PARIS — The Americans in Paris were drawing the crowds during an otherwise lackluster exhibition at the 110th French Congress for Surgery, the annual meeting of the French Surgery Association (Paris).

While French hospital budgets may be paralyzed for purchasing high-end medical machinery, the everyday work of general surgeons continues apace and the suppliers of more modest devices such as trocars, retractors and wound closure staplers were doing brisk business.

The crowd-pleaser was "le robo," the da Vinci Surgical System from Intuitive Surgical (Sunnyvale, California), which drew a steady stream of surgeons wanting to try their hand at remote laproscopic manipulations.

Intuitive is turning up buyers as well, despite a big price tag of €1.59 million ($2.19 million).

The company has installed 19 units in France, according to sales manager François-Xavier Bourdin, five of which are in Paris.

"Yes, financing is an issue," he said, "but there obviously can be capital available to invest in a unit with such convincing benefits for the patients and the surgeons."

Intuitive Surgical reports 119 da Vinci robotic surgery units have been placed in Europe over the past two years.

Positioned between the top two suppliers of everyday surgical suppliers in Europe, Johnson & Johnson's (New Brunswick, New Jersey) Ethicon Endo-Surgery (Cincinnati) and Covidien (Mansfield, Massachusetts), was Applied Medical Resources (Rancho Santa Margarita, California).

It is a familar position for Applied Medical, which has fought both companies through contract negotiations, court cases and congressional hearings to win a top spot in the American market.

"We are now No. 2 in the U.S.," Tom DeMarchi, president for international at Applied Medical, told Medical Device Daily.

"Sales this year will not hit $200 million, but we are getting very close, and we will pass that number for 2009," he said.

Applied Medical rolled out its full portfolio for Europe a year ago during the 109th meeting of the surgical group (MDD, Oct. 8, 2007), and DeMarchi said "the French market responded very well."

"We began in France because some of the most skilled laproscopic surgeons in the world are here," he said. "This was our first entry into Europe, yet today we already have established direct sales and distribution in seven countries."

The French market divides quickly into a public and the private sector, he said, with important features for each.

The French public purchasing policy is favorable to single-use devices and while this sector has 50% more hospitals at 650, the sector represents just 40% of the total market.

Meanwhile, there are 430 private hospitals and clinics that make up 60% of the total French purchasing and these tend to favor multiple-use products, putting Applied Medical at a disadvantage.

After France, Applied Medical moved quickly into Germany, but "after a year in Germany we are still learning," DeMarchi said.

"Germany is a very different market from France, dedicated to reusable products, for example," he said. "We do not yet have the answers. Instead we are still asking questions."

DeMarchi said Applied Medical has enjoyed successes with some German hospitals, "but we have more to learn and there is a long-term commitment to doing that."

By way of example he said sales of trocars are more complex there, "and it has not been as successful as in France. But we have a lot of other doors to try in opening the German market."

Laurent Leroy, responsible for Applied Medical's sales in France, Germany and Austria, said the company already has gained a 5% market share in trocars in France.

The UK was the third full-scale implantation for Applied Medical in Europe with a team on the ground in October, 2007.

The UK is "following the curve we have seen in France, except one year behind," said DeMarchi.

The company continued its expansion establishing direct sales and distribution in the Benelux countries this year, as well as in Austria.

He said that "Spain is on our radar, but I can't give a date for our launch in that market."

Applied Medical is "quite happy" with distribution and representation through independents in Portugal, Italy and the Nordic countries, said DeMarchi, ading that one distributor handles both Denmark and Sweden while Norway and Finland have respective in-country representative firms.

He said Applied Medical's entry into Europe is "not just about purchasing deals and budgets, but proving to these surgeons that our products meet or exceed their requirements."

In the middle of this positioning statement, DeMarchi was interrupted by a surgeon who crossed the exhibition aisle to pick up a plastic-wrapped circle lying on the counter.

"This is genial (brilliant)," said David Lechaux, a general and digestive surgeon with the Centre Hôpitalière de Saint Brieuc in the Brittany region. "If there is anything new here at the conference, this is it," he said. "I don't have anything to do with this company, but this is the innovation of the year as far as I am concerned."

He added, "As a retractor, it completely replaces everything made of steel I have been using and despite its simplicity, the spread and strength is extraordinary."

And then just as suddenly, Lechaux was gone, making his apologies as there was a scientific session starting down the hall.

DeMarchi arched his eyebrows, asking, "What was I saying?"

The Alexis O-ring retractor for colectomy that Applied Medical was introducing to French surgeons at the congress is embarrassingly simple for a medical device two plastic hoops joined by plastic sheeting.

One hoop is pushed into an incision and left to spread to its original diameter. The surgeon then rolls the plastic sheeting onto the second, external hoop and in less than a minute has a circular hand access to the patient's organs.

The significance of the simplicity of this proprietary product is that it eliminates the classic array of clamps and stainless steel retractors used to pull back the skin and muscle to open a patient to surgery.

At €35, this single-use product is cost-competitive with the estimated €200-per-procedure expense for retractors and sterilization, according to DeMarchi.

A study published in the January 2007 issue of the Journal of Trauma showed significant reductions in infection risk for the Alexis O-ring.