- there's some trade-in dynamics that I think the team has been discussing with you the last couple of quarters. In general, I think we're feeling like it's reasonably stable.

關於第一個問題的概要，你只需思考一下已安裝基數的成長情況。如果你考慮底層的資本需求，你會發現已安裝基數的變化，例如在各地新增產能或舊系統置換。關於你提出的關於美國和歐洲的量化問題，我會讓馬歇爾來解答。但我認為，確實存在一些——這方面——存在一些置換動態，我認為團隊在過去幾季一直在和你討論這些動態。總的來說，我們認為目前市場相當穩定。

On the second piece of what will competitive advertising and conversation do, from time to time, we see delay deals. We definitely see increasing conversations as they get closer to market with what they want to do, where other companies are starting to get some clearances in other regions. In general, our teams have handled that pretty well. But I think the noise level will increase. I think that customers are interested in listening to other pitches. I think we're pretty well positioned to have a conversation about that. But I do see delay from time to time. It kind of comes in waves, and then it'll settle as the world figures out kind of what they're offering.

關於競爭性廣告和對話將如何影響產品上市的第二點，我們偶爾會看到一些延遲交易。隨著其他公司的產品上市日期臨近，相關對話也會越來越多，因為其他公司也開始在其他地區獲得一些許可。總的來說，我們的團隊處理得相當不錯。但我認為市場噪音會增加。我認為客戶有興趣了解其他方案。我認為我們在這方面處於有利地位，可以與他們展開對話。但我確實看到一些延遲交易會不時出現。這種情況會像潮水一樣起伏不定，然後隨著市場逐漸了解他們的產品，最終會趨於穩定。

But Marshall, maybe a little bit on -- a little more quantitative answer than that.

但馬歇爾或許會給出更具體的答案——比這更量化一些。

Yes. First, the capital environment has been approximately the same. There haven't been much in terms of change in motives and so forth over the last several quarters. The number of systems that we placed in the U.S., which is disclosed in the web -- website is what is healthy in our view. In fact, what you -- the other way we measure how healthy we're -- how well we're doing is the utilization of systems. And utilization of systems growth, as I said, was 6%, which is consistent with where it's been.

是的。首先，資本環境基本上保持不變。過去幾個季度，投資動機等方面並沒有太大變化。我們在美國部署的系統數量（已在網站上公佈）在我們看來是健康的。事實上，我們衡量自身健康狀況的另一個指標是系統利用率。正如我所說，系統利用率成長率為6%，與先前的水準基本一致。

And in Europe, we saw, as I said, maybe flattish number of systems placed both in the quarter as well as compared to the previous year in total. And just be aware of averages. And it's going to be lumpy. When you're in earlier stages of adoption in less mature markets, you're going to see a lumpiness to placements of capital. When we look at the 4 largest markets, we saw nice growth, which, again, as Calvin commented, procedure growth in Germany was strong, and we saw nice placements in Germany, for example. That help?

正如我之前所說，在歐洲，我們看到系統部署數量可能基本上持平，無論是本季還是與去年同期相比都是如此。請注意平均值，實際數據會有波動。當市場發展尚不成熟、技術應用尚處於早期階段時，資本部署量必然會出現波動。當我們觀察四大市場時，我們看到了良好的成長，正如卡爾文所提到的，德國的手術量增長強勁，我們在德國也看到了不錯的部署量。這些資訊對您有幫助嗎？

Our next question will come from the line of Tycho Peterson with JPMorgan.

我們的下一個問題將來自摩根大通的泰科·彼得森。

I'll start with SP. Just curious, following your discussions with FDA, any color you can provide on just when the trial is going to start, the size and what's expected for follow-up analysis? And then outside the U.S., you're obviously generating data on SP and thoracic and OSA in Korea. Can you just talk about some of the data generations outside the U.S. as well?

我先從SP說起。我很好奇，在您與FDA討論之後，能否透露一下試驗的具體啟動時間、規模以及後續分析的預期結果？另外，在美國以外，您顯然正在韓國收集SP、胸椎疾病和OSA的數據。能否也談談在美國以外收集的數據？

Sure. On the first one, I think we're settling in on what the trial will look like, and I'm not ready yet to answer that, but I think we're getting close. So in future quarters, we should be able to answer that question.

當然。關於第一個問題，我認為我們正在敲定審判的具體形式，我目前還不能回答，但我覺得我們已經接近完成。所以，在接下來的幾個季度裡，我們應該能夠回答這個問題。

With regard to what we're seeing elsewhere, we're starting to see, in terms of Korea, where we have more regulatory room and clinical indications, we'll start seeing a whole series of publications coming out talking about where there's opportunity. And it's, I think, going to be quite interesting and shows real potential for us. It's the thing that drives our underlying commitment and excitement. I don't have them at the tip of my fingers. I do know that in future quarters, we will start describing to you what the substance of some of these publications are as they start to release.

至於其他地區的情況，就韓國而言，由於監管空間和臨床適應症更為寬鬆，我們開始看到一系列出版物陸續發布，探討其中的機會。我認為這將會非常有趣，也展現了我們真正的潛力。這正是我們持續投入和充滿熱情的原因。我目前還無法一一列舉這些出版品的內容。但我知道，在接下來的幾個季度裡，我們會陸續向大家介紹其中一些出版物的具體內容。

And then just sticking with the pipeline for a minute. Can you just comment on IRIS, where we are in the rollout? It's obviously early days. And then also, if you could just comment separately on the Schölly endoscope acquisition. And have you worked the supply chain headwinds there?

然後我們再繼續討論產品線。您能否談談IRIS，目前它的推廣進度如何？顯然，現在還處於早期階段。另外，您能否單獨談談對Schölly內視鏡的收購？您是否已經克服了供應鏈的挑戰？

Great. I will do so. IRIS, first couple of accounts up and running. We expect more this quarter. It's really testing the whole order-to-delivery pipeline. Think of that as a digital pipeline that has to go through. Feedback is really encouraging. So this early part -- it's one of these things that's easy to describe, but to do well is hard, making sure all your cloud connections are right, making sure you have all your security protocols done, getting the turnaround times right, getting all your machine learning algorithms right. Feedback has been really good about its ability to help surgeons visualize pre-case, which is fantastic, use in other kinds of ways in terms of patient consultation and then access during the case. So the kind of the core idea, I think, is being vetted nicely. We have said before, we don't think it's a significant revenue driver in 2020. I think I would encourage people to think about this as baseline core technology, the kinds of things that as you develop systems like this in the future, that customers will come to expect, a little bit like our Firefly product. It is additive in the way that it's -- the system itself becomes greater than the sum of its parts. So IRIS, I think, looks quite strong.

好的，我會的。 IRIS 的首批幾個帳戶已經上線運行。我們預計本季會有更多帳戶投入使用。它實際上是在測試整個訂單到交付流程。你可以把它想像成一個必須經歷的數位化流程。回饋非常令人鼓舞。所以，早期階段——這很容易描述，但要做好卻很難，需要確保所有雲端連接都正確，確保所有安全協定都已落實，確保週轉時間符合要求，確保所有機器學習演算法都正確無誤。回饋非常好，它能夠幫助外科醫生進行術前可視化，這非常棒，還可以用於其他方面，例如患者諮詢，以及在手術過程中訪問。所以，我認為，其核心理念正在得到很好的驗證。我們之前說過，我們認為它在2020年不會成為重要的營收驅動因素。我建議大家把它看作是基礎核心技術，是未來開發類似系統時客戶會逐漸習以為常的技術，有點像我們的Firefly產品。它的附加功能在於－系統本身的功能大於各部分功能的總和。所以，我認為IRIS看起來相當強勁。

On the Schölly acquisition, the team's doing a really nice job. We were right to bring it in. We were right to bring it in when we did. That is doing a couple of things for us. It's giving us a little more alignment around next-gen products, which is exciting for us. It's helping us double down on some investments in terms of capacity and efficiency that goes with that capacity. And it will, in the medium term, start releasing some profitability and financing with regard to the way we produce our endoscopes that can be turned around and reinvested in the business.

關於對Schölly的收購，團隊做得非常出色。我們當初決定收購它是正確的，時機也掌握得恰到好處。這給我們帶來了多方面的好處。首先，它讓我們在下一代產品方面更加協調一致，這讓我們感到非常興奮。其次，它幫助我們加大對產能和效率的投資。從中長期來看，它將開始釋放我們內視鏡生產方式的獲利能力和資金，這些資金可以重新投入業務。

So, so far, so good. It is real work. They are a very good team. I think we knew what we were bringing in and acquiring. I'm really pleased with the leadership of the group and our team members that have joined us in Germany and in Boston or in Massachusetts. It's not to say there isn't work to be done, but so far, so good.

目前為止一切順利。這的確是一項實實在在的工作。他們是一支非常優秀的團隊。我想我們很清楚自己引進和收購的是什麼。我對團隊的領導層以及加入我們在德國、波士頓或麻薩諸塞州的團隊成員都非常滿意。當然，這並不意味著沒有工作要做，但目前為止，一切都很順利。

Okay. And then one just last clarification for Marshall. You called out a China pull-forward dynamic around the tariff. Can you just -- in the context of the 39 systems, are you able to quantify how much of that was tied to the tariff?

好的。最後還有一個問題想請教馬歇爾。您提到了圍繞關稅的中國提前撤軍動態。您能否結合這39個系統的情況，量化一下其中有多少是與關稅有關？

Well, not -- I can't quantify specifically. I would just tell you that there were a number of systems that the customers decided to expedite the process, and we were the beneficiary of that, obviously.

嗯，不——我無法具體量化。我只能說，客戶決定採用一些系統來加快流程，而我們顯然從中受益。

Our next question will come from the line of Bob Hopkins with Bank of America.

下一個問題將來自美國銀行的鮑伯霍普金斯。

Just a first quick question on the I&A revenue per case. You highlighted some (inaudible) tailwind, potential headwinds that called out that revenue per case could decline next year.

關於I&A的單案收入，我先問一個簡短的問題。您提到了一些（聽不清楚）利好因素，以及一些潛在的不利因素，這些因素表明明年的單案收入可能會下降。

Bob, we heard -- you got kind of broken -- yes, kind of broken up on the call. So could you reask the question?

鮑勃，我們聽說——你在電話裡情緒有點崩潰——是的，有點崩潰了。那你能再問一次那個問題嗎？

Sorry about that. Just on Instrument (inaudible). I just want to make sure I hear the messaging because there's some positives in this. I probably thought it could decline. (inaudible) stapling. I just want to sure the messaging on the I&A line for the next 12 months.

抱歉。剛才在儀器（聽不清楚）。我只是想確認一下訊息內容，因為這裡面有一些正面的方面。我可能以為情況會惡化。 （聽不清楚）裝訂。我只是想確認一下未來12個月I&A線路上的信息。

Yes. So what I said, Bob, was we've really seen good contribution to I&A revenue overall from benign procedures. But as we've described before, the increase in the I&A per procedure is really a reflection of additional advanced instrument revenue and then a per procedure offset by benign procedure growth. So all I'm calling out is if we're successful in growing benign procedures much faster than complex procedures, then you will see -- then it will win the tug-of-war, and therefore, your I&A per procedure might decline.

是的。鮑勃，我剛才說的是，我們看到良性手術對整體I&A收入的貢獻確實不錯。但正如我們之前所述，單次手術I&A費用的成長實際上反映了先進器械收入的增加，然後又被良性手術的成長所抵消。所以我想強調的是，如果我們能夠成功地讓良性手術的增長速度遠超複雜手術，那麼你會發現——良性手術將在這場拉鋸戰中勝出，因此，單次手術的I&A費用可能會下降。

On the advanced instruments, we've enjoyed further penetration into the procedures in which advanced instruments are used. And as that has occurred, then our revenue associated with procedures, our revenue per procedure has grown disproportionately to the number of procedures. Over time, as you penetrate that, then you will revert to your advanced technology growth, will be consistent with the number of additional procedures you add versus adding also incremental procedures that were previously not including it. So all we're saying is that there's the potential that the growth rate will decline. We still expect growth, just a lower rate.

在先進儀器方面，我們已進一步拓展了其在相關手術中的應用。隨著這一趨勢的出現，我們與手術相關的收入，即單次手術收入，增長速度遠超手術數量。隨著時間的推移，隨著我們應用範圍的擴大，先進技術的成長將回歸到與新增手術數量而非先前未應用該技術的手術數量保持一致。因此，我們想表達的是，成長率有可能下降。我們仍然預期成長，只是成長會放緩。

Okay. And then a quick question on U.S. capital. Over the last couple of years, the growth in procedures per average system has been remarkably consistent at about 5%, especially in the U.S. Is there a reason in your view why that number might change meaningfully in 2020? Or is that trend line expected to continue?

好的。接下來我想問一個關於美國資本市場的問題。過去幾年，平均每個醫療系統所進行的手術數量成長率一直非常穩定，約5%，尤其是在美國。您認為2020年這個數字可能會顯著改變嗎？還是說這種趨勢會持續下去？

No. I think, directionally, continued growth in procedures per system is something we would expect. It's something that we're actively working with customers, sharing analytics and data to help them -- to make their practices programs as efficient as they can be. So I think the trend -- I don't know if it's going to continue in exactly the same rates, but increasing utilization is something we would expect.

不。我認為，從整體方向來看，每個系統的手術量持續成長是符合預期的。我們正積極與客戶合作，分享分析數據，幫助他們盡可能提高診療流程的效率。所以我認為，雖然我不知道成長速度是否會保持不變，但提高利用率是符合預期的。

Our next question will come from the line of Larry Biegelsen with Wells Fargo.

我們的下一個問題將來自富國銀行的拉里·比格爾森。

Hopefully, you guys can hear me okay. Just one on Ion and then one on the P&L. How should we think about the ramp of Ion in 2020? Is it still going to be a controlled launch? Should we just expect a steady increase in placements? And I had one follow-up.

希望你們都能聽清楚。我先問一個關於Ion的問題，然後再問一個關於損益表的問題。我們該如何看待Ion在2020年的擴張計畫？它還會採取控制式發布嗎？還是應該預期安裝量會穩定成長？我還有一個後續問題。

As we've said in our prepared remarks, Ion is in the early stages of a measured launch. And so you should expect that it will grow slowly over time, slowly through 2020 and then more rapidly thereafter.

正如我們在事先準備好的發言稿中所述，Ion 目前正處於穩步推進的早期階段。因此，您可以預期其發展速度會隨著時間的推移而緩慢增長，2020 年全年增長緩慢，之後增長速度會加快。

I got it. And gross margins came in better than 2019 versus your original guidance. What are the puts and takes on the gross margin in 2020? And separately, Gary, R&D as a percent of sales has been increasing. Steadily, it's almost 10% of sales in 2019. Where do you see that going over time?

我明白了。毛利率比您最初預期的要好，2020 年的毛利率也高於 2019 年。您對 2020 年的毛利率有何預期？另外，Gary，研發支出佔銷售額的比例一直在成長。 2019 年，這一比例已接近 10%。您認為未來這比例會如何改變？

Sure. So for gross margins, the gives and takes are, as I outlined in my prepared remarks, pricing on systems, reductions in cost, manufacturing efficiency and mix, mix of both customers and types of product. And I think that what we're messaging for next year is that gross margins will decline slightly, reflecting primarily product mix and a shift -- the effect of new product and investments in the infrastructure.

當然。至於毛利率，如我在準備好的發言稿中所述，影響因素包括系統定價、成本降低、生產效率以及產品組合（包括客戶組合和產品類型組合）。我認為我們明年要傳達的訊息是，毛利率將略有下降，這主要反映了產品組合的變化以及新產品推出和基礎設施投資的影響。

And R&D, Marshall, as a percent of sales? Maybe I'm just curious if you expect that to continue to increase. Sorry, Gary?

研發支出佔銷售額的百分比是多少，馬歇爾？我只是好奇你是否預期這個比例會繼續成長。不好意思，蓋瑞？

Yes. No, I can jump in and take that one. I think about we have grown R&D as a percentage of sales pretty consistently over the last 3 years. And our messaging to you has been we're going to bring a couple of new platforms to market in parallel with some of our multiport efforts, SP and Ion being those two, that we think that next-gen imaging and nonoptical imaging is important, nonwhite light imaging is important, and we've been investing in that domain. We have been investing for scale. We've talked about the fact that I think there's a virtuous cycle here, which is as utilization goes up and volumes go up, it allows us to start taking advantage of automation opportunities and changing the way we manufacture that has taken the company to be a little more capital-intensive than in years past. But some of the things you were just talking about, the linkage to your prior question on gross margin, are enabled by these capital investments on multiyear time lines that allow us to get production scale advantages. And that allows us to share some of that cost savings with our customer and be able to be into lower complexity procedures at good economics and good economics for the company as well as the customer. So we've been doing that as well. And then lastly, it's been building in digital infrastructure.

是的。不，我可以插話回答這個問題。我認為在過去三年裡，我們的研發投入佔銷售額的比例一直保持著相當穩定的成長。我們一直向你們傳達的訊息是，我們將推出幾個新平台，同時推進我們的一些多端口項目，例如SP和Ion。我們認為下一代成像和非光學成像、非白光成像非常重要，因此我們一直在投資這個領域。我們一直在進行規模化投資。我們之前討論過，我認為這裡有一個良性循環：隨著產能利用率和產量的提高，我們可以開始利用自動化帶來的機遇，並改變我們的生產方式。這使得公司比往年需要投入更多的資金。但你剛才提到的一些方面，例如你之前關於毛利率的問題，正是得益於這些多年期的資本投資，它們使我們能夠獲得生產規模優勢。這樣一來，我們就能與客戶分享部分成本節約，並以經濟效益良好的方式進行複雜度較低的流程，這對公司和客戶都有好處。所以我們一直在做這件事。最後，我們還在建構數位化基礎設施。

So those are the major buckets that have been taking the R&D spend side. I think we are not thinking that, that number will leap going forward, but we also think we're still in the early innings of a baseball game here that have real opportunity long term for growth of the market. And we think that we can position ourselves really well by making sure that those 4 buckets are adequately staffed.

所以，這些就是研發支出主要集中在哪些領域。我們並不認為這個數字未來會大幅成長，但我們也認為目前仍處於市場發展的初期階段，市場長期成長潛力巨大。我們相信，確保這四個領域的人員配備充足，就能讓我們佔有有利地位。

Our next question will come from the line of Rick Wise with Stifel.

我們的下一個問題將來自 Stifel 的 Rick Wise 一線。

You talked -- Marshall mentioned it, I think Calvin mentioned that system trade-ins may slow, may trend down. I just want to make sure that I'm understanding the reasons why. Is it the lack of a major new next-gen system launch and so you've seen the trade-ins, "the easy trade-ins?" And maybe just as part of that, Gary, just reflecting back on R&D and innovation. Obviously, you're launching a lot of new products and innovation. But should we be thinking that you don't need to launch a next-gen big iron? Or how do we think about that, those 2 aspects of trade-ins and the pipeline?

您剛才提到了——馬歇爾也提到了，我想卡爾文也提到了，系統以舊換新的速度可能會放緩，甚至呈下降趨勢。我只是想確認一下我理解其中的原因。是因為缺乏新一代的大型系統發布，所以您看到的是以舊換新的情況，也就是「容易以舊換新的情況」嗎？加里，或許也正因為如此，我們才回顧研發和創新。顯然，你們推出了許多新產品和創新成果。但我們是否應該認為你們不需要推出下一代大型設備？或者我們應該如何看待以舊換新和產品線這兩個面向？

So trade-ins, we've been in the middle of a fairly strong cycle of trade-ins, and you've seen it go up quarter-over-quarter, last 2 quarters kind of flattening out. And what we commented on at the end of the third quarter, Rick, was that the total population of Sis that are out there that can be traded in, obviously, is decreasing as customers trade in their systems. And so the population is decreasing. And when we look back at historical patterns for previous-generation products, we think that we're at the peak of how much of that remaining base will be traded in, in any particular quarter. And so the 2 of those things lead us to the conclusion that you'll see a decrease in the number of trade-ins as we go forward.

所以，以舊換新方面，我們一直處於相當強勁的周期中，您可以看到它逐季增長，但最近兩個季度趨於平穩。正如我們在第三季末提到的，里克，隨著客戶置換他們的舊系統，可供置換的SIS設備總數顯然正在減少。因此，設備存量正在下降。回顧前幾代產品的歷史模式，我們認為目前剩餘設備在任何特定季度的置換量已經達到高峰。因此，這兩個因素使我們得出結論：隨著時間的推移，以舊換新的數量將會減少。

The second half of the question, I might quibble with the description is big iron, so I'm not going to own that. But I will talk to innovation in multiport. We're not done innovating in multiport. We're often asked, are you -- I see SP, I see Ion. Is that it? And the answer is categorically no. We think there's room for additional innovation beyond our Gen 4 multiport products, and we're working on those things.

問題的後半部分，我可能對「大型鐵塔」這個描述有點異議，所以我不打算就此發表意見。但我會談談多端口領域的創新。我們在多端口領域的創新遠未結束。我們常被問到，你們──我看到了SP，我看到了Ion，就這些了嗎？答案是絕對的否定。我們認為，除了第四代多埠產品之外，還有進一步創新的空間，我們正在努力實現這些目標。

And just 2 other quick ones. I'd be curious to hear more about sales force productivity. You highlighted, Gary, the improved productivity in the third quarter. It seems like that's part -- has to be part of the equation, I'm guessing, in the fourth quarter. How do we think about that factor as a driver in 2020?

還有兩個小問題。我很想了解一下銷售團隊的生產力狀況。 Gary，你重點提到了第三季生產力的提升。我猜想，這應該是第四季業績提升的一個因素。我們該如何看待這個因素在2020年對業績的影響呢？

I'll just ask my second one. Your competitors -- or potential robotic competitors are talking about digital surgery. And we've talked about this before, but I just wonder if you have competitors marketing something called digital surgery. How do we imagine Intuitive answering that kind of a functional or marketing push?

我再問第二個問題。你們的競爭對手——或者說潛在的機器人競爭對手——正在談論數位化手術。我們之前也討論過這個問題，但我只是想知道，你們的競爭對手是否也在推廣一種叫做「數位化手術」的技術。我們能想像Intuitive會如何應對這種功能性或市場性的衝擊嗎？

Okay. On the first question, the sales force productivity, we saw a move in the right direction in the fourth quarter. Some of the underlying dynamics in terms of rapid procedure growth or healthy procedure growth driving the need for new territories still exists. So I credit our sales leadership team is doing a really nice job, both managing growth and helping the organization become more productive while thinking through territory opportunities as well as efficiency opportunities. That's a long way of saying we made a step in the right direction. I think they have opportunity to keep moving in the right direction in terms of productivity. So far, so good.

好的。關於第一個問題，銷售團隊的生產力，我們在第四季度看到了積極的進展。一些潛在的因素，例如業務的快速成長或健康的成長，仍然推動著對新市場的需求。因此，我認為我們的銷售領導團隊做得非常出色，他們既有效地管理了業務成長，又幫助組織提高了生產力，同時也認真考慮了市場拓展和效率提升的機會。總而言之，我們朝著正確的方向邁出了一步。我認為他們在生產力方面還有提升的空間，可以繼續朝著正確的方向前進。目前為止，一切順利。

With regard to some of the commentary around digital surgery, the short answer is welcome to the party. I think that we've been working these issues for more than a decade. As I said before, my initial response is it's a valuable thing to be working on, and that's why we've been doing it. We've been the Internet of Things in surgical robots for a decade, cloud-enabled for a decade. We are quite deep.

關於一些圍繞數位化手術的評論，我的簡短回答是：歡迎加入！我認為我們在這些問題上已經耕耘了十多年。正如我之前所說，我的第一個反應是，這是一項非常有價值的研究，這也是我們一直致力於此的原因。十年來，我們一直在手術機器人領域應用物聯網技術，十年來也一直在應用雲端運算技術。我們在這方面累積了相當豐富的經驗。

As you go out and talk a little more than the tagline, you talk about what taglines are, what's the substance? So dig down a little bit, and the substance comes down to, I think, 4 opportunities. One opportunity is in the use of big data for analytic power. And that says that as you look across large sets of customers doing various things, can you help establish benchmarks that people can improve upon? And we have done that. It's been something we've been working on. So I think we're becoming quite skilled and will become more so. That's 1 category.

當你走出去，不再只是停留在標語層面，而是深入探討標語的本質和內涵時，你會發現，標語的內涵可以歸結為四個面向。其中一個面向是利用大數據進行分析。也就是說，當你觀察大量客戶的各種行為時，能否幫助他們建立可供改進的基準？我們已經做到了這一點，並且一直在努力。所以我認為我們在這方面已經相當熟練，而且會越來越熟練。這是第一類。

Another category is the use of computing power in real time to aid the surgeon or interventionalist during a case to get a better outcome. And absolutely interesting, there are many, many companies in the world that are thinking about that and making progress, and we are one of them. Ion is fundamentally powered by computing to help you make good decisions. IRIS is fundamentally a real-time computing capability in addition to big data. So that's one.

另一類應用是利用即時運算能力輔助外科醫師或介入醫師進行手術，以獲得更好的手術效果。這一點非常有趣，世界上有很多公司都在思考並致力於此，我們也是其中之一。 Ion 的核心在於運算能力，旨在幫助您做出明智的決策。 IRIS 的核心在於即時運算能力以及大數據技術。以上是其中一類應用。

The next bucket is around education and the reduction of variation team to team. We know that care team variation in any acute intervention, be it surgery, robotic surgery, laparoscopy, is highly variable. And the use of computing and analytics to help that process is clear. And I talked to you a little bit about how much we have in simulation, 200,000 simulated tasks done by surgeons this last year, 17,000 hours of simulation capability. These are things that we can help turn into better learning environments and reduction in care team variation.

下一個重點是教育以及如何減少團隊間的差異。我們知道，在任何急性介入措施中，無論是外科手術、機器人手術或腹腔鏡手術，醫療團隊之間的差異都很大。利用電腦和分析技術來輔助這一過程是顯而易見的。我之前也簡單提到我們在模擬上的投入，去年外科醫師完成了20萬次模擬任務，模擬時長達1.7萬小時。這些資源可以幫助我們創造更好的學習環境，並減少醫療團隊之間的差異。

And the last bucket is efficiency improvement. The use of computing technologies and networking to help hospitals become more productive and to help our company become more productive, and we're leveraging those opportunities on both to help our customers and otherwise.

最後一個面向是效率提升。我們利用電腦技術和網路來幫助醫院提高效率，也幫助我們公司提高效率，我們正在利用這些機會來幫助我們的客戶以及其他方面。

So I look forward to the conversation. I think it will win. The winner won't be the tagline. I think the winner will be those who deliver real value that's validated against those 4 categories.

所以我很期待這場對話。我認為它會勝出。贏家不會是那句標語，我認為贏家會是那些能夠提供真正價值，而這些價值能夠經受住這四個方面的考驗的人。

We'll take 1 more question, operator.

操作員，我們再回答一個問題。

Okay. The final question, one moment here. That final question will come from the line of Richard Newitter with SVB.

好的。最後一個問題，稍等片刻。最後一個問題將由SVB的理查德·紐維特提出。

Just 2 quick ones. The first, I'll ask them both just right upfront. The first one, the comments on cholecystectomy as a training procedure and kind of what you're seeing there as a spillover to, again, [comfortable about] the general surgery. Are you seeing that same dynamic increase in the usage or the utilization within hernia as kind of like a training ground for other types of general surgeries? Or is hernia kind of also equally as sticky?

就問兩個問題。第一個問題，我直接問他們兩個。第一個問題是關於膽囊切除術作為一種訓練手術，以及你們觀察到的它對其他普通外科手術的借鏡效果。你們是否也觀察到疝氣手術的使用率或利用率出現了同樣的動態增長，並將其作為其他普通外科手術的訓練場地？或者說，疝氣手術也同樣難以推廣？

And then the second question, just Marshall, on the I&A per case. If the benign growth does accelerate relative to the advanced type cases, what's the impact to gross margin there?

第二個問題，就馬歇爾而言，是關於每箱貨物的I&A成本。如果良性成長相對於高階類型貨物而言加速，這對毛利率會有什麼影響？

I'll take the first one. I'll let Marshall take the second one. One thing I would -- just to be clear, on general surgery is general surgery is quite a diverse set of procedures with quite a diverse set of practice patterns amongst general surgeon practitioners or practices. First of all, I think they choose procedures to do not simply to be trained because -- but because they think they and the patient can be benefited by that procedure. So I don't think they run off and train for the sake of training. I think they decide that there's some value here. They will sequence their way into a practice, and that would make sense, both by patient selection and by the type of procedure they do.

我來回答第一個問題，第二個問題就讓馬歇爾回答吧。首先我想澄清一點──一般外科手術種類繁多，一般外科醫師或診所的執業模式也各不相同。我認為，他們選擇進行哪些手術並非只是為了接受培訓，而是因為他們認為自己和病人都能從中受益。所以，我不認為他們是為了培訓而培訓。我認為他們會根據自身狀況判斷哪些手術有價值。他們會循序漸進地累積經驗，這既符合病人選擇原則，也符合他們所進行手術的類型。

You had asked, does the same kind of effect of, well, let's start with the right patient population for cholecystectomy also apply to something like hernia? The answer to that is yes. Some surgeons will elect to go into a hernia set first. Then if they find value in the product, find value in the process, they may like to move from there to a different procedure. Interestingly, we found that there's not a one-size-fits-all way that a practice adopts. They may choose a different entry point, depending on their interest and experiences.

您曾問，像膽囊切除術那樣，先從選擇合適的患者群體入手，這種方法是否也適用於疝氣手術？答案是肯定的。有些外科醫師會選擇先從疝氣手術開始。如果他們發現這種方法有效，並且對整個流程有所了解，他們可能會考慮在此基礎上進行其他手術。有趣的是，我們發現並沒有一種放諸四海皆準的模式。他們會根據自身的興趣和經驗，選擇不同的切入點。

Second question, Marshall?

第二個問題，馬歇爾？

I&A per case, if benign procedures were to grow faster than more complex procedures, it's a very slight improvement in gross margin. The advanced instruments have just a slightly lower gross margin than our other instruments.

如果良性手術的成長速度快於複雜手術，那麼每例手術的I&A費用只會略微提高毛利率。先進器械的毛利率也只比我們其他器械略低。

Okay. That was our last question. In closing, we believe there's a substantial and durable opportunity to fundamentally improve surgery and acute interventions. Our teams continue to work closely with hospitals, physicians and care teams in pursuit of our customers have termed their quadruple aim: better, more predictable patient outcomes, better patient experiences, better experiences for care teams and, ultimately, a lower total cost of care per patient episode. We believe value creation in surgery and acute care is foundationally human. It flows from respect for and understanding of patients and care teams, their needs and the environment in which they operate.

好的，這是我們最後一個問題。最後，我們相信，在從根本上改善外科手術和急診介入方面，存在著巨大且持久的機會。我們的團隊將繼續與醫院、醫生和護理團隊緊密合作，致力於實現客戶所稱的四重目標：更佳、更可預測的患者療效，更佳的患者體驗，更佳的護理團隊體驗，以及最終降低每次患者就診的總成本。我們相信，外科手術和急診的價值創造根植於人性。它源自於對病人和照護團隊的尊重和理解，以及對他們的需求和所處環境的關注。

Thank you for your support on this extraordinary journey. We look forward to talking with you again in 3 months.

感謝您在這段非凡旅程中的支持。我們期待三個月後再次與您交流。

Okay, ladies and gentlemen, that does conclude today's conference. I want to thank you for your participation. You may now disconnect.

好了，女士們、先生們，今天的會議到此結束。感謝各位的參與。現在可以斷開連線了。