For the past few months, neurosurgeons at hospitals in Florida, Connecticut and New York have been preparing for a wildly experimental operation designed to treat Alzheimer's disease, the dementia that leads to devastating memory loss. The surgery, which they've been practicing on cadavers, aims to clear the drainage pathways to the brain. This could help patients' own lymphatic systems flush out toxins that scientists believe are the hallmarks of the disease, which affects 7 million people in the U.S. alone.

To do so, they're turning to the smallest surgical robotic instruments in the world that can hold tiny needles the size of eyelashes, with scissors and dilators roughly the width of a human hair. The lymph vessels in the neck that surgeons would operate on for the Alzheimer’s procedure can be as little as 0.2 millimeters in diameter, the equivalent thickness of two sheets of paper. “It’s like taking a couple of strands of your hair and tying them together with little bitty sutures,” says Mark Toland, CEO of Jacksonville, Florida-based startup MMI, which makes the microrobots.

They aim to perform the first of these microrobotic surgeries on five people in March. While a very early-stage clinical study, it builds off reports from some 5,000 experimental surgeries performed in China and other Asian countries over the past five years that help the lymphatic system clear out build-up in the brain. They've shown remarkable, if largely anecdotal, results. Surgeons were not only able to slow the disease’s progression — they took patients with moderate Alzheimer’s back to a more mild stage of the disease, Toland says.

In November, MMI got the okay from the FDA to proceed with the trials, with the goal of first showing the procedure is safe in 15 people. If the initial trial is successful, Toland hopes to start enrolling 200 to 300 patients in a large-scale clinical trial later this year. With luck, he believes the startup could receive approval for the use of its microrobots to treat Alzheimer’s by the end of 2027.

"Nobody is going to adopt this procedure based on information coming out of China or even Korea." Mark Toland, MMI’s chief executive

"Nobody is going to adopt this procedure based on information coming out of China or even Korea."

It sounds pretty crazy. Once Alzheimer’s has progressed beyond its early stages, there is no known way to treat it, and attempts to do so have been abject failures. “As an investor if you say, ‘I’ve got a potential treatment for Alzheimer’s,’ the natural reaction is to say, ‘There’s no chance it’s going to work,’” says Dr. Andrew ElBardissi, an MMI investor and partner at Deerfield Management, which has more than $15 billion in assets invested in healthcare companies. “It has to be the most difficult biological disease with no clear mechanistic rationale for how to fix it and with a graveyard of failures. So that’s the starting point.”

But MMI’s clinical trials build off a relatively new body of scientific research on the brain’s waste removal system that may yield new hope for sufferers of the disease and their families.

The brains of people with Alzheimer’s show gummy clumps known as amyloid plaques and buildups of a protein called tau. Figuring out how to prevent these toxins from accumulating—let alone get rid of them once they do—has proven to be extraordinarily difficult. But the brain’s natural waste removal system, first discovered in 2012, provides a possibility for treatment. Researchers are looking at injecting proteins or stimulating the lymph nodes around the jaw with a pulsating device to help the brain clear out those toxins, among other things. This surgery, aided by microrobots, aims to help the brain’s waste drain naturally.

“It’s a plumbing issue,” says Toland, 56. “In heart surgery, you get a clogged artery and you bypass the clog to restore flow and you don’t have a heart attack. This is the same thing.”

Toland has a long history of using robots for such plumbing problems. Before joining MMI in 2021, he was CEO of Corindus Vascular Robotics, which treated coronary blockages and which he sold to Siemens Healthineers for $1.1 billion in 2019, and an exec at biomedical giant Boston Scientific.

Founded by three Italian roboticists in 2015, MMI (which stands for Medical Microinstruments, Inc.) currently sells precision robots that can handle tiny microneedles and scissors, which are used in surgeries like nerve repair, breast reconstruction after cancer and clearing fluid buildup (known as lymphedema). Called Symani, the robot enables surgeons to operate on lymph vessels smaller than 0.5 millimeters; doctors view the procedure on a screen with extreme magnification.

"It has to be the most difficult biological disease with no clear mechanistic rationale for how to fix it and with a graveyard of failures." Dr. Andrew ElBardissi, Deerfield Management partner

"It has to be the most difficult biological disease with no clear mechanistic rationale for how to fix it and with a graveyard of failures."

Each robot costs $1.5 million, and the company also makes money on those tiny needles and scissors, which can only be used once (similar to how razor companies bring in ongoing revenue from selling blades). Toland projects MMI’s revenue will reach $50 million this year, more than double its $20 million in sales in 2025. To date, MMI has raised a total of $220 million, including from Fidelity and top healthcare and life sciences investors Deerfield and RA Capital, at a valuation around $500 million.

But treating Alzheimer’s patients with surgery represents MMI’s biggest, boldest bet yet — with a potentially massive market. More than 55 million globally have Alzheimer’s or some other form of dementia, and that number is expected to reach 78 million by 2030. “Nobody is going to adopt this procedure based on information coming out of China or even Korea,” Toland says. “But if we establish a foundation of research in the United States, it’s a game changer for the whole world.”

Back in 2015, former Intuitive Surgical engineer Giuseppe Maria Prisco had a challenge for his friend Massimiliano Simi, who has a Ph.D. in innovative technologies and medical robotics from the Scuola Superiore Sant’Anna in Pisa, Italy. Could he design “the smallest instrument ever,” Simi, 43, recalls.

Now the company’s global vice president of R&D (and the only founder still with the company), Simi came back with the first prototype for MMI’s robot. The startup’s small team, based in Pisa, then spent the next two years refining it based on feedback from surgeons. “It was very ugly, but effective,” Simi says. Their original plan was to use the robot for reconstructive procedures in which surgeons move tissue from one part of the body to another after trauma or cancer.

By January 2021, when Toland joined as MMI’s chief executive, its robots had been used in just four surgeries in Florence, three of which involved reconstruction of the legs. Toland’s mandate was to commercialize the miniature bots—and bring in funding to do so.

In 2022, ElBardissi, who was scouting MMI as a potential investment, traveled to Italy to see the robot in action. “I knew if I could see the robot I could tell if it was adding value or was not ready for prime time,” he says. When he sat down at the robot’s controls to suture a tiny vessel, he says he was “blown away.” “I’m a cardiac surgeon, but we’re literally talking about something the width of a hair and I was putting sutures through the side of it and tying it together.”

That year, Elbardissi led a $75 million round in the business. MMI remains the first and only robotics company he’s invested in.

The company’s trial hinges on a lymphatic drainage procedure that was first pioneered by Dr. Qingping Xie, a surgeon based in Hangzhou, China, in 2020. But the surgery was experimental, and he’d only ever performed it by hand. In 2021, Xie began looking for robots to improve it, and he reached out to Toland. “He was showing me these crazy videos of how well these patients were doing,” Toland says. “I was extremely skeptical when I first saw this.”

But Toland was intrigued enough to send MMI staffers to China, where they followed patients for weeks after their surgery to better understand what was happening, he says. “Every time we sent someone to assess it, they came back more excited.”

Toland eventually pitched MMI’s board of directors on the potential of getting the company’s robots approved for the surgery. After watching pre- and post-operative videos of patients, ElBardissi decided, “it’s hard to argue there’s not something there.”

"He was showing me these crazy videos of how well these patients were doing." Mark Toland, MMI’s chief executive

"He was showing me these crazy videos of how well these patients were doing."

Within the scientific community, there’s both skepticism and hope. “It’s a very provocative and interesting idea,” says Jeff Iliff, a professor at UW Medicine and a leading researcher in this area. “There are some observational data out there, but definitive studies haven’t yet been done.”

Roslyn Bill, a professor at Aston University in Birmingham, U.K., whose own work on Alzheimer’s focuses on how a specific protein controls the brain’s waste clearance, points to the potential for brain swelling with surgery. “Would I want to be one of those patients? I think no, not at this stage,” she says.

Part of the problem is there hasn’t been a clinical study in the U.S. until now. “We never paid attention until this Chinese guy started talking about this and sparked all this interest,” says Dr. Ricardo Hanel, a neurosurgeon at Baptist Health in Jacksonville, Florida, who is one of the doctors involved in MMI’s clinical trial. It’s hard to assess the research from China and Korea so far, he says — and the Chinese government agrees. In July 2025, Beijing’s top health authority banned the popular surgery pending further clinical studies. “All this is very new, so when you talk to neurosurgeons about this, people say, ‘Is this voodoo medicine?’” he says.

But surveys of the Asian operations and existing research studies have concluded there’s enough evidence to merit further investigation. This January, a group of French doctors published a review of the nine studies that exist on the surgery in the Journal of Prevention of Alzheimer’s Disease. They concluded that “although clinical evidence is limited,” the surgery showed “promising therapeutic possibilities.”

Toland hopes that going through the FDA approval process will ultimately show what the surgeries in Asia already indicate: that lymphatic surgery, especially when performed with MMI’s microrobots, can be a safe and potentially effective treatment for moderate Alzheimer’s. “I have worked on the plumbing of the body my entire life,” he says. “If you fix the plumbing of the body, the body works well.” Now he just has to prove it.

© Forbes