0001437749-21-005730 | 10-K | XBRL Viewer

Organization, Consolidation, Basis of Presentation, Business Description and Accounting Policies [Text Block]

1. Organization and Capitalization

In February 2021, TransEnterix, Inc. changed the name of the company to Asensus Surgical, Inc. Asensus Surgical, Inc. (the "Company") is a medical device company that is digitizing the interface between the surgeon and the patient to pioneer a new era of Performance-Guided Surgery^TM by unlocking clinical intelligence for surgeons to enable consistently superior outcomes and a new standard of surgery. The Company is focused on the market development for and commercialization of the Senhance® Surgical System, which digitizes laparoscopic minimally invasive surgery, or MIS. The Senhance System is the first and only digital, multi-port laparoscopic platform designed to maintain laparoscopic MIS standards while providing digital benefits such as haptic feedback, robotic precision, comfortable ergonomics, advanced instrumentation including 3 mm microlaparoscopic instruments, eye-sensing camera control and fully-reusable standard instruments to help maintain per-procedure costs similar to traditional laparoscopy.

The Senhance System is available for sale in Europe, the United States, Japan, Taiwan, Russia and select other countries.

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The Senhance System has a CE Mark in Europe for adult and pediatric laparoscopic abdominal and pelvic surgery, as well as limited thoracic surgeries excluding cardiac and vascular surgery.

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In the United States, the Company has received 510(k) clearance from the FDA for use of the Senhance System in general laparoscopic surgical procedures and laparoscopic gynecologic surgery in a total of 31 indicated procedures, including benign and oncologic procedures, laparoscopic inguinal, hiatal and paraesophageal hernia, sleeve gastrectomy and laparoscopic cholecystectomy (gallbladder removal) surgery.

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In Japan, the Company has received regulatory approval and reimbursement for 98 laparoscopic procedures.

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The Senhance System received its registration certificate by the Russian medical device regulatory agency, Roszdravnadzor, in December 2020, allowing for its sale and utilization throughout the Russian Federation.

In 2020, the Company obtained regulatory clearance for the Senhance ultrasonic system in both Taiwan and Japan. On March 13, 2020 the Company announced that it received FDA clearance for the Intelligent Surgical Unit™ (ISU™) for use with the Senhance System. The Company believes it is the first such FDA submission seeking clearance for machine vision technology in abdominal robotic surgery. On September 23, 2020, we announced the first surgical procedures successfully completed using the ISU. On January 19, 2021, the Company announced that it received CE Mark for the ISU. Finally, in the EU, the Company expanded its claims for the Senhance System to include pediatric patients, allowing accessibility to more surgeons and patients, as well as expanding its potential market to include pediatric hospitals in Europe. The Company anticipates the robotic precision provided by the Senhance System, coupled with the already available 3 mm instruments will prove to be an effective tool in surgery with smaller patients. As of February 15, 2021, two hospitals have installed the Senhance System for pediatric use.

On October 31, 2018, the Company acquired the assets, intellectual property and highly experienced multidisciplinary personnel of MST Medical Surgical Technologies, Inc., or MST, an Israeli-based medical technology company. Through this acquisition the Company acquired MST’s AutoLap™ assets and technology, one of the only image-guided robotic scope positioning systems with FDA clearance and CE Mark. The Company believes MST’s image analytics technology will accelerate and drive meaningful Senhance System developments, and allow the Company to expand the Senhance System to add augmented, intelligent vision capability. See Note 3 for a description of the acquisition transaction. The Company sold the AutoLap assets, while retaining the core technology, in October 2019. See Note 3 for a description of the asset sale.

The Company has also developed the SurgiBot System, a single-port, robotically enhanced laparoscopic surgical platform. In December 2017, the Company entered into an agreement with Great Belief International Limited, or GBIL, to advance the SurgiBot System towards global commercialization. The agreement transferred ownership of the SurgiBot System assets to GBIL, while the Company retained the option to distribute or co-distribute the SurgiBot System outside of China. GBIL intends to manufacture the SurgiBot System in China, obtain Chinese regulatory clearance from the National Medical Products Administration ("NMPA"), and commercialize in the Chinese market. The agreement provides the Company with proceeds of at least $29.0 million, of which $15.0 million has been received to date. The remaining $14.0 million represents future minimum royalties payable beginning at the earlier of receipt of Chinese regulatory approval or March 2023. In estimating the consideration in this transaction, the Company applied the guidance on constraining estimates of variable consideration. The Company reassesses the estimate every reporting period and the variable consideration will be adjusted when it is deemed no longer constrained. The Company recorded a gain during the year ended December 31, 2018 based on the cash proceeds (excluding future royalties) in excess of the carrying value of the assets sold.

On September 18, 2015, the Company entered into a Membership Interest Purchase Agreement, (the “Purchase Agreement”) with Sofar S.p.A., (“Sofar”) as seller, Vulcanos S.r.l. (“Vulcanos”), as the acquired company, and Asensus International, Inc. (“Asensus International”), a direct, wholly owned subsidiary of the Company that was incorporated in September 2015, as buyer. The closing of the transactions occurred on September 21, 2015 (the “Closing Date”) pursuant to which the Company acquired all of the membership interests of Vulcanos from Sofar (now known as the “Senhance Acquisition”), and changed the name of Vulcanos to TransEnterix Italia S.R.L. (“TransEnterix Italia”). On February 24, 2021, TransEnterix Italia changed its name to Asensus Surgical Italia S.r.l. The Senhance Acquisition included all of the assets, employees and contracts related to the Senhance System. See Note 3 for a description of the related transactions.

On September 3, 2013, TransEnterix Surgical, Inc.. a Delaware corporation (“TransEnterix Surgical”), and SafeStitch Medical, Inc., a Delaware corporation (“SafeStitch”) consummated a merger transaction whereby TransEnterix Surgical merged with a merger subsidiary of SafeStitch, with TransEnterix Surgical as the surviving entity in the merger (the “Merger”). As a result of the Merger, TransEnterix Surgical became a wholly owned subsidiary of SafeStitch. On December 6, 2013, SafeStitch changed its name to TransEnterix, Inc. and increased the authorized shares of common stock from 225,000,000 to 750,000,000, and authorized 25,000,000 shares of preferred stock, par value $0.01 per share. On February 23, 2021, TransEnterix, Inc. changed its name to Asensus Surgical, Inc. On February 25, 2021, TransEnterix Surgical changed its name to Asensus Surgical US, Inc.

As used herein, the term “Company” refers to the combination of SafeStitch and TransEnterix Surgical after giving effect to the Merger, and includes Asensus Surgical US, Inc., SafeStitch LLC, Asensus International, Inc.; Asensus Surgical Italia S.r.l.; Asensus Surgical Europe S.à.R.L; TransEnterix Taiwan Ltd.; TransEnterix Japan KK; Asensus Surgical Israel Ltd., Asensus Surgical Netherlands B.V., and Asensus Surgical Canada, Inc.

Note 2 - Summary of Significant Accounting Policies

12 Months Ended

Dec. 31, 2020

Significant Accounting Policies [Text Block]

2. Summary of Significant Accounting Policies

Basis of Presentation

The accompanying Consolidated Financial Statements have been prepared in accordance with U.S. generally accepted accounting principles (“U.S. GAAP”) and include the accounts of the Company and its direct and indirect wholly owned subsidiaries. All material inter-company accounts and transactions have been eliminated in consolidation.

On December 11, 2019, following receipt of approval from stockholders at a special meeting of stockholders held on the same day, the Company filed an amendment to our Amended and Restated Certificate of Incorporation to effect a reverse stock split of the Company’s common stock at a ratio of one-for-thirteen, or the Reverse Stock Split. The Company’s common stock began trading on a split-adjusted basis on NYSE American on the morning of December 12, 2019. No fractional shares were issued in connection with the Reverse Stock Split. Instead, the Company rounded up each fractional share resulting from the reverse stock split to the nearest whole share. As a result of the Reverse Stock Split, the Company’s outstanding common stock decreased from approximately 261.9 million shares to approximately 20.2 million shares (without giving effect to the rounding up for each fractional share).

Unless otherwise noted, all share and per share data referenced in the consolidated financial statements and the notes thereto have been retroactively adjusted to reflect the Reverse Stock Split. As a result of the Reverse Stock Split, certain amounts in the consolidated financial statements and the notes thereto may be slightly different than previously reported due to rounding of fractional shares, and certain amounts within the consolidated balance sheets were reclassified between common stock and additional paid-in capital.

Liquidity

The Company had an accumulated deficit of $722.9 million, working capital of $23.7 million, and cash and cash equivalents, excluding restricted cash, of $16.4 million as of December 31, 2020. The Company has not established sufficient sales revenues to cover its operating costs and requires additional capital to proceed with its operating plan.

The Company believes the COVID-19 pandemic will continue to negatively impact its operations and ability to implement its market development efforts, which will have a negative effect on its financial condition. At December 31, 2020, the Company had cash and cash equivalents, excluding restricted cash, of approximately $16.4 million. Subsequent to December 31, 2020, the Company has raised additional capital through equity offerings, including raising net proceeds of $73.5 million in the January 2021 public offering, $28.8 million in the January 2021 registered direct offering, and $28.1 million in the 2020 ATM Offering. Also Series B, C and D warrants have been exercised in 2021 for aggregate proceeds to the Company of $30.4 million. While the Company believes that its existing cash and cash equivalents at December 31, 2020 and the proceeds from the January 2021 public offering and registered direct offering, ATM offering, and exercise of the warrants will be sufficient to sustain operations for at least the next 12 months from the issuance of these financial statements, the Company will need to obtain additional financing to proceed with its business plan. Management's plan to obtain additional resources for the Company may include additional sales of equity, traditional financing, such as loans, entry into a strategic collaboration, entry into an out-licensing arrangement or provision of additional distribution rights in some or all of our markets. However, management cannot provide any assurance that the Company will be successful in accomplishing any or all of its plans.

Use of Estimates

The preparation of financial statements in conformity with U.S. GAAP requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and the disclosure of contingent assets and liabilities at the date of the financial statements and the reported amounts of revenues and expenses during the reporting period. Actual results could differ from those estimates. Significant items subject to such estimates and assumptions include impairment considerations for intangible assets, fair value estimates related to contingent consideration, warrant liabilities, stock compensation expense, revenue recognition, accounts receivable reserves, excess and obsolete inventory reserves, inventory classification between current and non-current, and deferred tax asset valuation allowances.

The COVID-19 pandemic has caused significant social and economic restrictions that have been imposed in the United States and abroad, which has resulted in significant volatility in the global economy and led to reduced economic activity. In the preparation of these financial statements and related disclosures, the Company has assessed the impact that COVID-19 has had on its estimates, assumptions, forecasts, and accounting policies. The Company continues to monitor closely the COVID-19 pandemic impact on its estimates, assumptions and forecasts used in the preparation of its financial statements. As the COVID-19 situation is unprecedented and ever evolving, future events and effects related to COVID-19 cannot be determined with precision, and actual results could significantly differ from estimates or forecasts.

Cash and Cash Equivalents and Restricted Cash

The Company considers all highly liquid investments with original maturities of 90 days or less at the time of purchase to be cash equivalents.

Restricted cash at December 31, 2020 and 2019 includes $1.2 million and $1.0 million, respectively, in cash accounts held as collateral primarily under the terms of an office operating lease, credit cards, automobile leases, and a performance guarantee required by the government of a country in which a Senhance System was sold in 2018.

Concentrations and Credit Risk

The Company’s principal financial instruments subject to potential concentration of credit risk are cash and cash equivalents, including amounts held in money market accounts. The Company places cash deposits with a federally insured financial institution. The Company maintains its cash at banks and financial institutions it considers to be of high credit quality; however, the Company’s domestic cash deposits may at times exceed the Federal Deposit Insurance Corporation’s insured limit. Balances in excess of federally insured limitations may not be insured. The Company has not experienced losses on these accounts, and management believes that the Company is not exposed to significant risks on such accounts.

The Company’s accounts receivable are derived from sales to customers located throughout the world. The Company evaluates its customers’ financial condition and, generally, requires no collateral from its customers. The Company provided reserves for potential credit losses and recorded a bad debt charge totaling $0 million during the year ended December 31, 2020 and $1.6 million during the year ended December 31, 2019. The Company had 7 customers who constituted 68% of the Company’s net accounts receivable at December 31, 2020. The Company had eight customers who constituted 85% of the Company’s net accounts receivable at December 31, 2019. The Company had nine customers who accounted for 55% of revenue in 2020 and six customers who accounted for 82% of revenue in 2019.

Accounts Receivable

Accounts receivable are recorded at net realizable value, which includes an allowance for estimated uncollectible accounts. The allowance for uncollectible accounts was determined on a customer specific basis based on deemed collectability. The allowance for doubtful accounts was $1.8 million and $1.7 million as of December 31, 2020 and December 31, 2019, respectively.

Inventories

Inventories are stated at the lower of cost (determined on a first-in, first-out basis) or net realizable value. Inventory costs include direct materials, direct labor, and normal manufacturing overhead. The Company records reserves, when necessary, to reduce the carrying value of inventory to its net realizable value. Management considers forecast demand in relation to the inventory on hand, competitiveness of product offerings, market conditions and product life cycles when determining excess and obsolescence and net realizable value adjustments. At the point of loss recognition, a new, lower-cost basis for that inventory is established, and any subsequent improvements in facts and circumstances do not result in the restoration or increase in that newly established cost basis.

Any inventory on hand at the measurement date in excess of the Company's current requirements based on anticipated levels of sales is classified as long-term on the Company's consolidated balance sheets. The Company's classification of long-term inventory requires it to estimate the portion of on hand inventory that can be realized over the upcoming twelve months.

Identifiable Intangible Assets and Goodwill

Definite-Lived Intangible Assets - Intellectual Property

Intellectual property consists of purchased patent rights and developed technology acquired as part of a business acquisition. Developed technology includes reclassified IPR&D assets related to (i) the Senhance System acquired in 2015 and reclassified in 2017 and (ii) MST acquired in 2018 and reclassified in 2020. Amortization of the patent rights is recorded using the straight-line method over the estimated useful life of the patents of 10 years. Amortization of the developed technology is recorded using the straight-line method over the estimated useful life of 5 to 7 years.

The Company periodically evaluates intellectual property for impairment whenever events or changes in circumstances indicate that the carrying amount may not be recoverable. To determine the recoverability, the Company evaluates the probability that future estimated undiscounted net cash flows will be less than the carrying amount of the assets. If such estimated cash flows are less than the carrying amount of the assets, then such assets are written down to their fair value. No impairment of intellectual property was identified during the year ended December 31, 2020 and 2019.

Indefinite-Lived Intangible Assets – In-Process Research and Development

In-process research and development (“IPR&D”) assets represent the fair value assigned to technologies that were acquired, which at the time of acquisition have not reached technological feasibility and have no alternative future use. IPR&D assets are considered to be indefinite-lived until the completion or abandonment of the associated research and development projects. During the period that the IPR&D assets are considered indefinite-lived, they are tested for impairment on an annual basis, or more frequently if the Company becomes aware of any events occurring or changes in circumstances that indicate that the fair value of the IPR&D assets are less than their carrying amounts. To determine the recoverability, the Company evaluates the probability that future estimated discounted net cash flows will be less than the carrying amount of the assets. If such estimated cash flows are less than the carrying amount of the assets, then such assets are written down to their fair value.

The Company reclassifies IPR&D assets to intellectual property when development is complete, which generally occurs upon regulatory approval when the Company is able to commercialize products. The completed IPR&D assets are then classified as definite-lived intangible assets (developed technology) and are amortized based on their estimated useful lives at that point in time. If development is terminated or abandoned, the Company may have a full or partial impairment charge related to the IPR&D assets, calculated as the excess of carrying value of the IPR&D assets over fair value.

The Company performed an impairment test of its IPR&D at the end of the third quarter 2019 as recent events and changes in market conditions indicated that the asset might be impaired. During the third quarter of 2019, the Company concluded that the fair value determined by the market value approach was lower than the carrying value and recognized a $7.9 million impairment charge to its IPR&D. The Company performed its annual impairment assessment at December 31, 2019 and no additional impairment was required. As of December 31, 2020, all IPR&D asset development was completed and reclassified to intellectual property.

As of December 31, 2020, there were no remaining IPR&D assets.

Goodwill

Goodwill of $93.8 million was recorded in connection with a September 2013 merger transaction, goodwill of $38.3 million was recorded in connection with the Senhance Acquisition and goodwill of $9.6 million was recorded in connection with the MST Medical Surgical Technologies, Ltd. Acquisition (see Note 3). During the third quarter of 2019, the Company’s stock price declined significantly as a result of decreased sales and goodwill was deemed to be fully impaired, resulting in an impairment charge of $79.0 million.

As of December 31, 2020, there was no remaining Goodwill asset.

Property and Equipment

Property and equipment consists primarily of operating lease Senhance System assets, machinery, manufacturing equipment, demonstration equipment, computer equipment, furniture, and leasehold improvements, which are recorded at cost.

Depreciation is recorded using the straight-line method over the estimated useful lives of the assets as follows:

Years

Operating lease assets – Senhance System leasing
5

Machinery, manufacturing, and demonstration equipment
3 - 5

Computer equipment
3

Furniture
5

Leasehold improvements

Lesser of lease term or 3 to 10

Upon retirement or sale, the cost of assets disposed of and the related accumulated depreciation and amortization are removed from the accounts and any resulting gain or loss is credited or charged to operations. Repairs and maintenance costs are expensed as incurred.

Impairment of Long-Lived Assets

The Company reviews its property and equipment assets for possible impairment whenever events or changes in circumstances indicate that the carrying amount of the assets may not be fully recoverable. To determine the recoverability of its long-lived assets, the Company evaluates the probability that future estimated undiscounted net cash flows will be less than the carrying amount of the assets. If such estimated cash flows are less than the carrying amount of the long-lived assets, then such assets are written down to their fair value. The Company did not identify any impairment during the years ended December 31, 2020 and 2019.

Contingent Consideration

Contingent consideration is recorded as a liability and is the estimate of the fair value of potential milestone payments related to business acquisitions. Contingent consideration is measured at fair value using a discounted cash flow model utilizing significant unobservable inputs including the probability of achieving each of the potential milestones, future Euro-to-USD exchange rates, and an estimated discount rate associated with the risks of the expected cash flows attributable to the various milestones. Significant increases or decreases in any of the probabilities of success or changes in expected achievement of any of these milestones would result in a significantly higher or lower fair value of these milestones, respectively, and commensurate changes to the associated liability. The contingent consideration is revalued at each reporting period and changes in fair value are recognized in the consolidated statements of operations and comprehensive loss.

Warrant Liabilities

The Company’s Series B Warrants (see Note 16) are measured at fair value using a simulation model which takes into account, as of the valuation date, factors including the current exercise price, the expected life of the warrant, the current price of the underlying stock, its expected volatility, holding cost and the risk-free interest rate for the term of the warrant (see Note 5). The warrant liability is revalued at each reporting period and changes in fair value are recognized in the consolidated statements of operations and comprehensive loss. The selection of the appropriate valuation model and the inputs and assumptions that are required to determine the valuation requires significant judgment and requires management to make estimates and assumptions that affect the reported amount of the related liability and reported amounts of the change in fair value. Actual results could differ from those estimates, and changes in these estimates are recorded when known.

Translation of Foreign Currencies

The functional currency of the Company’s operational foreign subsidiaries is predominantly the Euro. The assets and liabilities of the Company’s foreign subsidiaries are translated into U.S. dollars at exchange rates in effect at the balance sheet date. Income and expense items are translated at the average exchange rates prevailing during the period. The cumulative translation effect for a subsidiary using a functional currency other than the U.S. dollar is included in accumulated other comprehensive income or loss as a separate component of stockholders’ equity.

The Company’s intercompany accounts are denominated in the functional currency of the foreign subsidiary. Gains and losses resulting from the remeasurement of intercompany receivables that the Company considers to be of a long-term investment nature are recorded as a cumulative translation adjustment in accumulated other comprehensive income or loss as a separate component of stockholders’ equity, while gains and losses resulting from the remeasurement of intercompany receivables from a foreign subsidiary for which the Company anticipates settlement in the foreseeable future are recorded in the consolidated statements of operations and comprehensive loss. The net gains and losses included in net loss in the consolidated statements of operations and comprehensive loss for the years ended December 31, 2020 and 2019 were not significant.

Business Acquisitions

Business acquisitions are accounted for using the acquisition method of accounting in accordance with ASC 805, “Business Combinations.” ASC 805 requires, among other things, that assets acquired and liabilities assumed be recognized at their fair values, as determined in accordance with ASC 820, “Fair Value Measurements,” as of the acquisition date. For certain assets and liabilities, book value approximates fair value. In addition, ASC 805 establishes that consideration transferred be measured at the closing date of the acquisition at the then-current market price. Under ASC 805, acquisition-related costs (i.e., advisory, legal, valuation and other professional fees) and certain acquisition-related restructuring charges impacting the target company are expensed in the period in which the costs are incurred. The application of the acquisition method of accounting requires the Company to make estimates and assumptions related to the estimated fair values of net assets acquired.

Significant judgments are used during this process, particularly with respect to intangible assets. Therefore, the purchase price allocation to intangible assets and goodwill has a significant impact on future operating results.

Risk and Uncertainties

The Company is subject to risks similar to other similarly sized companies in the medical device industry. These risks include, without limitation: potential negative impacts on the Company's operations caused by the COVID-19 pandemic; the Company’s ability to continue as a going concern; the historical lack of profitability; the Company’s ability to raise additional capital; the success of its market development efforts, the liquidity and capital resources of its partners; its ability to successfully develop, clinically test and commercialize its products; the timing and outcome of the regulatory review process for its products; changes in the health care and regulatory environments of the United States, the United Kingdom, the European Union, Japan, Taiwan and other countries in which the Company operates or intends to operate; its ability to attract and retain key management, marketing and scientific personnel; its ability to successfully prepare, file, prosecute, maintain, defend and enforce patent claims and other intellectual property rights; its ability to successfully transition from a research and development company to a marketing, sales and distribution concern; competition in the market for robotic surgical devices; and its ability to identify and pursue development of additional products.

Revenue Recognition

The Company’s revenue consists of product revenue resulting from the sale and lease of Systems, System components, instruments and accessories, and service revenue. The Company accounts for a contract with a customer when there is a legally enforceable contract between the Company and the customer, the rights of the parties are identified, the contract has commercial substance, and collectability of the contract consideration is probable. The Company's revenues are measured based on consideration specified in the contract with each customer, net of any sales incentives and taxes collected from customers that are remitted to government authorities. The Company’s System sale arrangements generally include a five-year service period; the first year of service is generally free and included in the System sale arrangement and the remaining four years are generally included at a stated service price.

The Company’s System sale arrangements generally contain multiple products and services. For these consolidated sale arrangements, the Company accounts for individual products and services as separate performance obligations if they are distinct, which is if a product or service is separately identifiable from other items in the consolidated package, and if a customer can benefit from it on its own or with other resources that are readily available to the customer. The Company’s System sale arrangements may include a combination of the following performance obligations: System(s), System components, instruments, accessories, and System service.

For arrangements that contain multiple performance obligations, revenue is allocated to each performance obligation based on its relative estimated standalone selling price. When available, standalone selling prices are based on observable prices at which the Company separately sells the products or services; however due to limited sales to date, standalone selling prices generally are not directly observable. The Company estimates the standalone selling price using the market assessment approach considering market conditions and entity-specific factors including, but not limited to, features and functionality of the products and services, geographies, type of customer, and market conditions. The Company regularly reviews estimated standalone selling prices and updates these estimates if necessary.

The Company recognizes revenues as the performance obligations are satisfied by transferring control of the product or service to a customer. The Company generally recognizes revenue for the performance obligations as follows:

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System sales. For Systems and System components sold directly to end customers, revenue is recognized when the Company transfers control to the customer, which is generally at the point when acceptance occurs that indicates customer acknowledgment of delivery or installation, depending on the terms of the arrangement. For Systems sold through distributors, for which distributors are responsible for installation, revenue is recognized generally at the time of shipment. The Company’s System arrangements generally do not provide a right of return. The Systems are generally covered by a one-year warranty. Warranty costs were not material for the periods presented.

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Instruments and accessories. Revenue from sales of instruments and accessories is recognized when control is transferred to the customers, which generally occurs at the time of shipment, but also occurs at the time of delivery depending on the customer arrangement.

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Service. Service revenue is recognized ratably over the term of the service period as the customers benefit from the service throughout the service period. Revenue related to services performed on a time-and-materials basis is recognized when performed.

The following table presents revenue disaggregated by type and geography:

Year Ended
December 31,

2020

2019

(in thousands)

U.S.

Systems
$ 282 $ 90

Instruments and accessories
187 108

Services
380 338

Total U.S. revenue
849 536

Outside of U.S. ("OUS")

Systems
490 5,459

Instruments and accessories
653 1,447

Services
1,183 1,089

Total OUS revenue
2,326 7,995

Total

Systems
772 5,549

Instruments and accessories
840 1,555

Services
1,563 1,427

Total revenue
$ 3,175 $ 8,531

The Company recognizes sales by geographic area based on the country in which the customer is based. Operating lease revenue from Senhance System Leasing (see discussion below) is included as Systems in the above table and was approximately $0.7 million and $0 million for the years ended December 31, 2020 and 2019, respectively.

Transaction price allocated to remaining performance obligations relates to amounts allocated to products and services for which the revenue has not yet been recognized. A significant portion of this amount relates to service obligations performed under the Company's system sales contracts that will be invoiced and recognized as revenue in future periods. Transaction price allocated to remaining performance obligations was approximately $3.1 million and $3.7 million as of December 31, 2020 and 2019, respectively.

The Company invoices its customers based on the billing schedules in its sales arrangements. Contract assets for the periods presented primarily represent the difference between the revenue that was recognized based on the relative selling price of the related performance obligations and the contractual billing terms in the arrangements. Contract assets are included in accounts receivable and totaled $0.1 million and $0.2 million as of December 31, 2020 and 2019, respectively. Deferred revenue for the periods presented was primarily related to service obligations, for which the service fees are billed up-front, generally annually. The associated deferred revenue is generally recognized ratably over the service period. The Company did not have any significant impairment losses on its contract assets for the periods presented. Revenue recognized for the years ended December 31, 2020 and 2019, that was included in the deferred revenue balance at the beginning of each reporting period was $0.6 million and $1.0 million, respectively. Revenue for the year ended December 31, 2019 also included $1.3 million from a System sold in 2017 for which revenue was deferred until its first clinical use, which occurred in the second quarter of 2019. The aggregate amount of transaction price allocated to performance obligations that remain unsatisfied as of December 31, 2020 was $3.1 million, which is expected to be recognized as revenue over one to three years.

In connection with assets recognized from the costs to obtain a contract with a customer, the Company determined that the sales incentive programs for its sales team do not meet the requirements to be capitalized as the Company does not expect to generate future economic benefits from the related revenue from the initial sales transaction and such costs are expensed as incurred.

Senhance System Leasing

The Company enters into lease arrangements with certain qualified customers. Revenue related to arrangements including lease elements are allocated to lease and non-lease elements based on their relative standalone selling prices. Lease elements generally include a Senhance System, while non-lease elements generally include training and proctoring services, instruments, and accessories. For some lease arrangements, the customers are provided with the right to purchase the leased System at some point during and/or at the end of the lease term. In some arrangements lease payments are based on the usage of the System.

In determining whether a transaction should be classified as a sales-type or operating lease, the Company considers the following terms at lease commencement: (1) whether title of the Senhance System transfers automatically or for a nominal fee by the end of the lease term, (2) whether the present value of the minimum lease payments equals or exceeds substantially all of the fair value of the leased System, (3) whether the lease term is for the major part of the remaining economic life of the leased System, (4) whether the lease grants the lessee an option to purchase the leased System that the lessee is reasonably certain to exercise, and (5) whether the underlying System is of such a specialized nature that it is expected to have no alternative use to the Company at the end of the lease term. All such arrangements through December 31, 2020 are classified as operating leases.

Revenue related to lease elements from operating lease arrangements is generally recognized on a straight-line basis over the lease term or based upon System usage and is presented as product revenue. Revenue related to lease elements from operating lease arrangements was approximately $0.7 million and $0 million for the years ended December 31, 2020 and 2019, respectively.

Cost of Revenue

Cost of revenue consists of contract manufacturing, materials, labor and manufacturing overhead incurred internally to produce the products. Shipping and handling costs incurred by the Company are included in cost of revenue. During the years ended December 31, 2020 and 2019, the Company recorded $0 and $1.5 million of expenses, respectively, for inventory obsolescence related to certain System components.

Research and Development Costs

Research and development expenses primarily consist of engineering, product development and regulatory expenses, incurred in the design, development, testing and enhancement of our products. Research and development costs are expensed as incurred.

Stock-Based Compensation

The Company follows ASC 718 “Stock Compensation”, which provides guidance in accounting for share-based awards exchanged for services rendered and requires companies to expense the estimated fair value of these awards over the requisite service period. The Company recognizes as expense, the grant-date fair value of stock options and other stock-based compensation issued to employees and non-employee directors over the requisite service periods, which are typically the vesting periods. The Company uses the Black-Scholes-Merton model to estimate the fair value of our stock-based payments. The volatility assumption used in the Black-Scholes-Merton model is based on the calculated historical volatility based on an analysis of reported data for a peer group of companies as well as the Company’s historical volatility. The expected term of options granted has been determined based upon the simplified method, because the Company does not have sufficient historical information regarding its options to derive the expected term. Under this approach, the expected term is the mid-point between the weighted average of vesting period and the contractual term. The risk-free interest rate is based on U.S. Treasury rates whose term is consistent with the expected life of the stock options. The Company has not paid and does not anticipate paying cash dividends on its shares of common stock; therefore, the expected dividend yield is assumed to be zero. The Company estimates forfeitures based on its historical experience and adjust the estimated forfeiture rate based upon actual experience.

The fair value of restricted stock units is determined by the market price of the Company’s common stock on the date of grant.

The Company records as expense the fair value of stock-based compensation awards, including stock options and restricted stock units. Compensation expense for stock-based compensation was approximately $7.9 million and $11.5 million for the years ended December 31, 2020 and 2019, respectively.

Income Taxes

The Company accounts for income taxes using the asset and liability method, which requires the recognition of deferred tax assets or liabilities for the temporary differences between financial reporting and tax basis of the Company’s assets and liabilities, and for tax carryforwards at enacted statutory rates in effect for the years in which the asset or liability is expected to be realized. The effect on deferred taxes of a change in tax rates is recognized in income during the period that includes the enactment date. In addition, valuation allowances are established when necessary to reduce deferred tax assets and liabilities to the amounts expected to be realized. The Company has elected to account for global intangible low-taxed income (“GILTI”) as a period expense in the year the tax is incurred.

The Company recognizes the financial statement benefit of an income tax position only after determining that the relevant taxing authority would more likely than not sustain the position following audit. For tax positions meeting the more likely than not threshold, the amount recognized in the financial statements is the largest benefit that has a greater than 50% likelihood of being realized upon ultimate settlement with the relevant taxing authority. The Company recognizes interest accrued related to unrecognized tax benefits and penalties in the provision for income taxes.

Tax regulations within each jurisdiction are subject to the interpretation of the related tax laws and regulations and require application of significant judgment. The Company is subject to U.S. federal and various state, local and foreign jurisdictions. Due to the Company’s net operating loss carryforwards, the Company may be subject to examination by authorities for all previously filed income tax returns.

In a referendum held on May 19, 2019, Swiss voters adopted the Federal Act on Tax Reform and AVS Financing (TRAF). TRAF introduces major changes in the Swiss tax system by abolishing certain current preferential tax regimes and replacing them with new measures that are in line with international standards. The referendum did not have a material impact on the Company for the 2020 or 2019 tax provisions. The Company will continue to evaluate the impact of these provisions in future periods as the enactment process is completed.

On March 27, 2020, the CARES Act was signed into law in response to the COVID-19 pandemic. The CARES Act, as amended on June 5, 2020 through the enactment of the Paycheck Protection Program Flexibility Act, provides numerous tax provisions and stimulus measures, including temporary changes regarding the prior and future utilization of net operating losses, temporary changes to the prior and future limitations on interest deductions, and technical corrections from prior tax legislation for tax depreciation of certain qualified improvement property. The Company continues to evaluate the provisions of the CARES Act, as amended, relating to income taxes which may result in adjustments to certain deferred tax assets and liabilities.

Comprehensive Loss

Comprehensive loss is defined as the change in equity of a business enterprise during a period from transactions and other events and circumstances from non-owner sources.

Segments

The Company operates in one business segment—the research, development and sale of medical device robotics to improve minimally invasive surgery. The Company’s chief operating decision maker (determined to be the Chief Executive Officer) does not manage any part of the Company separately, and the allocation of resources and assessment of performance are based on the Company’s consolidated operating results.

Approximately 27% and 19% of the Company’s total consolidated assets are located within the U.S. as of December 31, 2020 and 2019, respectively. The remaining assets are mostly located in Europe and are primarily related to the Company’s facility in Italy, and include intellectual property, in-process research and development, other current assets, property and equipment, cash, accounts receivable, other long-term assets and inventory of $56.8 million and $60.5 million as of December 31, 2020 and 2019, respectively. Total assets outside of the United States amounted to 73% and 81% of total consolidated assets at December 31, 2020 and 2019, respectively. Long-lived assets in the U.S. were 11% and 8%, Italy were 48% and 63%, and Switzerland were 41% and 27%, as of December 31, 2020 and 2019, respectively. The Company recognizes sales by geographic area based on the country in which the customer is based. For the years ended December 31, 2020 and 2019, 27% and 6%, respectively, of net revenue were generated in the United States; while 53% and 39%, respectively, were generated in Europe; and 20% and 55% were generated in Asia.

Impact of Recently Issued Accounting Standards

In August 2018, the FASB issued Accounting Standards Update (“ASU”) 2018-13, Fair Value Measurement (Topic 820): Disclosure Framework—Changes to the Disclosure Requirements for Fair Value Measurement. This ASU eliminates, adds and modifies certain disclosure requirements for fair value measurements as part of its disclosure framework project. The Company adopted this ASU effective January 1, 2020 and the adoption did not have a material impact on the consolidated financial statements.

In December 2019, the FASB issued ASU 2019-12, Simplifying the Accounting for Income Taxes, which is intended to simplify various aspects related to accounting for income taxes. ASU 2019-12 removes certain exceptions to the general principles in ASC 740, Income Tax and also clarifies and amends existing guidance to improve consistent application. ASU 2019-12 will be effective for public business entities for annual reporting periods beginning after December 15, 2020, and interim periods within those periods, with early adoption permitted. The guidance is not expected to have a material impact on the Company's financial statements and related disclosures.

In June 2016, the FASB issued ASU 2016-13, Financial Instruments-Credit Losses (Topic 326): Measurement of Credit Losses on Financial Instruments, which is designed to provide financial statement users with more information about the expected credit losses on financial instruments and other commitments to extend credit held by a reporting entity at each reporting date. When determining such expected credit losses, the guidance requires companies to apply a methodology that reflects expected credit losses and requires consideration of a broader range of reasonable and supportable information to inform credit loss estimates. This guidance is effective on a modified retrospective basis for fiscal years beginning after December 15, 2022, including interim periods within those fiscal years. The guidance is not expected to have a material impact on the Company's financial statements and related disclosures.

In August 2020, the FASB issued ASU 2020-06 Debt – Debt with Conversion and Other Options (Subtopic 470-20) and Derivatives and Hedging – Contracts in Entity’s Own Equity (subtopic 815-40) guidance on the accounting for convertible debt instruments and contracts in an entity’s own equity. The guidance simplifies the accounting for convertible instruments by reducing the various accounting models that can require the instrument to be separated into a debt component and equity component or derivative component. Additionally, the guidance eliminated certain settlement conditions previously required to be able to classify a derivative in equity. The new guidance is effective on a modified or full retrospective basis for fiscal years beginning after December 15, 2023, including interim periods with those fiscal years. The Company is currently evaluating the impact on the consolidated financial statements upon adoption.

The Company has evaluated all other issued and unadopted ASUs and believes the adoption of these standards will not have a material impact on its consolidated statements of operations and comprehensive loss, balance sheets, or statements of cash flows.

Note 3 - Acquisitions

12 Months Ended

Dec. 31, 2020

Business Combination Disclosure [Text Block]

3. Acquisitions

MST Medical Surgery Technologies Ltd. Acquisition

On September 23, 2018, the Company entered into an Asset Purchase Agreement (the “MST Purchase Agreement”) with MST Medical Surgery Technologies Ltd., an Israeli private company (the “Seller”), and two of the Company’s wholly owned subsidiaries, as purchasers of the assets of the Seller, (collectively, the “Buyers”). The closing of the transactions occurred on October 31, 2018, pursuant to which the Company acquired the Seller’s assets consisting of intellectual property and tangible assets related to surgical analytics with its core image analytics technology designed to empower and automate the surgical environment, with a focus on medical robotics and computer-assisted surgery. The core technology acquired under the MST Purchase Agreement is a software-based image analytics information platform powered by advanced visualization, scene recognition, artificial intelligence, machine learning and data analytics.

Under the terms of the MST Purchase Agreement, at the closing the Buyers purchased substantially all of the assets of MST. The acquisition price consisted of two tranches. At or prior to the closing of the transaction the Buyers paid $5.8 million in cash and the Company issued approximately 242,310 shares of the Company’s common stock (the "Initial Shares"). A second tranche of $6.6 million in additional consideration was payable in cash, stock or cash and stock, at the discretion of the Company, within one year after the closing date. On August 7, 2019, the Company notified MST that the Company would satisfy the additional consideration payment of $6.6 million by issuing shares of the Company’s common stock. The number of shares issued to MST was 370,423 (the “Additional Consideration Shares” and, together with the Initial Shares, the “Securities Consideration”). The Additional Consideration Shares were released from the lock-up restrictions on February 7, 2020.

On July 3, 2019, the Company entered into a System Sale Agreement with GBIL to sell certain assets related to the AutoLap technology. On October 15, 2019, the Company amended the prior AutoLap Sale Agreement with GBIL. Pursuant to the amended agreement the Company sold the AutoLap laparoscopic vision system, or AutoLap, and related assets to GBIL. The assets include inventory, spare parts, production equipment, testing equipment and certain intellectual property specifically related to the AutoLap. The purchase price was $17.0 million, all of which was received in 2019 in the form of $16 million in cash and a commitment by GBIL to pay $1.0 million to settle certain Company obligations in China. GBIL subsequently paid the obligation. Under the amended AutoLap Agreement, the Company entered into a cross‑license agreement with GBIL to retain rights to use any AutoLap-related intellectual property sold to GBIL, and to non-exclusively license additional intellectual property to GBIL. The Company recorded a $16.0 million gain on the sale of the AutoLap assets during the year ended December 31, 2019, which represented the proceeds received in excess of the carrying value of the assets, less contract costs.

Senhance Surgical Robotic System

On September 21, 2015, the Company completed the strategic acquisition, through its wholly owned subsidiary TransEnterix International, from Sofar, of all of the assets, employees and contracts related to the advanced robotic system for minimally invasive laparoscopic surgery now known as the Senhance System. Under the terms of the Purchase Agreement, the consideration consisted of the issuance of (i) 1,195,647 shares of the Company’s common stock (the “Securities Consideration”) and (ii) approximately $25.0 million U.S. Dollars and €27.5 million Euro in cash consideration (the “Cash Consideration”). On February 25, 2021, TransEnterix International changed its name to Asensus International.

On December 30, 2016, the Company and Sofar entered into an Amendment to the Purchase Agreement (the “Amendment”) to restructure the terms of the second tranche of the Cash Consideration (the “Second Tranche”). The initial Securities Consideration was issued in full at the closing of the Senhance Acquisition; under the Amendment, the Second Tranche of the Cash Consideration was restructured, and an additional issuance of 286,360 shares of the Company’s common stock with an aggregate fair market value of €5.0 million occurred in January 2017. Following the Amendment, the total Cash Consideration was $25.0 million U.S. Dollars and approximately €22.5 million Euro, of which all but €15.1 million Euro has been paid as of December 31, 2019. The remaining Cash Consideration to be paid is the third tranche of the Cash Consideration (the “Third Tranche”) of €15.0 million which shall be payable upon achievement of trailing revenues from sales or services contracts of the Senhance System of at least €25.0 million over a calendar quarter.

The fourth tranche of the Cash Consideration of €2.5 million was payable in installments by December 31 of each year as reimbursement for certain debt payments made by Sofar under an existing Sofar loan agreement in such year, with payments beginning as of December 31, 2017. As of December 31, 2020, the Company had paid all installments of the fourth tranche.

The Third Tranche payments will be accelerated in the event that (i) the Company or Asensus International is acquired, (ii) the Company significantly reduces or suspends selling efforts of the Senhance System, or (iii) the Company acquires a business that offers alternative products that are directly competitive with the Senhance System. The remaining amounts due to Sofar are included in contingent consideration as of December 31, 2020 and 2019 at their estimated fair value.

Note 4 - Cash, Cash Equivalents, and Restricted Cash

12 Months Ended

Dec. 31, 2020

Cash, Cash Equivalents, and Restricted Cash Disclosure [Text Block]

4. Cash, Cash Equivalents, and Restricted Cash

Cash, cash equivalents and restricted cash consist of the following:

	December 31, 2020		December 31, 2019
	(In thousands)
Cash	$	6,679	$	9,596
Money market		9,684		2
Total cash and cash equivalents	$	16,363	$	9,598
Restricted cash		1,166		969
Total	$	17,529	$	10,567

Restricted cash at December 31, 2020 and 2019 includes $1.2 million and $1.0 million, respectively, in cash accounts held as collateral primarily under the terms of an office operating lease, credit cards, automobile leases, and a performance guarantee required by the government of a country in which a Senhance System was sold in 2018.

Note 5 - Fair Value

12 Months Ended

Dec. 31, 2020

Fair Value Disclosures [Text Block]

5. Fair Value

The Company held certain assets and liabilities that are required to be measured at fair value on a recurring basis. These assets and liabilities include cash and cash equivalents, restricted cash, contingent consideration and warrant liabilities. ASC 820-10 (“Fair Value Measurement Disclosure”) requires the valuation using a three-tiered approach, which requires that fair value measurements be classified and disclosed in one of three tiers. These tiers are: Level 1, defined as quoted prices in active markets for identical assets or liabilities; Level 2, defined as valuations based on observable inputs other than those included in Level 1, such as quoted prices for similar assets and liabilities in active markets, or other inputs that are observable or can be corroborated by observable input data; and Level 3, defined as valuations based on unobservable inputs reflecting the Company’s own assumptions, consistent with reasonably available assumptions made by other market participants. The Company did not have any transfers of assets and liabilities between Level 1, Level 2, and Level 3 of the fair value hierarchy during the years ended December 31, 2020 and 2019.

For assets and liabilities recorded at fair value, it is the Company’s policy to maximize the use of observable inputs and minimize the use of unobservable inputs when developing fair value measurements, in accordance with the fair value hierarchy. Fair value measurements for assets and liabilities where there exists limited or no observable market data and therefore, are based primarily upon estimates, are often calculated based on the economic and competitive environment, the characteristics of the asset or liability and other factors. Therefore, the results cannot be determined with precision and may not be realized in an actual sale or immediate settlement of the asset or liability. Additionally, there may be inherent weaknesses in any calculation technique, and changes in the underlying assumptions used, including discount rates and estimates of future cash flows, could significantly affect the results of current or future values. The Company utilizes fair value measurements to record fair value adjustments to certain assets and liabilities and to determine fair value disclosures.

As prescribed by U.S. GAAP, the Company groups assets and liabilities at fair value in three levels, based on the markets in which the assets and liabilities are traded and the reliability of the assumptions used to determine fair value. An adjustment to the pricing method used within either Level 1 or Level 2 inputs could generate a fair value measurement that effectively falls in a lower level in the hierarchy.

The determination of where an asset or liability falls in the hierarchy requires significant judgment. The Company evaluates its hierarchy disclosures and based on various factors, it is possible that an asset or liability may be classified differently from period to period. However, the Company expects changes in classifications between levels will be rare.

The carrying values of accounts receivable, other current assets, accounts payable, and certain accrued expenses at December 31, 2020 and 2019, approximate their fair values due to the short-term nature of these items. The Company’s notes payable balance also approximates fair value as of December 31, 2020, as the interest rate on the notes payable approximates the rates available to the Company as of this date.

The following are the major categories of assets and liabilities measured at fair value on a recurring basis as of December 31, 2020 and 2019, using quoted prices in active markets for identical assets (Level 1); significant other observable inputs (Level 2); and significant unobservable inputs (Level 3):

	December 31, 2020
	(In thousands)
Description	Quoted Prices in Active Markets for Identical Assets (Level 1)		Significant Other Observable Inputs (Level 2)		Significant Unobservable Inputs (Level 3)		Total
Assets measured at fair value
Cash and cash equivalents	$	16,363	$	—	$	—	$	16,363
Restricted cash		1,166		—		—		1,166
Total Assets measured at fair value	$	17,529	$	—	$	—	$	17,529
Liabilities measured at fair value
Contingent consideration	$	—	$	—	$	3,936	$	3,936
Warrant liabilities		—		—		255		255
Total liabilities measured at fair value	$	—	$	—	$	4,191	$	4,191

	December 31, 2019
	(In thousands)
Description	Quoted Prices in Active Markets for Identical Assets (Level 1)		Significant Other Observable Inputs (Level 2)		Significant Unobservable Inputs (Level 3)		Total
Assets measured at fair value
Cash and cash equivalents	$	9,598	$	—	$	—	$	9,598
Restricted cash		969		—		—		969
Total Assets measured at fair value	$	10,567	$	—	$	—	$	10,567
Liabilities measured at fair value
Contingent consideration	$	—	$	—	$	1,084	$	1,084
Warrant liabilities		—		—		2,388		2,388
Total liabilities measured at fair value	$	—	$	—	$	3,472	$	3,472

The Company’s financial liabilities consisted of contingent consideration payable to Sofar related to the Senhance Acquisition in September 2015 (Note 3). This liability is reported as Level 3 as estimated fair value of the contingent consideration related to the acquisition requires significant management judgment or estimation and is calculated using the income approach, using various revenue and cost assumptions and applying a probability to each outcome. The increase in fair value of the contingent consideration of $2.9 million for the year ended December 31, 2020 was primarily due to a lower discount rate, stronger Euro versus the U.S. dollar, and the passage of time. The decrease in fair value of the contingent consideration of $9.6 million for the year ended December 31, 2019 was primarily due to changes in the Company's long-range forecast. Adjustments associated with the change in fair value of contingent consideration are included in the Company’s consolidated statements of operations and comprehensive loss. The Company uses a probability-weighted income approach for estimating the fair value of the contingent consideration. The significant unobservable inputs used in this approach include estimates of amounts and timing of stated milestones and the discount rate.

On April 28, 2017, the Company sold 24.9 million units (the “Units”), each consisting of approximately 0.077 shares of the Company's Common Stock, a Series A warrant to purchase approximately 0.077 shares of Common Stock with an exercise price of $13.00 per share (the “Series A Warrants”), and a Series B warrant to purchase approximately 0.058 shares of Common Stock with an exercise price of $13.00 per share (the “Series B Warrants,” together with the Series A Warrants, the “Warrants”), at an offering price of $1.00 per Unit. All of the Series A Warrants were exercised prior to the expiration date of October 31, 2017. Each Series B Warrant may be exercised at any time beginning on the date of issuance and from time to time thereafter through and including the fifth anniversary of the issuance date.

The exercise prices and the number of shares issuable upon exercise of each of the Series B Warrants are subject to adjustment upon the occurrence of certain events, including, but not limited to, stock splits or dividends, business combinations, sale of assets, similar recapitalization transactions, or other similar transactions. The Series B warrants contain provisions, often referred to as “down-round protection,” that leads to adjustment of the exercise price and number of underlying warrant shares if the Company issues securities, including its common stock or convertible securities or debt securities, in the future at sale prices below the then-current exercise price. As a result of this adjustment feature and after giving effect to the Company’s reverse stock split at a ratio of one-for-thirteen shares effective December 11, 2019, or the Reverse Stock Split, the exercise price of all outstanding Series B Warrants has been adjusted to $0.35 per share and the number of shares of common stock reserved for and issuable upon the exercise of outstanding Series B Warrants has been adjusted to 567,660 warrant shares as of December 31, 2020.

The change in fair value of all outstanding Series B warrants for the years ended December 31, 2020 and 2019 of an increase of $0.3 million and a decrease of $2.2 million, respectively, was included in the Company’s consolidated statements of operations and comprehensive loss. The increase in fair value of the Series B warrants of $0.3 million for the year ended December 31, 2020 was primarily due to a lower discount rate, increased volatility, and the passage of time. The increase in fair value of the Series B warrants of $2.2 million for the year ended December 31, 2019 was primarily due to a lower discount rate, increased volatility, and the passage of time. The following table presents the inputs and valuation methodologies used for the Company’s fair value of the Series B warrants:

Series B	December 31, 2020			December 31, 2019
Fair value (million)	$	0.3		$	2.4
Valuation methodology	Black-Scholes-Merton			Monte Carlo
Term (years)		1.32			2.32
Risk free rate		0.10	%		1.59	%
Dividends		—			—
Volatility		150.97	%		109.80	%
Share price	$	0.63		$	1.47
Probability of additional financing		N/A		100% in 2020

The following table presents quantitative information about the inputs and valuation methodologies used for the Company’s fair value measurements for contingent consideration as of December 31, 2020 and 2019:

Valuation
Methodology

Significant
Unobservable Input

Weighted Average
(range, if
applicable)

December 31, 2020

December 31, 2019

Contingent consideration

Probability weighted
income approach

Milestone dates

2024

2029

2020

2024

Discount rate

9.5%

15.75%

10%

11%

The following table summarizes the change in fair value, as determined by Level 3 inputs for the warrants and the contingent consideration for the years ended December 31, 2020 and 2019:

	Fair Value Measurement at Reporting Date (Level 3)
	(In thousands)
	Common stock warrants			Contingent consideration
Balance at December 31, 2018	$	4,636		$	10,637
Change in fair value		(2,248	)		(9,553	)
Balance at December 31, 2019		2,388			1,084
Exchange of warrants for common stock		(2,469	)		—
Payment for contingent consideration		—			(74	)
Change in fair value		336			2,924
Balance at December 31, 2020		255			3,936
Current portion		—			—
Long-term portion		255			3,936
Balance at December 31, 2020	$	255		$	3,936

The entire disclosure for the fair value of financial instruments (as defined), including financial assets and financial liabilities (collectively, as defined), and the measurements of those instruments as well as disclosures related to the fair value of non-financial assets and liabilities. Such disclosures about the financial instruments, assets, and liabilities would include: (1) the fair value of the required items together with their carrying amounts (as appropriate); (2) for items for which it is not practicable to estimate fair value, disclosure would include: (a) information pertinent to estimating fair value (including, carrying amount, effective interest rate, and maturity, and (b) the reasons why it is not practicable to estimate fair value; (3) significant concentrations of credit risk including: (a) information about the activity, region, or economic characteristics identifying a concentration, (b) the maximum amount of loss the entity is exposed to based on the gross fair value of the related item, (c) policy for requiring collateral or other security and information as to accessing such collateral or security, and (d) the nature and brief description of such collateral or security; (4) quantitative information about market risks and how such risks are managed; (5) for items measured on both a recurring and nonrecurring basis information regarding the inputs used to develop the fair value measurement; and (6) for items presented in the financial statement for which fair value measurement is elected: (a) information necessary to understand the reasons for the election, (b) discussion of the effect of fair value changes on earnings, (c) a description of [similar groups] items for which the election is made and the relation thereof to the balance sheet, the aggregate carrying value of items included in the balance sheet that are not eligible for the election; (7) all other required (as defined) and desired information.

+ References + Details

Note 6 - Accounts Receivable, Net

12 Months Ended

Dec. 31, 2020

Loans, Notes, Trade and Other Receivables Disclosure [Text Block]

6. Accounts Receivable, Net

The following table presents the components of accounts receivable:

	December 31, 2020			December 31, 2019
	(In thousands)
Gross accounts receivable	$	2,917		$	2,274
Allowance for uncollectible accounts		(1,802	)		(1,654	)
Total accounts receivable, net	$	1,115		$	620

The Company recorded $1.6 million in bad debt expense during the year ended December 31, 2019. No bad debt expense was incurred during the year ended December 31, 2020.

Note 7 - Inventories

12 Months Ended

Dec. 31, 2020

Inventory Disclosure [Text Block]

7. Inventories

The components of inventories are as follows:

	December 31, 2020		December 31, 2019
	(In thousands)
Finished goods	$	10,749	$	9,737
Raw materials		8,098		8,510
Total inventories	$	18,847	$	18,247

Current Portion	$	10,034	$	10,653
Long-term portion		8,813		7,594
Total inventories	$	18,847	$	18,247

The Company recorded a write-down of obsolete inventory for the year-ended December 31, 2019 totaling $7.4 million as part of a restructuring plan and a $1.5 million charge for inventory obsolescence related to certain System components. There were no such write-downs or charges for the year ended December 31, 2020.

Note 8 - Other Current Assets

12 Months Ended

Dec. 31, 2020

Other Current Assets [Text Block]

8. Other Current Assets

The following table presents the components of other current assets:

	December 31, 2020		December 31, 2019
	(In thousands)
Advances to vendors	$	1,925	$	2,534
Prepaid expenses		1,706		1,834
VAT receivable		2,870		2,716
Total	$	6,501	$	7,084

Note 9 - Property and Equipment

12 Months Ended

Dec. 31, 2020

Property, Plant and Equipment Disclosure [Text Block]

9. Property and Equipment

Property and equipment consisted of the following:

	December 31, 2020			December 31, 2019
	(In thousands)
Machinery, manufacturing and demonstration equipment	$	10,153		$	9,711
Operating lease assets - Senhance System leasing		9,203			710
Computer equipment		2,297			2,321
Furniture		640			637
Leasehold improvements		2,309			2,295
Total property and equipment		24,602			15,674
Accumulated depreciation and amortization		(14,260	)		(10,968	)
Property and equipment, net	$	10,342		$	4,706

Depreciation expense was approximately $2.9 million and $2.2 million for the years ended December 31, 2020 and 2019, respectively.

Note 10 - Goodwill, In-process Research and Development and Intellectual Property

12 Months Ended

Dec. 31, 2020

Goodwill and Intangible Assets Disclosure [Text Block]

10. Goodwill, In-Process Research and Development and Intellectual Property

Goodwill

Goodwill of $93.8 million was recorded in connection with the Merger, as described in Note 1, goodwill of $38.3 million was recorded in connection with the Senhance Acquisition, as described in Note 3, and goodwill of $9.6 million was recorded in connection with the MST Acquisition, as described in Note 3. The carrying value of goodwill and the change in the balance for the year ended December 31, 2019 is as follows:

	Goodwill
	(In thousands)
Balance at December 31, 2018	$	80,131
Foreign currency translation impact		(1,162	)
Impairment		(78,969	)
Balance at December 31, 2019	$	—

The Company performed an annual impairment test of goodwill at December 31, or more frequently if events or changes in circumstances indicated that the carrying value of the Company’s one reporting unit may not be recoverable. During the third quarter of 2019, the Company's stock price declined significantly as a result of decreased sales. As of September 30, 2019, goodwill was deemed to be fully impaired, and the Company recorded an impairment charge of $79.0 million.

In-Process Research and Development

As described in Note 3, on October 31, 2018, the Company acquired the MST assets, technology and business from MST and recorded $10.6 million of IPR&D. The estimated fair value of the IPR&D was determined using a probability-weighted income approach, which discounts expected future cash flows to present value. The projected cash flows were based on certain key assumptions, including estimates of future revenue and expenses, taking into account the stage of development of the technology at the acquisition date and the time and resources needed to complete development. The Company used a discount rate of 15% and cash flows that have been probability adjusted to reflect the risks of product integration, which the Company believes are appropriate and representative of market participant assumptions.

The Company performed an impairment test of its IPR&D at the end of the third quarter 2019 as recent events and changes in market conditions indicated that the asset might be impaired. The impairment test consisted of a comparison of the fair value of the IPR&D with its carrying amount. If the carrying amount of the IPR&D exceeds its fair value, an impairment loss is recognized in an amount equal to that excess. Significant judgment is applied when testing for impairment. This judgment includes developing cash flow projections, selecting appropriate discount rates, identifying relevant market comparables, and incorporating general economic and market conditions. During the third quarter of 2019, the Company concluded that the fair value determined by the market value approach was lower than the carrying value. As a result, the Company recognized a $7.9 million impairment charge to its IPR&D. The company performed its annual impairment assessment at December 31, 2019 and no additional impairment was required. As of December 31, 2020, all IPR&D asset development was completed and reclassified to intellectual property.

The carrying value of the Company’s IPR&D assets and the change in the balance for the years ended December 31, 2019 and 2020 is as follows:

	In-Process Research and Development
	(In thousands)
Balance at December 31, 2018	$	10,747
Impairment		(7,912	)
Foreign currency translation impact		(365	)
Balance at December 31, 2019		2,470
Impairment		—
Foreign currency translation impact		(45	)
Transfer of in-process research and development to intellectual property		(2,425	)
Balance at December 31, 2020	$	—

Intellectual Property

As described in Note 3, on September 21, 2015, the Company acquired all of the assets related to the Senhance System and recorded $17.1 million of IPR&D. The estimated fair value of the IPR&D was determined using a probability-weighted income approach, which discounts expected future cash flows to present value. The projected cash flows were based on certain key assumptions, including estimates of future revenue and expenses, taking into account the stage of development of the technology at the acquisition date and the time and resources needed to complete development. The Company used a discount rate of 45% and cash flows that have been probability adjusted to reflect the risks of product commercialization, which the Company believes are appropriate and representative of market participant assumptions. On October 13, 2017, upon regulatory approval and the ability to commercialize the products associated with the IPR&D assets, the assets were deemed definite-lived, reclassified to intellectual property and are now being amortized based on their estimated useful lives.

As described above, on March 13, 2020, upon regulatory approval and the ability to commercialize the products associated with the IPR&D assets in the United States, the remaining MST assets were deemed definite-lived, reclassified to intellectual property and are now being amortized based on their estimated useful lives.

The components of gross intellectual property, accumulated amortization, and net intellectual property as of December 31, 2020 and 2019 are as follows:

	December 31, 2020									December 31, 2019
	(In thousands)									(In thousands)
	Gross Carrying Amount		Accumulated Amortization			Foreign currency translation impact		Net Carrying Amount		Gross Carrying Amount		Accumulated Amortization			Foreign currency translation impact			Net Carrying Amount
Developed technology	$	68,838	$	(51,734	)	$	4,872	$	21,976	$	66,413	$	(36,918	)	$	(1,208	)	$	28,287
Technology and patents purchased		400		(168	)		59		291		400		(112	)		21			309
Total intellectual property	$	69,238	$	(51,902	)	$	4,931	$	22,267	$	66,813	$	(37,030	)	$	(1,187	)	$	28,596

The weighted average remaining useful life of the developed technology and technology and patents purchased was 2.2 years and 6.3 years, respectively as of December 31, 2020.

The estimated future amortization expense of intangible assets as of December 31, 2020 is as follows:

	Year ending December 31, 2020
	(In thousands)
2021	$	11,634
2022		8,833
2023		430
2024		430
2025		430
Thereafter		510
Total	$	22,267

Note 11 - Income Taxes

12 Months Ended

Dec. 31, 2020

Income Tax Disclosure [Text Block]

11. Income Taxes

The components for the income tax expense (benefit) are as follows for the years ended December 31 (in thousands):

	2020			2019
Current income taxes
Federal	$	—		$	—
State		—			—
Foreign		169			100
Deferred income taxes
Federal		—			—
State		—			—
Foreign		(1,685	)		(3,224	)
Total income tax expense (benefit)	$	(1,516	)	$	(3,124	)

The United States and foreign components of loss from operations before taxes are as follows for the years ended December 31 (in thousands):

	2020			2019
United States	$	(34,398	)	$	(91,935	)
Foreign		(26,430	)		(65,390	)
Total loss from operations before taxes	$	(60,828	)	$	(157,325	)

Significant components of the Company’s deferred tax assets consist of the following at December 31 (in thousands):

	2020			2019
Deferred tax assets:
Stock-based compensation	$	4,253		$	3,665
Accrued expenses and other		906			1,007
Research credit carryforward		7,209			6,776
Fixed assets		385			345
Capitalized start-up costs and other intangibles		2,686			3,618
Net operating loss carryforwards		122,193			113,410
		137,632			128,821
Valuation allowance		(132,928	)		(123,108	)
Net deferred tax asset		4,704			5,713
Deferred tax liabilities
Fixed assets and other		(1,590	)		(1,445	)
Purchase accounting intangibles		(2,807	)		(5,660	)
Net deferred tax liability		(4,397	)		(7,105	)
Net deferred tax asset (liability)	$	307		$	(1,392	)

At December 31, 2020 and 2019, the Company has provided a full valuation allowance against its net deferred assets in the U.S., Canada, Italy, Luxembourg, Swiss, and Taiwan tax jurisdictions, since realization of these benefits is not more likely than not. The valuation allowance increased approximately $9.8 million from the prior year. At December 31, 2020, the Company had U.S. federal net operating loss carryforwards of $364.3 million. Of this amount, $254.5 million begin to expire in 2027, while the remaining $109.8 million carry forward indefinitely. At December 31, 2020, the Company had U.S. state net operating loss carryforwards of $296.2 million. Of this amount, $289.3 million begin to expire in 2022, while the remaining $6.8 million carry forward indefinitely. At December 31, 2020, the Company had federal research credit carryforwards in the amount of $7.2 million. These carryforwards begin to expire in 2027. The utilization of the federal net operating loss carryforwards and credit carryforwards will depend on the Company’s ability to generate sufficient taxable income prior to the expiration of the carryforwards. In addition, the maximum annual use of net operating loss and research credit carryforwards is limited in certain situations where changes occur in stock ownership.

At December 31, 2020, the Company had foreign operating loss carryforwards in Italy of approximately $24.5 million, which can be carried forward indefinitely; foreign operating loss carryforwards in Luxembourg of approximately $95.1 million, which will begin to expire in 2035; and foreign operating loss carryforwards in Switzerland of approximately $61.9 million, which begin to expire in 2023.

The Company has evaluated its tax positions to consider whether it has any unrecognized tax benefits. As of December 31, 2020, the Company had gross unrecognized tax benefits of approximately $1.6 million. Of the total, none would reduce the Company’s effective tax rate if recognized. The Company does not anticipate a significant change in total unrecognized tax benefits or the Company’s effective tax rate due to the settlement of audits or the expiration of statutes of limitations within the next twelve months. Furthermore, the Company does not expect any cash settlement with the taxing authorities as a result of these unrecognized tax benefits as the Company has sufficient unutilized carryforward attributes to offset the tax impact of these adjustments.

The following is a tabular reconciliation of the Company’s change in gross unrecognized tax positions at December 31 (in thousands):

	2020		2019
Beginning balance	$	1,512	$	1,363
Gross increases for tax positions related to current periods		108		149
Gross increases for tax positions related to prior periods		—		—
Ending balance	$	1,620	$	1,512

The Company recognizes interest and penalties related to uncertain tax positions in the provision for income taxes. As of December 31, 2020 and 2019, the Company had no accrued interest or penalties related to uncertain tax positions.

The Company has analyzed its filing positions in all significant federal, state, and foreign jurisdictions where it is required to file income tax returns, as well as open tax years in these jurisdictions. With few exceptions, the Company is no longer subject to United States Federal, state, and local tax examinations by tax authorities for years before 2017, although carryforward attributes that were generated prior to 2017 may still be adjusted upon examination by the taxing authorities if they either have been or will be used in a future period. No income tax returns are currently under examination by taxing authorities.

Taxes computed at the then-current statutory federal income tax rate of 21% are reconciled to the provision for income taxes as follows for the years ended December 31:

	2020						2019
				Percent of Pretax						Percent of Pretax
	Amount			Earnings			Amount			Earnings
United States federal tax at statutory rate	$	(12,774	)		21.0	%	$	(33,038	)		21.0	%
State taxes (net of deferred benefit)		(1,768	)		2.9	%		(4,778	)		3.0	%
Nondeductible expenses		719			(1.2	%)		709			(0.5	%)
Change in fair market value of contingent consideration		717			(1.2	%)		(2,342	)		1.5	%
Warrant remeasurement and financing costs		82			(0.1	%)		(551	)		0.4	%
Research & Development credits		(542	)		0.9	%		(743	)		0.5	%
Change in unrecognized tax benefits		108			(0.2	%)		149			(0.1	%)
Foreign tax rate differential		1,589			(2.6	%)		2,590			(1.6	%)
Goodwill and investment impairments		—			(0	%)		(6,638	)		4.2	%
Change in enacted tax rates and other, net		533			(0.9	%)		(253	)		0.2	%
Change in valuation allowance		9,820			(16.1	%)		41,771			(26.6	%)
Income tax benefit	$	(1,516	)		2.5	%	$	(3,124	)		2.0	%

The Company has analyzed its filing positions in all significant federal, state, and foreign jurisdictions where it is required to file income tax returns, as well as open tax years in these jurisdictions. Pursuant to the Internal Revenue Code, as amended (the “Code”) Sections 382 and 383, annual use of a company’s NOL and research and development credit carryforwards may be limited if there is a cumulative change in ownership of greater than 50% within a three-year period. The amount of the annual limitation is determined based on the value of the Company immediately prior to the ownership change. Subsequent ownership changes may further affect the limitation in future years. The Company has not completed such an analysis pursuant to Sections 382 and 383. Due to the existence of the valuation allowance, further changes in the Company’s unrecognized tax benefits will not impact the Company’s effective tax rate. With few exceptions, the Company is no longer subject to United States Federal, state, and local tax examinations by tax authorities for years before 2017, although carryforward attributes that were generated prior to 2017 may still be adjusted upon examination by the taxing authorities if they either have been or will be used in a future period. No income tax returns are currently under examination by taxing authorities.

The entire disclosure for income taxes. Disclosures may include net deferred tax liability or asset recognized in an enterprise's statement of financial position, net change during the year in the total valuation allowance, approximate tax effect of each type of temporary difference and carryforward that gives rise to a significant portion of deferred tax liabilities and deferred tax assets, utilization of a tax carryback, and tax uncertainties information.

+ References + Details

Note 12 - Accrued Expenses

12 Months Ended

Dec. 31, 2020

Accrued Liabilities [Text Block]

12. Accrued Expenses

The following table presents the components of accrued expenses:

	December 31, 2020		December 31, 2019
	(In thousands)
Compensation and benefits	$	4,541	$	5,061
Restructuring costs		—		882
Consulting and other vendors		66		308
Other		177		242
Lease Liability		686		1,112
Royalties		147		148
Legal and professional fees		314		474
Taxes and other assessments		351		326
Interest		19		—
Total	$	6,301	$	8,553

Note 13 - Notes Payable

12 Months Ended

Dec. 31, 2020

Debt Disclosure [Text Block]

13. Notes Payable

Paycheck Protection Program

The CARES Act was passed in the United States and signed into law on March 7, 2020 and was amended on June 5, 2020 through the enactment of the Paycheck Protection Program Flexibility Act. On April 27, 2020, Asensus Surgical US, Inc., a wholly owned subsidiary of the Company, received funding under a promissory note dated April 18, 2020 (the “Promissory Note”), evidencing an unsecured non-recourse loan in the principal amount of $2,815,200 under the PPP provisions of the CARES Act. The PPP is administered by the U.S. Small Business Administration (the “SBA”). The Promissory Note was made through City National Bank of Florida, a national banking association (the “Lender”). The Company accounted for the PPP loan as debt and included the principal amount within notes payable on the consolidated balance sheet.

The Promissory Note has a two-year term, maturing on April 27, 2022, and bears interest at 1.00% per annum. The Promissory Note may be forgiven partially or fully if the proceeds are used for covered payroll, rent and utility costs incurred during the Covered Period and if at least 60% of the proceeds are used for covered payroll costs. All or a portion of the Promissory Note may be forgiven by the SBA upon application by the Company and documentation of expenditures in accordance with the SBA requirements. If the Promissory Note is not forgiven, payments can be deferred until 10 months after the end of the Company’s covered period, which is the 24-week period beginning on the date the Company received the PPP loan proceeds from the Lenders (the “Covered Period”). The Promissory Note contains customary events of default relating to, among other things, payment defaults, and breach of representations and warranties, or other provisions of the Promissory Note. The Promissory Note is classified as long term except for the portion to be paid within twelve months of the year end, which is classified as current.

Any forgiveness of the Promissory Note will be subject to approval by the SBA and the Lender. The Company recognizes that its restructuring activities unrelated to COVID-19 led to a decrease in the number of employees and, the Company may not be able to comply with the available safe harbor and savings provisions of the CARES Act, therefore, not all of the Promissory Note may be eligible for forgiveness. The Company submitted its application for forgiveness of the Promissory Note in full to the Lender on February 10, 2021.

Hercules Loan Agreement

On May 23, 2018, the Company and its domestic subsidiaries, as co-borrowers, entered into a Loan and Security Agreement (the “Hercules Loan Agreement”) with several banks and other financial institutions or entities from time to time party to the Loan Agreement (collectively, the “Lender”) and Hercules Capital, Inc., as administrative agent and collateral agent (the “Agent”). The Hercules Loan Agreement was modified on two separate occasions in 2019.

The term loans bore interest at a rate equal to the greater of (i) 9.55% per annum (the “Fixed Rate”) and (ii) the Fixed Rate plus the prime rate (as reported in The Wall Street Journal) minus 5.00%. On the Initial Funding Date, the Company was obligated to pay a facility fee of $0.4 million, recorded as a debt discount. The Company also incurred other debt issuance costs totaling $1.1 million in conjunction with its entry into the Hercules Loan Agreement. In addition, the Company was permitted to prepay the term loans in full at any time, with a prepayment fee of 3.0% of the outstanding principal amount of the loan in the first year after the Initial Funding Date, 2.0% if the prepayment occurred in the second year after the Initial Funding Date and 1.0% thereafter. Upon prepayment of the term loans in full or repayment of the terms loans at the maturity date or upon acceleration, the Company was required to pay a final fee of 6.95% of the aggregate principal amount of term loans funded. The final payment fee was accreted to interest expense over the life of the term loan and included within notes payable on the consolidated balance sheet.

The Company’s obligations under the Hercules Loan Agreement were guaranteed by all current and future material foreign subsidiaries of the Company and were secured by a security interest in all of the assets of the Company and their current and future domestic subsidiaries and all of the assets of their current and future material foreign subsidiaries, including a security interest in the intellectual property. The Hercules Loan Agreement contained customary representations and covenants that, subject to exceptions, restricted the Company’s and its subsidiaries’ ability to do the following, among other things: declare dividends or redeem or repurchase equity interests; incur additional indebtedness and liens; make loans and investments; engage in mergers, acquisitions, and asset sales; transact with affiliates; undergo a change in control; add or change business locations; and engage in businesses that were not related to its existing business. Under the terms of the Hercules Loan Agreement, the Company was required to maintain cash and/or investment property in accounts which perfected the Agent’s first priority security interest in such accounts in an amount equal to the lesser of (i) (x) 120% of the then-outstanding principal balance of the term loans, including accrued interest and any other fees payable under the agreement to the extent accrued and payable plus (y) an amount equal to the then-outstanding accounts payable of the Company on a consolidated basis that were more than 90 days past due and (ii) 80% of the aggregate cash of the Company and its consolidated subsidiaries. The Agent was granted the option to invest up to $2.0 million in any future equity offering broadly marketed by the Company to investors on the same terms as the offering to other investors.

On November 4, 2019, the Company entered into a payoff letter with the Agent pursuant to which the Company terminated the Hercules Loan Agreement, as amended. The Company determined it was in the best interests of the Company to pay down the debt and terminate the Hercules Agreement to simplify the Company's balance sheet and provide additional flexibility as the Board of Directors continues to explore strategic and financial alternatives for the Company. Under the payoff letter, the Company repaid all amounts owed under the Hercules Loan Agreement totaling approximately $16.4 million, which included end of term fees of $1.4 million, and Hercules released all security interests held on the assets of the Company and its subsidiaries, including, without limitation, on the intellectual property assets of the Company. The Company recognized a loss of $1.0 million on the extinguishment of notes payable, which is included in interest expense on the consolidated statement of operations and comprehensive loss for the year ended December 31, 2019.

Note 14 - Stock-based Compensation

12 Months Ended

Dec. 31, 2020

Share-based Payment Arrangement [Text Block]

14. Stock-Based Compensation

The Company’s stock-based compensation plans include the Asensus Surgical, Inc. Amended and Restated Incentive Compensation Plan, previously named the TransEnterix, Inc. Amended and Restated Incentive Compensation Plan and prior to that named the TransEnterix, Inc. 2007 Incentive Compensation Plan, or the Plan, as well as options outstanding under the TransEnterix, Inc. Stock Option Plan, or the 2006 Plan. As part of the Merger, options outstanding, whether vested or unvested, under the 2006 Plan were adjusted by the Exchange Ratio of approximately 0.0887, and assumed by the Company concurrent with the closing of the Merger.

The Plan was initially approved by the majority of the stockholders on November 13, 2007. The Plan was amended on June 19, 2012 to increase the number of shares of common stock available for issuance to 76,923 and was amended on October 29, 2013 to (a) increase the number of shares of common stock authorized for issuance under the Plan from 76,923 shares of common stock to 380,000 shares of common stock, (b) increase the per-person award limitations for options or stock appreciation rights from 15,385 to 76,923 shares and for restricted stock, deferred stock, performance shares and/or other stock-based awards from 7,692 to 38,462 shares, and (c) change the name of the Plan to reflect the Merger-related change. The Plan was again amended on May 7, 2015 to (i) increase the number of shares reserved for issuance under the Plan to 918,462 shares; (ii) extend the term of the Plan until May 7, 2025; and (iii) make other changes and updates to the Plan and was further amended in October 2015 to add French Sub-Plan amendments applicable to awards made to France-based employees. The Plan was further amended on June 8, 2016 to (a) approve an increase in the number of shares reserved for issuance under the Plan to 1,456,923 shares and (b) establish maximum equity award limits for initial awards and annual awards to non-employee directors. The Plan was subsequently amended as of May 25, 2017, increasing the number of shares of Common Stock authorized under the Plan to 1,995,385. The Plan was again amended on May 24, 2018, increasing the number of shares of Common Stock authorized under the Plan to 3,149,231. The Plan was again amended in October 2018 to add an Israeli Sub-Plan applicable to awards made to Israel-based employees. The Plan was again amended on April 24, 2019, to increase the number of shares of Common Stock authorized under the Plan to 4,072,308 and to make other changes. The Plan was again amended on June 8, 2020, to increase the number of shares of Common Stock authorized under the Plan to 10,072,308 and to make other changes. The Plan was amended in October 2020 to include the Canadian Sub-Plan.

The October 2013, May 2015, June 2016, May 2017, May 2018, April 2019 and June 2020 amendments were approved by the Board of Directors and stockholders; the French Sub-Plan, the Israeli Sub-Plan, and the Canadian Sub-Plan were approved by the Board of Directors. Under the Plan, which is administered by the Compensation Committee, the Company may grant stock options, stock appreciation rights, restricted stock and/or deferred stock to employees, officers, directors, consultants and vendors. The exercise price of stock options or stock appreciation rights may not be less than the fair market value of the Company’s shares at the date of grant. Additionally, no stock options or stock appreciation rights granted under the Plan may have a term exceeding ten years.

On August 11, 2020, the Compensation Committee of the Board of Directors approved awards to a newly hired executive officer of non-qualified stock options to acquire 150,000 shares of the Company’s common stock with an exercise price equal to the closing price on the date of grant, 30,000 time-based restricted stock units and 20,000 performance-based restricted stock units, each as inducement grants made outside of the stockholder-approved incentive compensation plan in accordance with NYSE American Company Guide Section 711(a).

The 2006 Plan was adopted and approved by stockholders in September 2006 and provided for the granting of up to 6,154 stock options to employees, directors, and consultants. Under the 2006 Plan, both employees and non-employees were eligible for such stock options. In 2009, the 2006 Plan was amended to increase the total options pool to 85,389. In 2011, the 2006 Plan was amended to increase the total options pool to 259,861. The amendments were approved by the Board of Directors and stockholders. The Board of Directors had the authority to administer the plan and determine, among other things, the exercise price, term and dates of the exercise of all options at their grant date. Under the 2006 Plan, options become vested generally over four years, and expire not more than 10 years after the date of grant. As part of the Merger, options outstanding under the 2006 Plan were adjusted by the Conversion Ratio, and remain in existence as options of the Company.

During the years ended December 31, 2020 and 2019, the Company recognized approximately $7.9 million and $11.5 million, respectively, of stock-based compensation expense, including stock options and restricted stock units.

The Company recognizes as expense, the grant-date fair value of stock options and other stock-based compensation issued to employees and non-employee directors over the requisite service periods, which are typically the vesting periods. The Company uses the Black-Scholes-Merton model to estimate the fair value of its stock-based payments. The volatility assumption used in the Black-Scholes-Merton model is based on the calculated historical volatility based on an analysis of reported data for a peer group of companies as well as the Company’s historical volatility. The expected term of options granted by the Company has been determined based upon the simplified method, because the Company does not have sufficient historical information regarding its options to derive the expected term. Under this approach, the expected term is the mid-point between the weighted average of vesting period and the contractual term. The risk-free interest rate is based on U.S. Treasury rates whose term is consistent with the expected life of the stock options. The Company has not paid and does not anticipate paying cash dividends on its shares of common stock; therefore, the expected dividend yield is assumed to be zero. The Company estimates forfeitures based on the historical experience of the Company and adjusts the estimated forfeiture rate based upon actual experience.

The fair value of options granted were estimated using the Black-Scholes-Merton option pricing model based on the assumptions in the table below:

	Year ended December 31,
	2020			2019
Expected dividend yield		0%			0%
Expected volatility	82%	-	126%	81%	-	92%
Risk-free interest rate	0.2%	-	1.69%	1.39%	-	2.66%
Expected life (in years)	3.8	-	6.1	5.5	-	6.1

The following table summarizes the Company’s stock option activity, including grants to non-employees, for the year ended December 31, 2020:

	Number of Shares			Weighted- Average Exercise Price		Weighted- Average Remaining Contractual Term (Years)
Options outstanding at December 31, 2019		1,830,958		$	30.71		7.36
Granted		3,005,964			0.54
Forfeited		(293,102	)		19.08
Cancelled		(181,948	)		35.57
Exercised		-			-
Options Outstanding December 31, 2020		4,361,872		$	10.49		6.05

The following table summarizes information about stock options outstanding at December 31, 2020:

	Number of Shares		Weighted Average Exercise Price		Weighted Average Remaining Contractual Term (Years)
Exercisable at December 31, 2020		1,282,678	$	27.71		4.81
Vested or expected to vest at December 31, 2020		4,141,694	$	10.89		6.05

Stock options outstanding, exercisable, and vested or expected to vest at December 31, 2020 had no intrinsic value based on the closing market price of the Company’s common stock at December 31, 2020.

The total intrinsic value of options exercised during 2020 and 2019 was approximately $0 million and $0.2 million, respectively. Proceeds from options exercised during 2020 and 2019 were approximately $0 million and $0.5 million, respectively.

The Company granted 3,005,964 and 623,272 options to employees and non-employees during the years ended December 31, 2020 and 2019, respectively, with a weighted-average grant date fair value of $0.53 and $21.23, respectively.

As of December 31, 2020, the Company had future employee stock-based compensation expense of approximately $4.2 million related to unvested stock options, which is expected to be recognized over an estimated weighted-average period of 1.8 years.

Note 15 - Restricted Stock Units

12 Months Ended

Dec. 31, 2020

Share-based Payment Arrangement, Restricted Stock Units [Text Block]

15. Restricted Stock Units

In 2019 and 2020, the Company issued Restricted Stock Units (“RSUs”) to certain employees which vest over three years. The RSUs vest on defined vesting dates, subject to the continuous service with the Company at the applicable vesting event. Vesting can be accelerated upon a change in control under the Plan if the RSUs are not assumed by the successor company, and will be accelerated for certain executive officers under existing employment agreements if any such executive officer has a termination of employment in connection with a change in control event. When vested, the RSUs represent the right to be issued the number of shares of the Company’s common stock that is equal to the number of RSUs granted. The fair value of each RSU is estimated based upon the closing price of the Company’s common stock on the grant date. Share-based compensation expense related to RSUs is recognized over the requisite service period as adjusted for estimated forfeitures.

The following is a summary of the RSU activity for the years ended December 31, 2020 and 2019:

	Number of Restricted Stock Units Outstanding			Weighted Average Grant Date Fair Value
Unvested December 31, 2018		382,098		$	20.24
Granted		192,987			31.42
Vested		(85,153	)		25.98
Forfeited		(46,005	)		21.38
Unvested December 31, 2019		443,927		$	23.88
Granted		3,112,382			0.67
Vested		(354,808	)		19.38
Forfeited		(242,402	)		6.54
Unvested December 31, 2020		2,959,099		$	1.41

As of December 31, 2020 and 2019, the Company recorded approximately $1.7 million and $3.2 million, respectively, in compensation expense for the RSUs. As of December 31, 2020, the unrecognized stock-based compensation expense related to unvested RSUs was approximately $1.5 million, which is expected to be recognized over a weighted average period of approximately 1.1 years.

Note 16 - Warrants

12 Months Ended

Dec. 31, 2020

Warrants Disclosure [Text Block]

16. Warrants

On September 26, 2014, the Company entered into an amendment to the SVB Loan Agreement with the Prior Lenders. In connection with the first tranche borrowings under such amendment, the Company issued 2,948 common stock warrants to the Prior Lenders to purchase shares of the Company’s common stock, with an exercise price of $52.20 per share. The warrants expire seven years from their respective issue date. The Company concluded that the warrants are considered equity instruments. The warrants were recognized at the relative fair value on the issuance date as a debt discount and were amortized using the effective interest method from issuance to the maturity of the term loans. None of these warrants were exercised during the years ended December 31, 2020 or 2019.

On August 14, 2015, in connection with an amendment to the SVB Loan Agreement and first tranche borrowings thereunder, the Company issued 8,684 common stock warrants to the Prior Lenders to purchase shares of the Company’s common stock, with an exercise price of $40.30 per share. The warrants expire seven years from their respective issue date. The Company concluded that the warrants are considered equity instruments. The warrants were recognized at the relative fair value on the issuance date as a debt discount and were amortized using the effective interest method from issuance to the maturity of the note. None of these warrants were exercised during the years ended December 31, 2020 or 2019.

On April 28, 2017, the Company sold 24.9 million Units, each consisting of approximately 0.077 shares of the Company's Common Stock, a Series A Warrant to purchase approximately 0.077 shares of Common Stock with an exercise price of $13.00 per share, and a Series B Warrant to purchase approximately 0.058 shares of Common Stock with an exercise price of $13.00 per share at an offering price of $1.00 per Unit. Each Series A Warrant was exercisable at any time beginning on the date of issuance, and from time to time thereafter, through and including the first anniversary of the issuance date, unless terminated earlier as provided in the Series A Warrant. Receipt of 510(k) clearance for the Senhance System on October 13, 2017, triggered the acceleration of the expiration date of the Series A Warrants to October 31, 2017. As such, all of the Series A Warrants were exercised prior to the expiration date. Each Series B Warrant may be exercised at any time beginning on the date of issuance and from time to time thereafter through and including the fifth anniversary of the issuance date.

The exercisability of the Series B Warrants may be limited if, upon exercise, the holder or any of its affiliates would beneficially own more than 4.99% of the Common Stock. If, at any time Series B Warrants are outstanding, any fundamental transaction occurs, as described in the Series B Warrants and generally including any consolidation or merger into another corporation, the consummation of a transaction whereby another entity acquires more than 50% of the Company’s outstanding voting stock, or the sale of all or substantially all of its assets, the successor entity must assume in writing all of the obligations to the Series B Warrant holders. Additionally, in the event of a fundamental transaction, each Series B Warrant holder will have the right to require the Company, or its successor, to repurchase the Series B Warrants for an amount of cash equal to the Black-Scholes value of the remaining unexercised portion of such Series B Warrants. The Series B Warrants are liability classified.

On February 24, 2020, the Company entered into a Series B Warrants Exchange Agreement (the “Exchange Agreement”) with holders of its Series B Warrants. Under the terms of the Exchange Agreement, each Series B Warrant was canceled in exchange for 0.61 shares of common stock. The Warrant holders participating in the exchange held 3,373,900 of the 3,638,780 Series B Warrants then outstanding and received an aggregate of 2,040,757 shares of common stock. As a result, the warrant liability decreased by $2.5 million and the additional paid in capital increased by the same amount.

As a result of the March 2020 Public Offering and adjustment feature, the exercise price of all outstanding Series B Warrants has been adjusted to $0.35 per share and the number of shares of common stock reserved for and issuable upon the exercise of outstanding Series B Warrants has been adjusted to 567,660 underlying warrant shares as of December 31, 2020. The remaining Series B Warrants were exercised in full in February 2021.

On March 10, 2020, the Company closed an underwritten public offering under which it issued, as part of units and the exercise of an over-allotment option, 25,367,646 Series C Warrants, each to acquire one share of common stock at an exercise price of $0.68 per share, and 25,367,646 Series D Warrants, each to acquire one share of common stock at an exercise price of $0.68 per share. See Note 17 for a description of the public offering. As of March 9, 2021, 25,235,970 Series C Warrants and 24,094,899 Series D Warrants have been exercised.

The Series C Warrants and Series D Warrants are equity classified. The fair value of the Series C Warrants and Series D Warrants on the issuance date was determined using a Black-Scholes Merton model. The unit proceeds were then allocated to the Common Stock, Series A Preferred Stock, Series C Warrants, and Series D Warrants, respectively, based on their relative fair values. As a result, the Company determined that a beneficial conversion feature was created by the difference between the effective conversion price of the preferred stock and the fair value of the Company's Common Stock as of the issuance date. The Company therefore recorded a beneficial conversion feature of $0.4 million as a deemed dividend included in additional paid-in capital and an immediate charge to earnings available to common stockholders for the year ended December 31, 2020.

On May 10, 2017, in connection with the entry into the Innovatus Loan Agreement, the Company issued warrants to Innovatus to purchase shares of the Company’s common stock. The warrants are issued on the funding date of each tranche and will expire five (5) years from such issue date. The warrants issued in connection with funding of the first tranche will entitle Innovatus to purchase up to 95,750 shares of the Company’s common stock at an exercise price of $13.00 per share. None of these warrants were exercised as of December 31, 2020 or 2019.

On September 12, 2017, the Company entered into a service agreement with a third-party vendor. In connection with the service agreement, the Company issued 73,076 common stock warrants (“Service Warrants”) to purchase shares of the Company’s common stock, with an exercise price of $13.00 per share. The Service Warrants vest as follow: (a) twenty-five percent (25%) on the date of execution of the services agreement; (b) fifty percent (50%) upon completion of hiring the sales team; and (c) the remaining twenty-five percent (25%) upon achieving cumulative product revenue of $15.0 million. The Service Warrants expire ten years from their issue date. The Company concluded that the Service Warrants are considered equity instruments. The fair value of the Service Warrants on the issuance date was determined using a Black-Scholes Merton model. The fair value of the remaining Service Warrants was updated each reporting period and the expense was recorded over the service period. In February 2018, the Company terminated its relationship with the vendor and accelerated the full vesting of the Service Warrants in accordance with the service agreement. There were no exercises of these warrants in 2020. During the year ended December 31, 2019, 15,385 of these warrants were exercised.

	Number of Warrant Shares			Weighted Average Exercise Price		Weighted Average Remaining Contractual Life (in years)		Weighted Average Fair Value
Outstanding at December 31, 2018		333,034		$	13.39		3.7	$	3.38
Exercised		(15,385	)		13.00		0		—
Reserved for future issuance		1,753,523			1.39		2.2		1.22
Outstanding at December 31, 2019		2,071,172		$	2.05		2.4	$	1.34
Granted		50,735,292			0.68		2.4		0.19
Exercised		(4,911,764	)		0.68		0		—
Exchanged		(2,040,757	)		1.24		0		—
Reserved for future issuance		644,966			0.35		1.3		0.45
Outstanding at December 31, 2020		46,498,909		$	0.71		2.4	$	0.20

The aggregate intrinsic value of the common stock warrants in the above table was $0.2 million at each of December 31, 2020 and 2019. The aggregate intrinsic value is before applicable income taxes and is calculated based on the difference between the exercise price of the warrants and the estimated fair market value of the applicable stock as of the respective dates.

Note 17 - Equity Offerings

12 Months Ended

Dec. 31, 2020

Stockholders' Equity Note Disclosure [Text Block]

17. Equity Offerings

At-the-Market Offerings

On August 12, 2019, the Company entered into a Controlled Equity Offering Sales Agreement (the “2019 Sales Agreement”), with Cantor Fitzgerald & Co., (“Cantor”), and commenced an at-the-market offering (the “2019 ATM Offering”) pursuant to which the Company could sell from time to time, at its option, up to an aggregate of $25.0 million shares of the Company’s common stock, through Cantor, as sales agent. Sales of the common stock under the 2019 ATM Offering were made under the Company’s previously filed and currently effective shelf registration statement on Form S-3. The aggregate compensation payable to Cantor was 3.0% of the aggregate gross proceeds from each sale of the Company’s common stock. Under the 2019 ATM Offering, the Company raised gross proceeds of $7.2 million and net proceeds of $7.0 million during the year ended December 31, 2019, and an additional $11.6 million of gross proceeds and $11.2 million of net proceeds during the year ended December 31, 2020.

On October 9, 2020, the Company filed a prospectus supplement relating to an at-the-market offering with Cantor pursuant to which the Company may could from time to time, at its option, up to an aggregate of $40.0 million of shares of the Company’s common stock, through Cantor as sales agent, pursuant to the 2019 Sales Agreement (the “2020 ATM Offering”). Sales of the common stock were made on the Company’s shelf registration statement on Form S-3, which was declared effective by the SEC on February 10, 2020. The aggregate compensation payable to Cantor was 3.0% of the aggregate gross proceeds from each sale of the Company’s common stock.

The following table summarizes the total sales under the 2019 ATM Offering and 2020 ATM Offering for the period indicated (in thousands except for share and per share amounts):

	2019 ATM Offering		2019 ATM Offering		2020 ATM Offering
	For the year ended		For the year ended		For the year ended
	December 31, 2019		December 31, 2020		December 31, 2020
Total shares of common stock sold		1,374,686		6,687,846		16,320,793
Average price per share	$	5.23	$	1.73	$	0.58
Gross proceeds	$	7,193	$	11,558	$	9,264
Commissions earned by Cantor	$	212	$	347	$	278
Net Proceeds	$	6,981	$	11,211	$	8,986

From January 1, 2021 through the termination date of January 26, 2021, the Company has raised, under the 2020 ATM Offering, additional gross proceeds of $28.1 million through the sale of 19,120,037 shares of common stock.

Public Offerings of Securities

On March 10, 2020, the Company closed the March 2020 Public Offering and sold an aggregate of 14,121,766 Class A Units at a public offering price of $0.68 per Class A Unit and 7,937,057 Class B Units at a public offering price of $0.68 per Class B Unit. Each Class A Unit consists of one share of the Company’s common stock, one warrant to purchase one share of common stock that expires on the first anniversary of the date of issuance (collectively, the “Series C Warrants”), and one warrant to purchase one share of common stock that expires on the fifth anniversary of the date of issuance (collectively, the “Series D Warrants”). Each Class B Unit consists of one share of Series A Convertible Preferred Stock, par value $0.01 per share (the “Series A Preferred Stock”), convertible into one share of common stock, a Series C Warrant to purchase one share of common stock and a Series D Warrant to purchase one share of common stock. The Class A Units and Class B Units have no stand-alone rights and were not certificated or issued as stand-alone securities. The shares of common stock, Series A Preferred Stock, Series C Warrants and Series D Warrants are immediately separable. In addition, the underwriter for the public offering exercised an overallotment option and purchased 3,308,823 Series C Warrants and 3,308,823 Series D Warrants.

The shares of Series A Preferred Stock rank on par with the shares of the common stock, in each case, as to dividend rights and distributions of assets upon liquidation, dissolution or winding up of the Company. With certain statutory exceptions, as described in the Series A Preferred Stock Certificate of Designation, the shares of Series A Preferred Stock have no voting rights. Each share of Series A Preferred Stock was convertible at any time at the holder’s option into one share of common stock, which conversion ratio was subject to adjustment for stock splits, stock dividends, distributions, subdivisions and combinations and other similar transactions as specified in the Series A Preferred Stock Certificate of Designation. All of the shares of Series A Preferred Stock were converted to common stock by the holders by June 30, 2020. Upon conversion, the Company recorded $0.3 million as a deemed dividend as an immediate charge to earnings available to common stockholders for the year ended December 31, 2020. In accordance with the Series A Preferred Stock Certificate of Designation, the shares of Series A Preferred Stock regained the status of authorized and unissued shares of preferred stock.

The net proceeds to the Company from the March 2020 Public Offering were approximately $13.5 million, after deducting underwriting discounts and commissions and estimated offering expenses payable by the Company. All shares of Series A Preferred Stock were converted into 7.9 million shares of common stock prior to June 30, 2020. Approximately 4.9 million Series C Warrants were exercised during the year ended December 31, 2020, generating net proceeds of $3.3 million. The Class A Units, the Class B Units, the Series A Preferred Stock, the Series C Warrants and the Series D Warrants (together with the shares of common stock underlying the shares of Series A Preferred Stock and such warrants) were offered under the Company’s previously filed Registration Statement on Form S-3, which registration statement expired in May 2020. The Company filed a new registration statement on Form S-1 covering the exercise of the outstanding Series C Warrants and Series D Warrants, which was declared effective by the SEC on May 27, 2020.

On July 6, 2020, the Company completed an underwritten public offering of 42,857,142 shares of its common stock, including the underwriter’s full exercise of an over-allotment option, at the public offering price per share of $0.35 per share, generating net proceeds of approximately $13.6 million. Following the offering, the exercise price of the outstanding Series B Warrants was adjusted to $0.35 per share and the number of shares of common stock underlying such warrants increased to 567,660 shares (see Note 16).

Firm Commitment Offering

On September 4, 2019, the Company entered into an Underwriting Agreement, or the Underwriting Agreement, with Cantor. Subject to the terms and conditions of the 2019 Underwriting Agreement, the Company sold to Cantor, in a firm commitment underwritten offering, 2,153,846 shares of the Company’s common stock, or the Firm Commitment Offering. In addition, the Company granted Cantor a 30-day option to purchase 323,077 of additional shares of common stock. The Company raised $18.8 million in gross proceeds under this offering. The option to purchase additional shares of common stock was not exercised.

Lincoln Park Purchase Agreement

On February 10, 2020, we entered into a purchase agreement, or the LPC 2020 Purchase Agreement, with Lincoln Park, pursuant to which we have the right to sell to Lincoln Park up to an aggregate of $25,000,000 in shares of our common stock, subject to certain limitations and conditions set forth in the LPC 2020 Purchase Agreement, including a limitation on the number of shares of common stock we can put to LPC and the pricing parameters for the sales. In consideration for entering into the LPC 2020 Purchase Agreement, we issued to Lincoln Park 343,171 shares of Common Stock as commitment shares. We also committed to issue up to an additional 171,585 shares of Common Stock to Lincoln Park on a pro rata basis based on the number of shares Common Stock purchased by Lincoln Park pursuant to the LPC 2020 Purchase Agreement. No other shares were issued to Lincoln Park under the purchase agreement, and it was terminated in June 2020.

Note 18 - Restructuring

12 Months Ended

Dec. 31, 2020

Restructuring and Related Activities Disclosure [Text Block]

18. Restructuring

During the fourth quarter of 2019, the Company announced the implementation of a restructuring plan to reduce operating expenses as the Company continues the global market development of the Senhance platform. Under the restructuring plan, the Company reduced headcount primarily in the sales and marketing functions and determined that the carrying value of its inventory exceeded the net realizable value due to a decrease in expected sales. The restructuring charges amounted to $8.8 million, of which $7.4 million was an inventory write down and was included in cost of product revenue and $1.4 million related to employee severance costs and was included as restructuring and other charges in the consolidated statements of operations and comprehensive loss, for the year ended December 31, 2019. During the year ended December 31, 2020, the Company continued the restructuring efforts with additional headcount reductions which resulted in $0.9 million related to severance costs. Payments under the restructuring plan concluded in 2020. During the year ended December 31, 2020, the activity related to the Company's restructuring liability, which is included in accrued expenses in the consolidated balance sheet, was as follows:

	Restructuring Liability
	(In thousands)
Balance at December 31, 2019	$	882
Amount charged to operating expenses		851
Cash payments		(1,733	)
Balance at December 31, 2020	$	—

Note 19 - Basic and Diluted Net Loss Per Share

12 Months Ended

Dec. 31, 2020

Earnings Per Share [Text Block]

19. Basic and Diluted Net Loss per Share

Basic net loss per common share is computed by dividing net loss attributable to common stockholders by the weighted average number of common shares outstanding during the period. Diluted net loss per common share is computed giving effect to all potential dilutive common shares that were outstanding during the period when the effect is dilutive. Potential dilutive common shares consist of incremental shares issuable upon exercise of stock options, restricted stock units, warrants and preferred stock. For the year ended December 31, 2020, the effects of the Series A Preferred Stock beneficial conversion charge and conversion are included in the calculation of net loss attributable to common stockholders. No adjustments have been made to the weighted average outstanding common shares figures for the years ended December 31, 2020 or 2019 as the assumed exercise of outstanding options, warrants and restricted stock units would be anti-dilutive.

Potential common shares not included in calculating diluted net loss per share are as follows:

	December 31
	2020		2019
Stock options		4,361,872		1,830,958
Stock warrants		46,498,909		2,071,172
Nonvested restricted stock units		2,959,099		443,927
Total		53,819,880		4,346,057

Note 20 - Related Person Transactions

12 Months Ended

Dec. 31, 2020

20. Related Person Transactions

A member of the Company's Board of Directors is an executive officer of Sofar S.p.A. Various equipment was purchased by the Company from Sofar S.p.A. and totaled approximately $74,000 and $26,000 for the years ended December 31, 2020 and 2019, respectively.

In March 2018, Asensus Surgical Europe S.à.R.L entered into a Service Supply Agreement with 1 Med S.A. for certain regulatory consulting services. Andrea Biffi, a current member of the Company’s Board of Directors, owns a non-controlling interest in 1 Med S.A. Expenses under the Service Supply Agreement were approximately $110,000 and $12,000 for the years ended December 31, 2020 and 2019, respectively.

Note 21 - Commitments and Contingencies

12 Months Ended

Dec. 31, 2020

Commitments and Contingencies Disclosure [Text Block]

21. Commitments and Contingencies

Contingent Consideration

As discussed in Note 3, in September 2015, the Company completed the Senhance Acquisition using a combination of cash, stock and potential post-acquisition milestone payments. These milestone payments may be payable in the future, depending on the achievement of certain commercial milestones. On December 30, 2016, the Company entered into an Amendment to restructure the terms of the Second Tranche of the Cash Consideration. Under the Amendment, the Second Tranche was restructured to reduce the contingent cash consideration by €5.0 million in exchange for the issuance of 286,360 shares of the Company’s common stock with an aggregate fair market value of €5.0 million. The fair value of the contingent consideration was $3.9 million and $1.1 million as of December 31, 2020 and 2019, respectively.

Legal Proceedings

No liability or related charge was recorded to earnings in the Company’s consolidated financial statements for legal contingencies for the years ended December 31, 2020 and 2019.

Operating Leases

On January 1, 2019, the Company adopted ASU No. 2016-02, applying the package of practical expedients to leases that commenced before the effective date whereby the Company elected to not reassess the following: (i) whether any expired or existing contracts contain leases; (ii) the lease classification for any expired or existing leases; and (iii) initial direct costs for any existing leases. The Company also elected, for all classes of underlying assets, to not separate non-lease components from lease components and instead to account for them as a single component. The Company elected to apply the transition provisions as of January 1, 2019, the date of adoption, using the effective date approach, and recorded lease ROU assets and related liabilities on its balance sheet without restating prior periods. As a result of the adoption of ASU 2016-02, other long-term assets increased by $1.8 million, accrued expenses increased by $0.5 million, and other long-term liabilities increased by $1.2 million. There was no change to the Company’s consolidated statements of operations and comprehensive loss or cash flows as a result of the adoption of ASU 2016-02.

Many of the Company’s leases include base rental periods coupled with options to renew or terminate the lease, generally at the Company’s discretion. In evaluating the lease term, the Company considers whether renewal is reasonably certain. To the extent a significant economic incentive exists to renew the lease, the option is included within the lease term. Based on the Company’s leases, renewal options generally do not provide a significant economic incentive and are therefore excluded from the lease term. The ROU asset is included in other long-term assets on the consolidated balance sheets. The current portion of operating lease liabilities are presented within accrued liabilities while the non-current portion of operating lease liabilities are presented within other long-term liabilities on the consolidated balance sheets and represents the present value of the remaining lease payments, discounted using the Company’s incremental borrowing rate, which ranges between 6.1% and 8.5% based on the terms of the lease. The weighted average discount rate was 8.2% and 7.8% as of December 31, 2020 and December 31, 2019, respectively.

As of December 31, 2020, the right-of-use asset totaled $1.2 million and is included within other long-term assets on the consolidated balance sheet and the lease liability totaled $1.3 million, of which $0.7 million is classified as current within accrued expenses and $0.6 million is classified as non-current and makes up the full balance of other long term liabilities on the consolidated balance sheet. Operating lease costs for the year ended December 31, 2020 totaled $1.5 million and are included within operating expenses in the consolidated statement of operations and comprehensive loss. The weighted average remaining lease term for operating leases as of December 31, 2020 was 1.8 years. Total cash paid for operating leases during the year ended December 31, 2020 was $1.5 million and is included within cash flows from operating activities within the consolidated statement of cash flows.

As of December 31, 2019, the right-of-use asset totaled $2.3 million and is included within other long-term assets on the consolidated balance sheet and the lease liability totaled $2.5 million, of which $1.1 million is classified as current within accrued expenses and $1.4 million is classified as non-current and makes up the full balance of other long term liabilities on the consolidated balance sheet. Operating lease costs for the year ended December 31, 2019 totaled $1.4 million and are included within operating expenses in the consolidated statement of operations and comprehensive loss. The weighted average remaining lease term for operating leases as of December 31, 2019 was 2.6 years. Total cash paid for operating leases during the year ended December 31, 2019 was $1.7 million and is included within cash flows from operating activities within the consolidated statement of cash flows.

The following table presents the minimum lease payments as of December 31, 2020 (in thousands):

Fiscal Year
2021	$	883
2022		404
2023		120
2024		5
2025		—
Thereafter		—
Total minimum lease payments	$	1,412
Less: Amount of lease payments representing interest		(151	)
Present value of future minimum lease payments	$	1,261

The following table presents the minimum lease payments as of December 31, 2019 (in thousands):

Fiscal Year
2020	$	1,372
2021		716
2022		454
2023		207
2024		28
Thereafter		—
Total minimum lease payments	$	2,778
Less: Amount of lease payments representing interest		(266	)
Present value of future minimum lease payments	$	2,512

On November 2, 2009, Asensus Surgical US, Inc. (“Asensus Surgical US”) entered into an operating lease for its corporate offices for a period of five years commencing in April 2010. On June 12, 2014, the Company entered into a lease amendment extending the term of the lease for a period of 3 years and 2 months commencing on May 1, 2015 and expiring on June 30, 2018, with an option to renew for an additional three years. On January 8, 2018, the Company entered into a lease amendment extending the term of the lease for a period of eighteen months commencing on July 1, 2018 and expiring on December 31, 2019, with an option to renew for an additional five years. On June 10, 2019, the Company entered into a lease amendment extending the term of the lease for an additional twelve months commencing on January 1, 2020 and expiring on December 31, 2020, with no option to renew. The Company’s current North Carolina lease was extended for three months and expires on March 31, 2021.

In July 2020, Asensus Surgical US, entered into a lease agreement for new office, lab and warehouse space in Durham, North Carolina. The lease is expected to commence in the first quarter of 2021, has an initial lease term of 125 months following commencement, and includes tenant options to extend the lease term for up to two additional five-year periods. Monthly base rent payments begin five months after the commencement date and are subject to annual escalations. Total base rent payments over the initial 125-month term shall be approximately $5.0 million. A proportionate share of building operating costs and ad valorem property taxes are also due monthly. In conjunction with entering into the lease, Asensus Surgical US obtained a standby letter of credit issued by Silicon Valley Bank for approximately $0.5 million for the benefit of the landlord and has been required to increase restricted cash held with Silicon Valley Bank by $0.5 million. The Company has executed a guaranty for the payment and performance of obligations incurred under the lease.

On May 12, 2016, Asensus Surgical Italia S.r.l. entered into an operating lease for research and development and demonstration facilities for a period of six years commencing in July 2016. On April 15, 2019, Asensus Surgical Israel Ltd entered into an operating lease for research and development facilities for a period of five years commencing in April 2019. On April 25, 2018, TransEnterix Japan K.K. entered into an operating lease for office space for a period of five years commencing in April 2018. On July 1, 2018, Asensus Surgical Europe S.à.R.L entered into an operating lease for office space for a period of five years commencing in July 2018. Rent expense was approximately $1.5 million and $1.4 million for the years ended December 31, 2020 and 2019, respectively.

License and Supply Agreements

As discussed in Note 3, in September 2015, the Company completed the Senhance Acquisition. As part of this transaction, the Company assumed certain license and supply agreements. Commitments under these agreements amount to approximately $3.5 million in 2021, $0.5 million in 2022, $0.5 million in 2023, $0.5 million in 2024, and $0.5 million thereafter until termination in 2027. Payments under these arrangements generally become due and payable only upon the achievement of certain milestones. For instances in which the achievement of these milestones is neither probable nor reasonably estimable, such contingencies are not included in the estimated amount.

The Company has placed orders with various suppliers for the purchase of certain tooling, supplies and contract engineering and research services. Each of these orders has a duration or expected completion within the next twelve months.

Note 22 - Subsequent Events

12 Months Ended

Dec. 31, 2020

Subsequent Events [Text Block]

22. Subsequent Events

Financings

On January 12, 2021, the Company sold, in a registered direct offering, 25,000,000 shares of common stock at a purchase price per share of $1.25 for aggregate gross proceeds of $31.25 million, and net proceeds of $28.8 million.

On January 29, 2021, the Company completed an underwritten public offering of 26,725,832 shares of its common stock, including the underwriter’s full exercise of an over-allotment option on February 1, 2021, at the public offering price of $3.00 per share, generating net proceeds of approximately $73.5 million.

As of the date of this filing Series B, C and D warrants have been exercised during 2021 for aggregate proceeds to the Company of $30.4 million.

From January 1, 2021 through to the date of this filing the following table summarizes the total sales under the 2020 ATM Offering (in thousands except for per share amounts). The 2020 ATM Offering was terminated on January 26, 2021.

Total shares of common stock sold		19,120
Average price per share	$	1.47
Gross proceeds	$	28,100
Commissions earned by Cantor	$	843
Net Proceeds	$	27,257

Name change

Effective on February 23, 2021, the Company changed its name from TransEnterix, Inc. to Asensus Surgical, Inc. On March 5, 2021, the ticker symbol of the Company’s common stock on the NYSE American changed from “TRXC” to “ASXC.”

Significant Accounting Policies (Policies)

12 Months Ended

Dec. 31, 2020

Accounting Policies [Abstract]

Basis of Accounting, Policy [Policy Text Block]

Basis of Presentation

On December 11, 2019, following receipt of approval from stockholders at a special meeting of stockholders held on the same day, the Company filed an amendment to our Amended and Restated Certificate of Incorporation to effect a reverse stock split of the Company’s common stock at a ratio of one-for-thirteen, or the Reverse Stock Split. The Company’s common stock began trading on a split-adjusted basis on NYSE American on the morning of December 12, 2019. No fractional shares were issued in connection with the Reverse Stock Split. Instead, the Company rounded up each fractional share resulting from the reverse stock split to the nearest whole share. As a result of the Reverse Stock Split, the Company’s outstanding common stock decreased from approximately 261.9 million shares to approximately 20.2 million shares (without giving effect to the rounding up for each fractional share).

Unless otherwise noted, all share and per share data referenced in the consolidated financial statements and the notes thereto have been retroactively adjusted to reflect the Reverse Stock Split. As a result of the Reverse Stock Split, certain amounts in the consolidated financial statements and the notes thereto may be slightly different than previously reported due to rounding of fractional shares, and certain amounts within the consolidated balance sheets were reclassified between common stock and additional paid-in capital.

Substantial Doubt about Going Concern [Policy Text Block]

Liquidity

The Company had an accumulated deficit of $722.9 million, working capital of $23.7 million, and cash and cash equivalents, excluding restricted cash, of $16.4 million as of December 31, 2020. The Company has not established sufficient sales revenues to cover its operating costs and requires additional capital to proceed with its operating plan.

The Company believes the COVID-19 pandemic will continue to negatively impact its operations and ability to implement its market development efforts, which will have a negative effect on its financial condition. At December 31, 2020, the Company had cash and cash equivalents, excluding restricted cash, of approximately $16.4 million. Subsequent to December 31, 2020, the Company has raised additional capital through equity offerings, including raising net proceeds of $73.5 million in the January 2021 public offering, $28.8 million in the January 2021 registered direct offering, and $28.1 million in the 2020 ATM Offering. Also Series B, C and D warrants have been exercised in 2021 for aggregate proceeds to the Company of $30.4 million. While the Company believes that its existing cash and cash equivalents at December 31, 2020 and the proceeds from the January 2021 public offering and registered direct offering, ATM offering, and exercise of the warrants will be sufficient to sustain operations for at least the next 12 months from the issuance of these financial statements, the Company will need to obtain additional financing to proceed with its business plan. Management's plan to obtain additional resources for the Company may include additional sales of equity, traditional financing, such as loans, entry into a strategic collaboration, entry into an out-licensing arrangement or provision of additional distribution rights in some or all of our markets. However, management cannot provide any assurance that the Company will be successful in accomplishing any or all of its plans.

Use of Estimates, Policy [Policy Text Block]

Use of Estimates

The preparation of financial statements in conformity with U.S. GAAP requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and the disclosure of contingent assets and liabilities at the date of the financial statements and the reported amounts of revenues and expenses during the reporting period. Actual results could differ from those estimates. Significant items subject to such estimates and assumptions include impairment considerations for intangible assets, fair value estimates related to contingent consideration, warrant liabilities, stock compensation expense, revenue recognition, accounts receivable reserves, excess and obsolete inventory reserves, inventory classification between current and non-current, and deferred tax asset valuation allowances.

The COVID-19 pandemic has caused significant social and economic restrictions that have been imposed in the United States and abroad, which has resulted in significant volatility in the global economy and led to reduced economic activity. In the preparation of these financial statements and related disclosures, the Company has assessed the impact that COVID-19 has had on its estimates, assumptions, forecasts, and accounting policies. The Company continues to monitor closely the COVID-19 pandemic impact on its estimates, assumptions and forecasts used in the preparation of its financial statements. As the COVID-19 situation is unprecedented and ever evolving, future events and effects related to COVID-19 cannot be determined with precision, and actual results could significantly differ from estimates or forecasts.

Cash and Cash Equivalents, Restricted Cash and Cash Equivalents, Policy [Policy Text Block]

Cash and Cash Equivalents and Restricted Cash

The Company considers all highly liquid investments with original maturities of 90 days or less at the time of purchase to be cash equivalents.

Concentration Risk, Credit Risk, Policy [Policy Text Block]

Concentrations and Credit Risk

The Company’s principal financial instruments subject to potential concentration of credit risk are cash and cash equivalents, including amounts held in money market accounts. The Company places cash deposits with a federally insured financial institution. The Company maintains its cash at banks and financial institutions it considers to be of high credit quality; however, the Company’s domestic cash deposits may at times exceed the Federal Deposit Insurance Corporation’s insured limit. Balances in excess of federally insured limitations may not be insured. The Company has not experienced losses on these accounts, and management believes that the Company is not exposed to significant risks on such accounts.

The Company’s accounts receivable are derived from sales to customers located throughout the world. The Company evaluates its customers’ financial condition and, generally, requires no collateral from its customers. The Company provided reserves for potential credit losses and recorded a bad debt charge totaling $0 million during the year ended December 31, 2020 and $1.6 million during the year ended December 31, 2019. The Company had 7 customers who constituted 68% of the Company’s net accounts receivable at December 31, 2020. The Company had eight customers who constituted 85% of the Company’s net accounts receivable at December 31, 2019. The Company had nine customers who accounted for 55% of revenue in 2020 and six customers who accounted for 82% of revenue in 2019.

Receivable [Policy Text Block]

Accounts Receivable

Accounts receivable are recorded at net realizable value, which includes an allowance for estimated uncollectible accounts. The allowance for uncollectible accounts was determined on a customer specific basis based on deemed collectability. The allowance for doubtful accounts was $1.8 million and $1.7 million as of December 31, 2020 and December 31, 2019, respectively.

Inventory, Policy [Policy Text Block]

Inventories

Inventories are stated at the lower of cost (determined on a first-in, first-out basis) or net realizable value. Inventory costs include direct materials, direct labor, and normal manufacturing overhead. The Company records reserves, when necessary, to reduce the carrying value of inventory to its net realizable value. Management considers forecast demand in relation to the inventory on hand, competitiveness of product offerings, market conditions and product life cycles when determining excess and obsolescence and net realizable value adjustments. At the point of loss recognition, a new, lower-cost basis for that inventory is established, and any subsequent improvements in facts and circumstances do not result in the restoration or increase in that newly established cost basis.

Any inventory on hand at the measurement date in excess of the Company's current requirements based on anticipated levels of sales is classified as long-term on the Company's consolidated balance sheets. The Company's classification of long-term inventory requires it to estimate the portion of on hand inventory that can be realized over the upcoming twelve months.

Goodwill and Intangible Assets, Policy [Policy Text Block]

Identifiable Intangible Assets and Goodwill

Definite-Lived Intangible Assets - Intellectual Property

Intellectual property consists of purchased patent rights and developed technology acquired as part of a business acquisition. Developed technology includes reclassified IPR&D assets related to (i) the Senhance System acquired in 2015 and reclassified in 2017 and (ii) MST acquired in 2018 and reclassified in 2020. Amortization of the patent rights is recorded using the straight-line method over the estimated useful life of the patents of 10 years. Amortization of the developed technology is recorded using the straight-line method over the estimated useful life of 5 to 7 years.

The Company periodically evaluates intellectual property for impairment whenever events or changes in circumstances indicate that the carrying amount may not be recoverable. To determine the recoverability, the Company evaluates the probability that future estimated undiscounted net cash flows will be less than the carrying amount of the assets. If such estimated cash flows are less than the carrying amount of the assets, then such assets are written down to their fair value. No impairment of intellectual property was identified during the year ended December 31, 2020 and 2019.

Indefinite-Lived Intangible Assets – In-Process Research and Development

In-process research and development (“IPR&D”) assets represent the fair value assigned to technologies that were acquired, which at the time of acquisition have not reached technological feasibility and have no alternative future use. IPR&D assets are considered to be indefinite-lived until the completion or abandonment of the associated research and development projects. During the period that the IPR&D assets are considered indefinite-lived, they are tested for impairment on an annual basis, or more frequently if the Company becomes aware of any events occurring or changes in circumstances that indicate that the fair value of the IPR&D assets are less than their carrying amounts. To determine the recoverability, the Company evaluates the probability that future estimated discounted net cash flows will be less than the carrying amount of the assets. If such estimated cash flows are less than the carrying amount of the assets, then such assets are written down to their fair value.

The Company reclassifies IPR&D assets to intellectual property when development is complete, which generally occurs upon regulatory approval when the Company is able to commercialize products. The completed IPR&D assets are then classified as definite-lived intangible assets (developed technology) and are amortized based on their estimated useful lives at that point in time. If development is terminated or abandoned, the Company may have a full or partial impairment charge related to the IPR&D assets, calculated as the excess of carrying value of the IPR&D assets over fair value.

The Company performed an impairment test of its IPR&D at the end of the third quarter 2019 as recent events and changes in market conditions indicated that the asset might be impaired. During the third quarter of 2019, the Company concluded that the fair value determined by the market value approach was lower than the carrying value and recognized a $7.9 million impairment charge to its IPR&D. The Company performed its annual impairment assessment at December 31, 2019 and no additional impairment was required. As of December 31, 2020, all IPR&D asset development was completed and reclassified to intellectual property.

As of December 31, 2020, there were no remaining IPR&D assets.

Goodwill

Goodwill of $93.8 million was recorded in connection with a September 2013 merger transaction, goodwill of $38.3 million was recorded in connection with the Senhance Acquisition and goodwill of $9.6 million was recorded in connection with the MST Medical Surgical Technologies, Ltd. Acquisition (see Note 3). During the third quarter of 2019, the Company’s stock price declined significantly as a result of decreased sales and goodwill was deemed to be fully impaired, resulting in an impairment charge of $79.0 million.

As of December 31, 2020, there was no remaining Goodwill asset.

Property, Plant and Equipment, Policy [Policy Text Block]

Property and Equipment

Property and equipment consists primarily of operating lease Senhance System assets, machinery, manufacturing equipment, demonstration equipment, computer equipment, furniture, and leasehold improvements, which are recorded at cost.

Depreciation is recorded using the straight-line method over the estimated useful lives of the assets as follows:

	Years
Operating lease assets – Senhance System leasing			5
Machinery, manufacturing, and demonstration equipment		3	-	5
Computer equipment			3
Furniture			5
Leasehold improvements	Lesser of lease term or 3 to 10

Upon retirement or sale, the cost of assets disposed of and the related accumulated depreciation and amortization are removed from the accounts and any resulting gain or loss is credited or charged to operations. Repairs and maintenance costs are expensed as incurred.

Impairment or Disposal of Long-Lived Assets, Policy [Policy Text Block]

Impairment of Long-Lived Assets

The Company reviews its property and equipment assets for possible impairment whenever events or changes in circumstances indicate that the carrying amount of the assets may not be fully recoverable. To determine the recoverability of its long-lived assets, the Company evaluates the probability that future estimated undiscounted net cash flows will be less than the carrying amount of the assets. If such estimated cash flows are less than the carrying amount of the long-lived assets, then such assets are written down to their fair value. The Company did not identify any impairment during the years ended December 31, 2020 and 2019.

Contingent Consideration [Policy Text Block]

Contingent Consideration

Contingent consideration is recorded as a liability and is the estimate of the fair value of potential milestone payments related to business acquisitions. Contingent consideration is measured at fair value using a discounted cash flow model utilizing significant unobservable inputs including the probability of achieving each of the potential milestones, future Euro-to-USD exchange rates, and an estimated discount rate associated with the risks of the expected cash flows attributable to the various milestones. Significant increases or decreases in any of the probabilities of success or changes in expected achievement of any of these milestones would result in a significantly higher or lower fair value of these milestones, respectively, and commensurate changes to the associated liability. The contingent consideration is revalued at each reporting period and changes in fair value are recognized in the consolidated statements of operations and comprehensive loss.

Warrant Liabilities [Policy Text Block]

Warrant Liabilities

The Company’s Series B Warrants (see Note 16) are measured at fair value using a simulation model which takes into account, as of the valuation date, factors including the current exercise price, the expected life of the warrant, the current price of the underlying stock, its expected volatility, holding cost and the risk-free interest rate for the term of the warrant (see Note 5). The warrant liability is revalued at each reporting period and changes in fair value are recognized in the consolidated statements of operations and comprehensive loss. The selection of the appropriate valuation model and the inputs and assumptions that are required to determine the valuation requires significant judgment and requires management to make estimates and assumptions that affect the reported amount of the related liability and reported amounts of the change in fair value. Actual results could differ from those estimates, and changes in these estimates are recorded when known.

Foreign Currency Transactions and Translations Policy [Policy Text Block]

Translation of Foreign Currencies

The functional currency of the Company’s operational foreign subsidiaries is predominantly the Euro. The assets and liabilities of the Company’s foreign subsidiaries are translated into U.S. dollars at exchange rates in effect at the balance sheet date. Income and expense items are translated at the average exchange rates prevailing during the period. The cumulative translation effect for a subsidiary using a functional currency other than the U.S. dollar is included in accumulated other comprehensive income or loss as a separate component of stockholders’ equity.

The Company’s intercompany accounts are denominated in the functional currency of the foreign subsidiary. Gains and losses resulting from the remeasurement of intercompany receivables that the Company considers to be of a long-term investment nature are recorded as a cumulative translation adjustment in accumulated other comprehensive income or loss as a separate component of stockholders’ equity, while gains and losses resulting from the remeasurement of intercompany receivables from a foreign subsidiary for which the Company anticipates settlement in the foreseeable future are recorded in the consolidated statements of operations and comprehensive loss. The net gains and losses included in net loss in the consolidated statements of operations and comprehensive loss for the years ended December 31, 2020 and 2019 were not significant.

Business Combinations Policy [Policy Text Block]

Business Acquisitions

Business acquisitions are accounted for using the acquisition method of accounting in accordance with ASC 805, “Business Combinations.” ASC 805 requires, among other things, that assets acquired and liabilities assumed be recognized at their fair values, as determined in accordance with ASC 820, “Fair Value Measurements,” as of the acquisition date. For certain assets and liabilities, book value approximates fair value. In addition, ASC 805 establishes that consideration transferred be measured at the closing date of the acquisition at the then-current market price. Under ASC 805, acquisition-related costs (i.e., advisory, legal, valuation and other professional fees) and certain acquisition-related restructuring charges impacting the target company are expensed in the period in which the costs are incurred. The application of the acquisition method of accounting requires the Company to make estimates and assumptions related to the estimated fair values of net assets acquired.

Significant judgments are used during this process, particularly with respect to intangible assets. Therefore, the purchase price allocation to intangible assets and goodwill has a significant impact on future operating results.

Risk And Uncertainties, Policy [Policy Text Block]

Risk and Uncertainties

The Company is subject to risks similar to other similarly sized companies in the medical device industry. These risks include, without limitation: potential negative impacts on the Company's operations caused by the COVID-19 pandemic; the Company’s ability to continue as a going concern; the historical lack of profitability; the Company’s ability to raise additional capital; the success of its market development efforts, the liquidity and capital resources of its partners; its ability to successfully develop, clinically test and commercialize its products; the timing and outcome of the regulatory review process for its products; changes in the health care and regulatory environments of the United States, the United Kingdom, the European Union, Japan, Taiwan and other countries in which the Company operates or intends to operate; its ability to attract and retain key management, marketing and scientific personnel; its ability to successfully prepare, file, prosecute, maintain, defend and enforce patent claims and other intellectual property rights; its ability to successfully transition from a research and development company to a marketing, sales and distribution concern; competition in the market for robotic surgical devices; and its ability to identify and pursue development of additional products.

Revenue [Policy Text Block]

Revenue Recognition

The Company’s revenue consists of product revenue resulting from the sale and lease of Systems, System components, instruments and accessories, and service revenue. The Company accounts for a contract with a customer when there is a legally enforceable contract between the Company and the customer, the rights of the parties are identified, the contract has commercial substance, and collectability of the contract consideration is probable. The Company's revenues are measured based on consideration specified in the contract with each customer, net of any sales incentives and taxes collected from customers that are remitted to government authorities. The Company’s System sale arrangements generally include a five-year service period; the first year of service is generally free and included in the System sale arrangement and the remaining four years are generally included at a stated service price.

The Company’s System sale arrangements generally contain multiple products and services. For these consolidated sale arrangements, the Company accounts for individual products and services as separate performance obligations if they are distinct, which is if a product or service is separately identifiable from other items in the consolidated package, and if a customer can benefit from it on its own or with other resources that are readily available to the customer. The Company’s System sale arrangements may include a combination of the following performance obligations: System(s), System components, instruments, accessories, and System service.

For arrangements that contain multiple performance obligations, revenue is allocated to each performance obligation based on its relative estimated standalone selling price. When available, standalone selling prices are based on observable prices at which the Company separately sells the products or services; however due to limited sales to date, standalone selling prices generally are not directly observable. The Company estimates the standalone selling price using the market assessment approach considering market conditions and entity-specific factors including, but not limited to, features and functionality of the products and services, geographies, type of customer, and market conditions. The Company regularly reviews estimated standalone selling prices and updates these estimates if necessary.

The Company recognizes revenues as the performance obligations are satisfied by transferring control of the product or service to a customer. The Company generally recognizes revenue for the performance obligations as follows:

●

System sales. For Systems and System components sold directly to end customers, revenue is recognized when the Company transfers control to the customer, which is generally at the point when acceptance occurs that indicates customer acknowledgment of delivery or installation, depending on the terms of the arrangement. For Systems sold through distributors, for which distributors are responsible for installation, revenue is recognized generally at the time of shipment. The Company’s System arrangements generally do not provide a right of return. The Systems are generally covered by a one-year warranty. Warranty costs were not material for the periods presented.

●

Instruments and accessories. Revenue from sales of instruments and accessories is recognized when control is transferred to the customers, which generally occurs at the time of shipment, but also occurs at the time of delivery depending on the customer arrangement.

●

Service. Service revenue is recognized ratably over the term of the service period as the customers benefit from the service throughout the service period. Revenue related to services performed on a time-and-materials basis is recognized when performed.

The following table presents revenue disaggregated by type and geography:

	Year Ended December 31,
	2020		2019
	(in thousands)
U.S.
Systems	$	282	$	90
Instruments and accessories		187		108
Services		380		338
Total U.S. revenue		849		536

Outside of U.S. ("OUS")
Systems		490		5,459
Instruments and accessories		653		1,447
Services		1,183		1,089
Total OUS revenue		2,326		7,995

Total
Systems		772		5,549
Instruments and accessories		840		1,555
Services		1,563		1,427
Total revenue	$	3,175	$	8,531

The Company recognizes sales by geographic area based on the country in which the customer is based. Operating lease revenue from Senhance System Leasing (see discussion below) is included as Systems in the above table and was approximately $0.7 million and $0 million for the years ended December 31, 2020 and 2019, respectively.

Transaction price allocated to remaining performance obligations relates to amounts allocated to products and services for which the revenue has not yet been recognized. A significant portion of this amount relates to service obligations performed under the Company's system sales contracts that will be invoiced and recognized as revenue in future periods. Transaction price allocated to remaining performance obligations was approximately $3.1 million and $3.7 million as of December 31, 2020 and 2019, respectively.

The Company invoices its customers based on the billing schedules in its sales arrangements. Contract assets for the periods presented primarily represent the difference between the revenue that was recognized based on the relative selling price of the related performance obligations and the contractual billing terms in the arrangements. Contract assets are included in accounts receivable and totaled $0.1 million and $0.2 million as of December 31, 2020 and 2019, respectively. Deferred revenue for the periods presented was primarily related to service obligations, for which the service fees are billed up-front, generally annually. The associated deferred revenue is generally recognized ratably over the service period. The Company did not have any significant impairment losses on its contract assets for the periods presented. Revenue recognized for the years ended December 31, 2020 and 2019, that was included in the deferred revenue balance at the beginning of each reporting period was $0.6 million and $1.0 million, respectively. Revenue for the year ended December 31, 2019 also included $1.3 million from a System sold in 2017 for which revenue was deferred until its first clinical use, which occurred in the second quarter of 2019. The aggregate amount of transaction price allocated to performance obligations that remain unsatisfied as of December 31, 2020 was $3.1 million, which is expected to be recognized as revenue over one to three years.

In connection with assets recognized from the costs to obtain a contract with a customer, the Company determined that the sales incentive programs for its sales team do not meet the requirements to be capitalized as the Company does not expect to generate future economic benefits from the related revenue from the initial sales transaction and such costs are expensed as incurred.

Revenue Recognition Leases, Operating [Policy Text Block]

Senhance System Leasing

The Company enters into lease arrangements with certain qualified customers. Revenue related to arrangements including lease elements are allocated to lease and non-lease elements based on their relative standalone selling prices. Lease elements generally include a Senhance System, while non-lease elements generally include training and proctoring services, instruments, and accessories. For some lease arrangements, the customers are provided with the right to purchase the leased System at some point during and/or at the end of the lease term. In some arrangements lease payments are based on the usage of the System.

In determining whether a transaction should be classified as a sales-type or operating lease, the Company considers the following terms at lease commencement: (1) whether title of the Senhance System transfers automatically or for a nominal fee by the end of the lease term, (2) whether the present value of the minimum lease payments equals or exceeds substantially all of the fair value of the leased System, (3) whether the lease term is for the major part of the remaining economic life of the leased System, (4) whether the lease grants the lessee an option to purchase the leased System that the lessee is reasonably certain to exercise, and (5) whether the underlying System is of such a specialized nature that it is expected to have no alternative use to the Company at the end of the lease term. All such arrangements through December 31, 2020 are classified as operating leases.

Revenue related to lease elements from operating lease arrangements is generally recognized on a straight-line basis over the lease term or based upon System usage and is presented as product revenue. Revenue related to lease elements from operating lease arrangements was approximately $0.7 million and $0 million for the years ended December 31, 2020 and 2019, respectively.

Cost of Goods and Service [Policy Text Block]

Cost of Revenue

Cost of revenue consists of contract manufacturing, materials, labor and manufacturing overhead incurred internally to produce the products. Shipping and handling costs incurred by the Company are included in cost of revenue. During the years ended December 31, 2020 and 2019, the Company recorded $0 and $1.5 million of expenses, respectively, for inventory obsolescence related to certain System components.

Research and Development Expense, Policy [Policy Text Block]

Research and Development Costs

Research and development expenses primarily consist of engineering, product development and regulatory expenses, incurred in the design, development, testing and enhancement of our products. Research and development costs are expensed as incurred.

Share-based Payment Arrangement [Policy Text Block]

Stock-Based Compensation

The Company follows ASC 718 “Stock Compensation”, which provides guidance in accounting for share-based awards exchanged for services rendered and requires companies to expense the estimated fair value of these awards over the requisite service period. The Company recognizes as expense, the grant-date fair value of stock options and other stock-based compensation issued to employees and non-employee directors over the requisite service periods, which are typically the vesting periods. The Company uses the Black-Scholes-Merton model to estimate the fair value of our stock-based payments. The volatility assumption used in the Black-Scholes-Merton model is based on the calculated historical volatility based on an analysis of reported data for a peer group of companies as well as the Company’s historical volatility. The expected term of options granted has been determined based upon the simplified method, because the Company does not have sufficient historical information regarding its options to derive the expected term. Under this approach, the expected term is the mid-point between the weighted average of vesting period and the contractual term. The risk-free interest rate is based on U.S. Treasury rates whose term is consistent with the expected life of the stock options. The Company has not paid and does not anticipate paying cash dividends on its shares of common stock; therefore, the expected dividend yield is assumed to be zero. The Company estimates forfeitures based on its historical experience and adjust the estimated forfeiture rate based upon actual experience.

The fair value of restricted stock units is determined by the market price of the Company’s common stock on the date of grant.

The Company records as expense the fair value of stock-based compensation awards, including stock options and restricted stock units. Compensation expense for stock-based compensation was approximately $7.9 million and $11.5 million for the years ended December 31, 2020 and 2019, respectively.

Income Tax, Policy [Policy Text Block]

Income Taxes

The Company accounts for income taxes using the asset and liability method, which requires the recognition of deferred tax assets or liabilities for the temporary differences between financial reporting and tax basis of the Company’s assets and liabilities, and for tax carryforwards at enacted statutory rates in effect for the years in which the asset or liability is expected to be realized. The effect on deferred taxes of a change in tax rates is recognized in income during the period that includes the enactment date. In addition, valuation allowances are established when necessary to reduce deferred tax assets and liabilities to the amounts expected to be realized. The Company has elected to account for global intangible low-taxed income (“GILTI”) as a period expense in the year the tax is incurred.

The Company recognizes the financial statement benefit of an income tax position only after determining that the relevant taxing authority would more likely than not sustain the position following audit. For tax positions meeting the more likely than not threshold, the amount recognized in the financial statements is the largest benefit that has a greater than 50% likelihood of being realized upon ultimate settlement with the relevant taxing authority. The Company recognizes interest accrued related to unrecognized tax benefits and penalties in the provision for income taxes.

Tax regulations within each jurisdiction are subject to the interpretation of the related tax laws and regulations and require application of significant judgment. The Company is subject to U.S. federal and various state, local and foreign jurisdictions. Due to the Company’s net operating loss carryforwards, the Company may be subject to examination by authorities for all previously filed income tax returns.

In a referendum held on May 19, 2019, Swiss voters adopted the Federal Act on Tax Reform and AVS Financing (TRAF). TRAF introduces major changes in the Swiss tax system by abolishing certain current preferential tax regimes and replacing them with new measures that are in line with international standards. The referendum did not have a material impact on the Company for the 2020 or 2019 tax provisions. The Company will continue to evaluate the impact of these provisions in future periods as the enactment process is completed.

On March 27, 2020, the CARES Act was signed into law in response to the COVID-19 pandemic. The CARES Act, as amended on June 5, 2020 through the enactment of the Paycheck Protection Program Flexibility Act, provides numerous tax provisions and stimulus measures, including temporary changes regarding the prior and future utilization of net operating losses, temporary changes to the prior and future limitations on interest deductions, and technical corrections from prior tax legislation for tax depreciation of certain qualified improvement property. The Company continues to evaluate the provisions of the CARES Act, as amended, relating to income taxes which may result in adjustments to certain deferred tax assets and liabilities.

Comprehensive Income, Policy [Policy Text Block]

Comprehensive Loss

Comprehensive loss is defined as the change in equity of a business enterprise during a period from transactions and other events and circumstances from non-owner sources.

Segment Reporting, Policy [Policy Text Block]

Segments

The Company operates in one business segment—the research, development and sale of medical device robotics to improve minimally invasive surgery. The Company’s chief operating decision maker (determined to be the Chief Executive Officer) does not manage any part of the Company separately, and the allocation of resources and assessment of performance are based on the Company’s consolidated operating results.

Approximately 27% and 19% of the Company’s total consolidated assets are located within the U.S. as of December 31, 2020 and 2019, respectively. The remaining assets are mostly located in Europe and are primarily related to the Company’s facility in Italy, and include intellectual property, in-process research and development, other current assets, property and equipment, cash, accounts receivable, other long-term assets and inventory of $56.8 million and $60.5 million as of December 31, 2020 and 2019, respectively. Total assets outside of the United States amounted to 73% and 81% of total consolidated assets at December 31, 2020 and 2019, respectively. Long-lived assets in the U.S. were 11% and 8%, Italy were 48% and 63%, and Switzerland were 41% and 27%, as of December 31, 2020 and 2019, respectively. The Company recognizes sales by geographic area based on the country in which the customer is based. For the years ended December 31, 2020 and 2019, 27% and 6%, respectively, of net revenue were generated in the United States; while 53% and 39%, respectively, were generated in Europe; and 20% and 55% were generated in Asia.

New Accounting Pronouncements, Policy [Policy Text Block]

Impact of Recently Issued Accounting Standards

In August 2018, the FASB issued Accounting Standards Update (“ASU”) 2018-13, Fair Value Measurement (Topic 820): Disclosure Framework—Changes to the Disclosure Requirements for Fair Value Measurement. This ASU eliminates, adds and modifies certain disclosure requirements for fair value measurements as part of its disclosure framework project. The Company adopted this ASU effective January 1, 2020 and the adoption did not have a material impact on the consolidated financial statements.

In December 2019, the FASB issued ASU 2019-12, Simplifying the Accounting for Income Taxes, which is intended to simplify various aspects related to accounting for income taxes. ASU 2019-12 removes certain exceptions to the general principles in ASC 740, Income Tax and also clarifies and amends existing guidance to improve consistent application. ASU 2019-12 will be effective for public business entities for annual reporting periods beginning after December 15, 2020, and interim periods within those periods, with early adoption permitted. The guidance is not expected to have a material impact on the Company's financial statements and related disclosures.

In June 2016, the FASB issued ASU 2016-13, Financial Instruments-Credit Losses (Topic 326): Measurement of Credit Losses on Financial Instruments, which is designed to provide financial statement users with more information about the expected credit losses on financial instruments and other commitments to extend credit held by a reporting entity at each reporting date. When determining such expected credit losses, the guidance requires companies to apply a methodology that reflects expected credit losses and requires consideration of a broader range of reasonable and supportable information to inform credit loss estimates. This guidance is effective on a modified retrospective basis for fiscal years beginning after December 15, 2022, including interim periods within those fiscal years. The guidance is not expected to have a material impact on the Company's financial statements and related disclosures.

In August 2020, the FASB issued ASU 2020-06 Debt – Debt with Conversion and Other Options (Subtopic 470-20) and Derivatives and Hedging – Contracts in Entity’s Own Equity (subtopic 815-40) guidance on the accounting for convertible debt instruments and contracts in an entity’s own equity. The guidance simplifies the accounting for convertible instruments by reducing the various accounting models that can require the instrument to be separated into a debt component and equity component or derivative component. Additionally, the guidance eliminated certain settlement conditions previously required to be able to classify a derivative in equity. The new guidance is effective on a modified or full retrospective basis for fiscal years beginning after December 15, 2023, including interim periods with those fiscal years. The Company is currently evaluating the impact on the consolidated financial statements upon adoption.

The Company has evaluated all other issued and unadopted ASUs and believes the adoption of these standards will not have a material impact on its consolidated statements of operations and comprehensive loss, balance sheets, or statements of cash flows.

Note 2 - Summary of Significant Accounting Policies (Tables)

12 Months Ended

Dec. 31, 2020

Schedule of Property Plant and Equipment Useful Life [Table Text Block]

	Years
Operating lease assets – Senhance System leasing			5
Machinery, manufacturing, and demonstration equipment		3	-	5
Computer equipment			3
Furniture			5
Leasehold improvements	Lesser of lease term or 3 to 10

Disaggregation of Revenue [Table Text Block]

	Year Ended December 31,
	2020		2019
	(in thousands)
U.S.
Systems	$	282	$	90
Instruments and accessories		187		108
Services		380		338
Total U.S. revenue		849		536

Outside of U.S. ("OUS")
Systems		490		5,459
Instruments and accessories		653		1,447
Services		1,183		1,089
Total OUS revenue		2,326		7,995

Total
Systems		772		5,549
Instruments and accessories		840		1,555
Services		1,563		1,427
Total revenue	$	3,175	$	8,531

Note 4 - Cash, Cash Equivalents, and Restricted Cash (Tables)

12 Months Ended

Dec. 31, 2020

Schedule of Cash, Cash Equivalents, and Restricted Cash [Table Text Block]

	December 31, 2020		December 31, 2019
	(In thousands)
Cash	$	6,679	$	9,596
Money market		9,684		2
Total cash and cash equivalents	$	16,363	$	9,598
Restricted cash		1,166		969
Total	$	17,529	$	10,567

Note 5 - Fair Value (Tables)

12 Months Ended

Dec. 31, 2020

Fair Value, Assets Measured on Recurring Basis [Table Text Block]

	December 31, 2020
	(In thousands)
Description	Quoted Prices in Active Markets for Identical Assets (Level 1)		Significant Other Observable Inputs (Level 2)		Significant Unobservable Inputs (Level 3)		Total
Assets measured at fair value
Cash and cash equivalents	$	16,363	$	—	$	—	$	16,363
Restricted cash		1,166		—		—		1,166
Total Assets measured at fair value	$	17,529	$	—	$	—	$	17,529
Liabilities measured at fair value
Contingent consideration	$	—	$	—	$	3,936	$	3,936
Warrant liabilities		—		—		255		255
Total liabilities measured at fair value	$	—	$	—	$	4,191	$	4,191

	December 31, 2019
	(In thousands)
Description	Quoted Prices in Active Markets for Identical Assets (Level 1)		Significant Other Observable Inputs (Level 2)		Significant Unobservable Inputs (Level 3)		Total
Assets measured at fair value
Cash and cash equivalents	$	9,598	$	—	$	—	$	9,598
Restricted cash		969		—		—		969
Total Assets measured at fair value	$	10,567	$	—	$	—	$	10,567
Liabilities measured at fair value
Contingent consideration	$	—	$	—	$	1,084	$	1,084
Warrant liabilities		—		—		2,388		2,388
Total liabilities measured at fair value	$	—	$	—	$	3,472	$	3,472

Fair Value Measurement Inputs and Valuation Techniques [Table Text Block]

Series B	December 31, 2020			December 31, 2019
Fair value (million)	$	0.3		$	2.4
Valuation methodology	Black-Scholes-Merton			Monte Carlo
Term (years)		1.32			2.32
Risk free rate		0.10	%		1.59	%
Dividends		—			—
Volatility		150.97	%		109.80	%
Share price	$	0.63		$	1.47
Probability of additional financing		N/A		100% in 2020

Valuation
Methodology

Significant
Unobservable Input

Weighted Average
(range, if
applicable)

December 31, 2020

December 31, 2019

Contingent consideration

Probability weighted
income approach

Milestone dates

2024

2029

2020

2024

Discount rate

9.5%

15.75%

10%

11%

Fair Value, Liabilities Measured on Recurring Basis, Unobservable Input Reconciliation [Table Text Block]

	Fair Value Measurement at Reporting Date (Level 3)
	(In thousands)
	Common stock warrants			Contingent consideration
Balance at December 31, 2018	$	4,636		$	10,637
Change in fair value		(2,248	)		(9,553	)
Balance at December 31, 2019		2,388			1,084
Exchange of warrants for common stock		(2,469	)		—
Payment for contingent consideration		—			(74	)
Change in fair value		336			2,924
Balance at December 31, 2020		255			3,936
Current portion		—			—
Long-term portion		255			3,936
Balance at December 31, 2020	$	255		$	3,936

Note 6 - Accounts Receivable, Net (Tables)

12 Months Ended

Dec. 31, 2020

Schedule of Accounts, Notes, Loans and Financing Receivable [Table Text Block]

	December 31, 2020			December 31, 2019
	(In thousands)
Gross accounts receivable	$	2,917		$	2,274
Allowance for uncollectible accounts		(1,802	)		(1,654	)
Total accounts receivable, net	$	1,115		$	620

Note 7 - Inventories (Tables)

12 Months Ended

Dec. 31, 2020

Schedule of Inventory, Current [Table Text Block]

	December 31, 2020		December 31, 2019
	(In thousands)
Finished goods	$	10,749	$	9,737
Raw materials		8,098		8,510
Total inventories	$	18,847	$	18,247

Current Portion	$	10,034	$	10,653
Long-term portion		8,813		7,594
Total inventories	$	18,847	$	18,247

Note 8 - Other Current Assets (Tables)

12 Months Ended

Dec. 31, 2020

Schedule of Other Current Assets [Table Text Block]

	December 31, 2020		December 31, 2019
	(In thousands)
Advances to vendors	$	1,925	$	2,534
Prepaid expenses		1,706		1,834
VAT receivable		2,870		2,716
Total	$	6,501	$	7,084

Note 9 - Property and Equipment (Tables)

12 Months Ended

Dec. 31, 2020

Property, Plant and Equipment [Table Text Block]

	December 31, 2020			December 31, 2019
	(In thousands)
Machinery, manufacturing and demonstration equipment	$	10,153		$	9,711
Operating lease assets - Senhance System leasing		9,203			710
Computer equipment		2,297			2,321
Furniture		640			637
Leasehold improvements		2,309			2,295
Total property and equipment		24,602			15,674
Accumulated depreciation and amortization		(14,260	)		(10,968	)
Property and equipment, net	$	10,342		$	4,706

Note 10 - Goodwill, In-process Research and Development and Intellectual Property (Tables)

12 Months Ended

Dec. 31, 2020

Schedule of Goodwill [Table Text Block]

	Goodwill
	(In thousands)
Balance at December 31, 2018	$	80,131
Foreign currency translation impact		(1,162	)
Impairment		(78,969	)
Balance at December 31, 2019	$	—

Schedule of Finite-Lived Intangible Assets [Table Text Block]

	In-Process Research and Development
	(In thousands)
Balance at December 31, 2018	$	10,747
Impairment		(7,912	)
Foreign currency translation impact		(365	)
Balance at December 31, 2019		2,470
Impairment		—
Foreign currency translation impact		(45	)
Transfer of in-process research and development to intellectual property		(2,425	)
Balance at December 31, 2020	$	—

	December 31, 2020									December 31, 2019
	(In thousands)									(In thousands)
	Gross Carrying Amount		Accumulated Amortization			Foreign currency translation impact		Net Carrying Amount		Gross Carrying Amount		Accumulated Amortization			Foreign currency translation impact			Net Carrying Amount
Developed technology	$	68,838	$	(51,734	)	$	4,872	$	21,976	$	66,413	$	(36,918	)	$	(1,208	)	$	28,287
Technology and patents purchased		400		(168	)		59		291		400		(112	)		21			309
Total intellectual property	$	69,238	$	(51,902	)	$	4,931	$	22,267	$	66,813	$	(37,030	)	$	(1,187	)	$	28,596

Schedule of Finite-Lived Intangible Assets, Future Amortization Expense [Table Text Block]

	Year ending December 31, 2020
	(In thousands)
2021	$	11,634
2022		8,833
2023		430
2024		430
2025		430
Thereafter		510
Total	$	22,267

Note 11 - Income Taxes (Tables)

12 Months Ended

Dec. 31, 2020

Schedule of Components of Income Tax Expense (Benefit) [Table Text Block]

	2020			2019
Current income taxes
Federal	$	—		$	—
State		—			—
Foreign		169			100
Deferred income taxes
Federal		—			—
State		—			—
Foreign		(1,685	)		(3,224	)
Total income tax expense (benefit)	$	(1,516	)	$	(3,124	)

Schedule of Income before Income Tax, Domestic and Foreign [Table Text Block]

	2020			2019
United States	$	(34,398	)	$	(91,935	)
Foreign		(26,430	)		(65,390	)
Total loss from operations before taxes	$	(60,828	)	$	(157,325	)

Schedule of Deferred Tax Assets and Liabilities [Table Text Block]

	2020			2019
Deferred tax assets:
Stock-based compensation	$	4,253		$	3,665
Accrued expenses and other		906			1,007
Research credit carryforward		7,209			6,776
Fixed assets		385			345
Capitalized start-up costs and other intangibles		2,686			3,618
Net operating loss carryforwards		122,193			113,410
		137,632			128,821
Valuation allowance		(132,928	)		(123,108	)
Net deferred tax asset		4,704			5,713
Deferred tax liabilities
Fixed assets and other		(1,590	)		(1,445	)
Purchase accounting intangibles		(2,807	)		(5,660	)
Net deferred tax liability		(4,397	)		(7,105	)
Net deferred tax asset (liability)	$	307		$	(1,392	)

Schedule of Unrecognized Tax Benefits Roll Forward [Table Text Block]

	2020		2019
Beginning balance	$	1,512	$	1,363
Gross increases for tax positions related to current periods		108		149
Gross increases for tax positions related to prior periods		—		—
Ending balance	$	1,620	$	1,512

Schedule of Effective Income Tax Rate Reconciliation [Table Text Block]

	2020						2019
				Percent of Pretax						Percent of Pretax
	Amount			Earnings			Amount			Earnings
United States federal tax at statutory rate	$	(12,774	)		21.0	%	$	(33,038	)		21.0	%
State taxes (net of deferred benefit)		(1,768	)		2.9	%		(4,778	)		3.0	%
Nondeductible expenses		719			(1.2	%)		709			(0.5	%)
Change in fair market value of contingent consideration		717			(1.2	%)		(2,342	)		1.5	%
Warrant remeasurement and financing costs		82			(0.1	%)		(551	)		0.4	%
Research & Development credits		(542	)		0.9	%		(743	)		0.5	%
Change in unrecognized tax benefits		108			(0.2	%)		149			(0.1	%)
Foreign tax rate differential		1,589			(2.6	%)		2,590			(1.6	%)
Goodwill and investment impairments		—			(0	%)		(6,638	)		4.2	%
Change in enacted tax rates and other, net		533			(0.9	%)		(253	)		0.2	%
Change in valuation allowance		9,820			(16.1	%)		41,771			(26.6	%)
Income tax benefit	$	(1,516	)		2.5	%	$	(3,124	)		2.0	%

Note 12 - Accrued Expenses (Tables)

12 Months Ended

Dec. 31, 2020

Schedule of Accrued Liabilities [Table Text Block]

	December 31, 2020		December 31, 2019
	(In thousands)
Compensation and benefits	$	4,541	$	5,061
Restructuring costs		—		882
Consulting and other vendors		66		308
Other		177		242
Lease Liability		686		1,112
Royalties		147		148
Legal and professional fees		314		474
Taxes and other assessments		351		326
Interest		19		—
Total	$	6,301	$	8,553

Note 14 - Stock-based Compensation (Tables)

12 Months Ended

Dec. 31, 2020

Schedule of Share-based Payment Award, Stock Options, Valuation Assumptions [Table Text Block]

	Year ended December 31,
	2020			2019
Expected dividend yield		0%			0%
Expected volatility	82%	-	126%	81%	-	92%
Risk-free interest rate	0.2%	-	1.69%	1.39%	-	2.66%
Expected life (in years)	3.8	-	6.1	5.5	-	6.1

Share-based Payment Arrangement, Option, Activity [Table Text Block]

	Number of Shares			Weighted- Average Exercise Price		Weighted- Average Remaining Contractual Term (Years)
Options outstanding at December 31, 2019		1,830,958		$	30.71		7.36
Granted		3,005,964			0.54
Forfeited		(293,102	)		19.08
Cancelled		(181,948	)		35.57
Exercised		-			-
Options Outstanding December 31, 2020		4,361,872		$	10.49		6.05

Share-based Compensation Arrangement by Share-based Payment Award, Options, Vested and Expected to Vest, Exercisable [Table Text Block]

	Number of Shares		Weighted Average Exercise Price		Weighted Average Remaining Contractual Term (Years)
Exercisable at December 31, 2020		1,282,678	$	27.71		4.81
Vested or expected to vest at December 31, 2020		4,141,694	$	10.89		6.05

Note 15 - Restricted Stock Units (Tables)

12 Months Ended

Dec. 31, 2020

Share-based Payment Arrangement, Restricted Stock Unit, Activity [Table Text Block]

	Number of Restricted Stock Units Outstanding			Weighted Average Grant Date Fair Value
Unvested December 31, 2018		382,098		$	20.24
Granted		192,987			31.42
Vested		(85,153	)		25.98
Forfeited		(46,005	)		21.38
Unvested December 31, 2019		443,927		$	23.88
Granted		3,112,382			0.67
Vested		(354,808	)		19.38
Forfeited		(242,402	)		6.54
Unvested December 31, 2020		2,959,099		$	1.41

Note 16 - Warrants (Tables)

12 Months Ended

Dec. 31, 2020

Schedule of Stockholders' Equity Note, Warrants or Rights [Table Text Block]

	Number of Warrant Shares			Weighted Average Exercise Price		Weighted Average Remaining Contractual Life (in years)		Weighted Average Fair Value
Outstanding at December 31, 2018		333,034		$	13.39		3.7	$	3.38
Exercised		(15,385	)		13.00		0		—
Reserved for future issuance		1,753,523			1.39		2.2		1.22
Outstanding at December 31, 2019		2,071,172		$	2.05		2.4	$	1.34
Granted		50,735,292			0.68		2.4		0.19
Exercised		(4,911,764	)		0.68		0		—
Exchanged		(2,040,757	)		1.24		0		—
Reserved for future issuance		644,966			0.35		1.3		0.45
Outstanding at December 31, 2020		46,498,909		$	0.71		2.4	$	0.20

Note 17 - Equity Offerings (Tables)

12 Months Ended

Dec. 31, 2020

Schedule of Sales Under Sales Agency Agreement [Table Text Block]

	2019 ATM Offering		2019 ATM Offering		2020 ATM Offering
	For the year ended		For the year ended		For the year ended
	December 31, 2019		December 31, 2020		December 31, 2020
Total shares of common stock sold		1,374,686		6,687,846		16,320,793
Average price per share	$	5.23	$	1.73	$	0.58
Gross proceeds	$	7,193	$	11,558	$	9,264
Commissions earned by Cantor	$	212	$	347	$	278
Net Proceeds	$	6,981	$	11,211	$	8,986

Note 18 - Restructuring (Tables)

12 Months Ended

Dec. 31, 2020

Restructuring and Related Costs [Table Text Block]

	Restructuring Liability
	(In thousands)
Balance at December 31, 2019	$	882
Amount charged to operating expenses		851
Cash payments		(1,733	)
Balance at December 31, 2020	$	—

Note 19 - Basic and Diluted Net Loss Per Share (Tables)

12 Months Ended

Dec. 31, 2020

Schedule of Antidilutive Securities Excluded from Computation of Earnings Per Share [Table Text Block]

	December 31
	2020		2019
Stock options		4,361,872		1,830,958
Stock warrants		46,498,909		2,071,172
Nonvested restricted stock units		2,959,099		443,927
Total		53,819,880		4,346,057

Note 21 - Commitments and Contingencies (Tables)

12 Months Ended

Dec. 31, 2020

Lessee, Operating Lease, Liability, Maturity [Table Text Block]

Fiscal Year
2021	$	883
2022		404
2023		120
2024		5
2025		—
Thereafter		—
Total minimum lease payments	$	1,412
Less: Amount of lease payments representing interest		(151	)
Present value of future minimum lease payments	$	1,261

Fiscal Year
2020	$	1,372
2021		716
2022		454
2023		207
2024		28
Thereafter		—
Total minimum lease payments	$	2,778
Less: Amount of lease payments representing interest		(266	)
Present value of future minimum lease payments	$	2,512

Note 22 - Subsequent Events (Tables)

12 Months Ended

Dec. 31, 2020

Schedule of Sales Under Sales Agency Agreement [Table Text Block]

	2019 ATM Offering		2019 ATM Offering		2020 ATM Offering
	For the year ended		For the year ended		For the year ended
	December 31, 2019		December 31, 2020		December 31, 2020
Total shares of common stock sold		1,374,686		6,687,846		16,320,793
Average price per share	$	5.23	$	1.73	$	0.58
Gross proceeds	$	7,193	$	11,558	$	9,264
Commissions earned by Cantor	$	212	$	347	$	278
Net Proceeds	$	6,981	$	11,211	$	8,986

The 2020 ATM Offering [Member]

Schedule of Sales Under Sales Agency Agreement [Table Text Block]

Total shares of common stock sold		19,120
Average price per share	$	1.47
Gross proceeds	$	28,100
Commissions earned by Cantor	$	843
Net Proceeds	$	27,257

Note 1 - Organization and Capitalization (Details Textual) - USD ($) $ / shares in Units, $ in Millions	1 Months Ended	36 Months Ended
	Dec. 31, 2017	Dec. 31, 2020	Dec. 31, 2019	Dec. 06, 2013	Dec. 05, 2013
Common Stock, Shares Authorized (in shares)		750,000,000	750,000,000	750,000,000	225,000,000
Preferred Stock, Shares Authorized (in shares)		25,000,000	25,000,000	25,000,000
Preferred Stock, Par or Stated Value Per Share (in dollars per share)		$ 0.01	$ 0.01	$ 0.01
China National Scientific and Instruments and Materials Company [Member]
Proceeds from Distribution Agreement		$ 15
Distribution Agreement, Minimum Royalties Receivable Upon Regulatory Approval		$ 14
China National Scientific and Instruments and Materials Company [Member] \| Minimum [Member]
Expected Proceeds from Distribution Agreement	$ 29

Note 2 - Summary of Significant Accounting Policies 1 (Details Textual) $ in Thousands				1 Months Ended	2 Months Ended	3 Months Ended		12 Months Ended
	Jan. 29, 2021 USD ($)	Jan. 12, 2021 USD ($)	Dec. 11, 2019 shares	Jan. 31, 2021 USD ($)	Mar. 11, 2021 USD ($)	Dec. 31, 2019 USD ($) shares	Sep. 30, 2019 USD ($)	Dec. 31, 2020 USD ($) shares	Dec. 31, 2019 USD ($) shares	Dec. 10, 2019 shares	Dec. 31, 2018 USD ($)	Sep. 23, 2018 USD ($)	Sep. 21, 2015 USD ($)	Sep. 03, 2013 USD ($)
Common Stock, Shares, Outstanding, Ending Balance (in shares) \| shares			20,200,000			20,691,301		116,231,072	20,691,301	261,900,000
Retained Earnings (Accumulated Deficit), Ending Balance						$ (663,600)		$ (722,912)	$ (663,600)
Working Capital								23,700
Cash and Cash Equivalents, at Carrying Value, Ending Balance						9,598		16,363	9,598
Proceeds from Warrant Exercises								3,340	538
Restricted Cash and Cash Equivalents, Noncurrent, Total						969		1,166	969
Accounts Receivable, Credit Loss Expense (Reversal)								0	1,634
Accounts Receivable, Allowance for Credit Loss, Ending Balance						1,654		1,802	1,654
Impairment of Intangible Assets, Finite-lived								0	7,912
Finite-Lived Intangible Assets, Net, Ending Balance						28,596		22,267	28,596
Goodwill, Ending Balance						0			0		$ 80,131
Goodwill, Impairment Loss						79,000	$ 79,000	$ 0	78,969
Period Of Service Sale Arrangement (Year)								5 years
Period of Service Sale Arrangement at Stated Service Price (Year)								4 years
Operating Lease, Lease Income, Total								$ 700	0
Revenue, Remaining Performance Obligation, Amount						3,700		3,100	3,700
Contract with Customer, Asset, after Allowance for Credit Loss, Current, Total						200		100	200
Contract with Customer, Liability, Revenue Recognized								600	1,000
Inventory Write-down								0	8,931
Share-based Payment Arrangement, Expense								$ 7,900	11,500
Number of Operating Segments								1
Assets, Total						74,779		$ 78,258	74,779
Non-US [Member]
Assets, Total						60,500		56,800	60,500
System Sold in 2017 [Member]
Contract with Customer, Liability, Revenue Recognized									1,300
Systems [Member]
Inventory Write-down								$ 0	1,500
Safe Stitch Medical Inc [Member]
Goodwill, Ending Balance														$ 93,800
Senhance Surgical Robotic System Acquisition [Member]
Goodwill, Ending Balance													$ 38,300
Medical Surgery Technologies Limited [Member]
Goodwill, Ending Balance												$ 9,600
Patents [Member]
Finite-Lived Intangible Asset, Useful Life (Year)								10 years
Developed Technology Rights [Member]
Finite-Lived Intangible Assets, Net, Ending Balance						28,287		$ 21,976	28,287
Developed Technology Rights [Member] \| Minimum [Member]
Finite-Lived Intangible Asset, Useful Life (Year)								5 years
Developed Technology Rights [Member] \| Maximum [Member]
Finite-Lived Intangible Asset, Useful Life (Year)								7 years
Intellectual Property [Member]
Impairment of Intangible Assets, Finite-lived								$ 0	0
Finite-Lived Intangible Assets, Net, Ending Balance						28,596		22,267	28,596
In Process Research and Development [Member]
Impairment of Intangible Assets, Finite-lived						0	$ 7,900	0	(7,912)
Finite-Lived Intangible Assets, Net, Ending Balance						$ 2,470		$ 0	$ 2,470		$ 10,747
Accounts Receivable [Member] \| Customer Concentration Risk [Member] \| Seven Customers [Member]
Number of Major Customers								7
Concentration Risk, Percentage								68.00%
Accounts Receivable [Member] \| Customer Concentration Risk [Member] \| Eight Customers [Member]
Number of Major Customers									8
Concentration Risk, Percentage									85.00%
Revenue Benchmark [Member] \| Customer Concentration Risk [Member] \| Nine Customers [Member]
Number of Major Customers								9
Concentration Risk, Percentage								55.00%
Revenue Benchmark [Member] \| Customer Concentration Risk [Member] \| Six Customers [Member]
Number of Major Customers									6
Concentration Risk, Percentage									82.00%
Revenue Benchmark [Member] \| Geographic Concentration Risk [Member] \| UNITED STATES
Concentration Risk, Percentage								27.00%	6.00%
Revenue Benchmark [Member] \| Geographic Concentration Risk [Member] \| Europe [Member]
Concentration Risk, Percentage								53.00%	39.00%
Revenue Benchmark [Member] \| Geographic Concentration Risk [Member] \| Asia [Member]
Concentration Risk, Percentage								20.00%	55.00%
Assets, Total [Member] \| Geographic Concentration Risk [Member] \| UNITED STATES
Concentration Risk, Percentage								27.00%	19.00%
Assets, Total [Member] \| Geographic Concentration Risk [Member] \| Non-US [Member]
Concentration Risk, Percentage								73.00%	81.00%
Long-lived Assets [Member] \| Geographic Concentration Risk [Member] \| UNITED STATES
Concentration Risk, Percentage								11.00%	8.00%
Long-lived Assets [Member] \| Geographic Concentration Risk [Member] \| ITALY
Concentration Risk, Percentage								48.00%	63.00%
Long-lived Assets [Member] \| Geographic Concentration Risk [Member] \| SWITZERLAND
Concentration Risk, Percentage								41.00%	27.00%
Subsequent Event [Member]
Proceeds from Warrant Exercises					$ 30,400
Subsequent Event [Member] \| Public Offering [Member]
Proceeds from Issuance of Common Stock	$ 73,500			$ 73,500
Subsequent Event [Member] \| Registered Direct Offering [Member]
Proceeds from Issuance of Common Stock		$ 28,800		28,800
Subsequent Event [Member] \| ATM Offering [Member]
Proceeds from Issuance of Common Stock				$ 28,100
Reverse Stock Split [Member]
Stockholders' Equity Note, Stock Split, Conversion Ratio			13

Note 2 - Summary of Significant Accounting Policies 2 (Details Textual) - Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Start Date [Axis]: 2021-01-01	Dec. 31, 2020
Minimum [Member]
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Period (Year)	1 year
Maximum [Member]
Revenue, Remaining Performance Obligation, Expected Timing of Satisfaction, Period (Year)	3 years

Note 2 - Summary of Significant Accounting Policies - Estimated Useful Lives of Assets (Details)	12 Months Ended
	Dec. 31, 2020
Operating Lease Assets [Member]
Property and equipment, estimated useful lives (Year)	5 years
Machinery, Manufacturing and Demonstration Equipment [Member] \| Minimum [Member]
Property and equipment, estimated useful lives (Year)	3 years
Machinery, Manufacturing and Demonstration Equipment [Member] \| Maximum [Member]
Property and equipment, estimated useful lives (Year)	5 years
Computer Equipment [Member]
Property and equipment, estimated useful lives (Year)	3 years
Furniture and Fixtures [Member]
Property and equipment, estimated useful lives (Year)	5 years
Leasehold Improvements [Member]
Leasehold improvements	Lesser of lease term or 3 to 10

Note 2 - Summary of Significant Accounting Policies - Revenue Disaggregated by Type and Geography (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Revenue	$ 3,175	$ 8,531
Systems [Member]
Revenue	772	5,549
Instruments and Accessories [Member]
Revenue	840	1,555
Service [Member]
Revenue	1,563	1,427
UNITED STATES
Revenue	849	536
UNITED STATES \| Systems [Member]
Revenue	282	90
UNITED STATES \| Instruments and Accessories [Member]
Revenue	187	108
UNITED STATES \| Service [Member]
Revenue	380	338
Non-US [Member]
Revenue	2,326	7,995
Non-US [Member] \| Systems [Member]
Revenue	490	5,459
Non-US [Member] \| Instruments and Accessories [Member]
Revenue	653	1,447
Non-US [Member] \| Service [Member]
Revenue	$ 1,183	$ 1,089

Amount, excluding tax collected from customer, of revenue from satisfaction of performance obligation by transferring promised good or service to customer. Tax collected from customer is tax assessed by governmental authority that is both imposed on and concurrent with specific revenue-producing transaction, including, but not limited to, sales, use, value added and excise.

+ References

Reference 1: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
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Reference 2: http://www.xbrl.org/2003/role/disclosureRef
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-Name Accounting Standards Codification
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Reference 3: http://www.xbrl.org/2003/role/disclosureRef
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-Name Accounting Standards Codification
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Reference 4: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
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Reference 5: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
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Reference 6: http://www.xbrl.org/2003/role/disclosureRef
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-Name Accounting Standards Codification
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Reference 7: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
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Reference 8: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
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Reference 9: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
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-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e9054-108599

Reference 10: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
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-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130545-203045

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-Publisher FASB
-Name Accounting Standards Codification
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-URI http://asc.fasb.org/extlink&oid=6472922&loc=d3e499488-122856

+ Details

Note 3 - Acquisitions (Details Textual) $ in Thousands, € in Millions								12 Months Ended
	Oct. 15, 2019 USD ($)	Aug. 07, 2019 USD ($) shares	Oct. 31, 2018 USD ($) shares	Dec. 30, 2016 USD ($) shares	Dec. 30, 2016 EUR (€) shares	Sep. 21, 2015 USD ($) shares	Sep. 21, 2015 EUR (€) shares	Dec. 31, 2020 EUR (€)	Dec. 31, 2019 USD ($)	Dec. 31, 2020 USD ($)	Dec. 31, 2020 EUR (€)	Dec. 31, 2019 EUR (€)
Business Combination, Contingent Consideration, Liability, Total									$ 1,084	$ 3,936
Auto Lap [Member]
Disposal Group, Including Discontinued Operation, Consideration	$ 17,000
Proceeds from Sale of Productive Assets, Total	16,000
Disposal Group Including Discontinued Operation Consideration Receivable	$ 1,000
Gain (Loss) on Disposition of Assets, Total									16,000
Medical Surgery Technologies Limited [Member]
Payments to Acquire Businesses, Gross			$ 5,800
Business Acquisition, Equity Interest Issued or Issuable, Number of Shares (in shares) \| shares		370,423	242,310
Business Combination, Consideration Transferred, Equity Interests Issued and Issuable		$ 6,600
Senhance Surgical Robotic System Acquisition [Member]
Payments to Acquire Businesses, Gross				$ 25,000	€ 22.5	$ 25,000
Business Acquisition, Equity Interest Issued or Issuable, Number of Shares (in shares) \| shares				286,360	286,360	1,195,647	1,195,647
Business Combination, Consideration Transferred, Equity Interests Issued and Issuable \| €					€ 5.0
Business Combination, Consideration Transferred, Liabilities Incurred \| €							€ 27.5
Business Combination, Contingent Consideration, Liability, Total									$ 1,100	$ 3,900
Senhance Surgical Robotic System Acquisition [Member] \| Second Tranche [Member]
Business Combination, Contingent Consideration, Liability, Total \| €												€ 15.1
Senhance Surgical Robotic System Acquisition [Member] \| Third Tranche [Member]
Business Combination, Contingent Consideration, Liability, Total \| €											€ 15.0
Senhance Surgical Robotic System Acquisition [Member] \| Third Tranche [Member] \| Minimum [Member]
Business Combination Contingent Consideration Arrangements Target Revenue \| €								€ 25.0
Senhance Surgical Robotic System Acquisition [Member] \| Fourth Tranche [Member]
Business Combination, Contingent Consideration, Liability, Total \| €							€ 2.5

Note 4 - Cash, Cash Equivalents, and Restricted Cash (Details Textual) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Restricted Cash and Cash Equivalents, Noncurrent, Total	$ 1,166	$ 969

Note 4 - Cash, Cash Equivalents, and Restricted Cash - Cash, Cash Equivalents, and Restricted Cash (Details) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Cash	$ 6,679	$ 9,596
Money market	9,684	2
Total cash and cash equivalents	16,363	9,598
Restricted Cash and Cash Equivalents, Noncurrent, Total	1,166	969
Total	$ 17,529	$ 10,567

Note 5 - Fair Value (Details Textual) $ / shares in Units, $ in Thousands			12 Months Ended
	Dec. 11, 2019	Apr. 28, 2017 $ / shares shares	Dec. 31, 2020 USD ($) $ / shares shares	Dec. 31, 2019 USD ($)	Sep. 30, 2020 $ / shares
Business Combination, Contingent Consideration Arrangements, Change in Amount of Contingent Consideration, Liability \| $			$ 2,924	$ (9,553)
Number of Units Sold (in shares)		24,900,000
Number of Shares in Each Unit (in shares)		0.077
Shares Issued, Price Per Share (in dollars per share) \| $ / shares		$ 1.00
Fair Value Adjustment of Warrants \| $			$ 336	$ (2,248)
Reverse Stock Split [Member]
Stockholders' Equity Note, Stock Split, Conversion Ratio	13
Series A Warrant [Member]
Class of Warrant or Right, Number of Securities Called by Each Warrant or Right (in shares)		0.077
Class of Warrant or Right, Exercise Price of Warrants or Rights (in dollars per share) \| $ / shares		$ 13.00
Series B Warrant [Member]
Class of Warrant or Right, Number of Securities Called by Each Warrant or Right (in shares)		0.058
Class of Warrant or Right, Exercise Price of Warrants or Rights (in dollars per share) \| $ / shares		$ 13.00	$ 0.35		$ 0.35
Share-based Compensation Arrangement by Share-based Payment Award, Non-Option Equity Instruments, Outstanding, Number, Ending Balance (in shares)			567,660

Note 5 - Fair Value - Summary of Assets and Liabilities Measured at Fair Value on Recurring Basis (Details) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Cash and cash equivalents	$ 16,363	$ 9,598
Restricted cash	1,166	969
Total Assets measured at fair value	17,529	10,567
Contingent consideration	3,936	1,084
Warrant liabilities	255	2,388
Total liabilities measured at fair value	4,191	3,472
Fair Value, Inputs, Level 1 [Member]
Cash and cash equivalents	16,363	9,598
Restricted cash	1,166	969
Total Assets measured at fair value	17,529	10,567
Contingent consideration	0	0
Warrant liabilities	0	0
Total liabilities measured at fair value	0	0
Fair Value, Inputs, Level 2 [Member]
Cash and cash equivalents	0	0
Restricted cash	0	0
Total Assets measured at fair value	0	0
Contingent consideration	0	0
Warrant liabilities	0	0
Total liabilities measured at fair value	0	0
Fair Value, Inputs, Level 3 [Member]
Cash and cash equivalents	0	0
Restricted cash	0	0
Total Assets measured at fair value	0	0
Contingent consideration	3,936	1,084
Warrant liabilities	255	2,388
Total liabilities measured at fair value	$ 4,191	$ 3,472

Note 5 - Fair Value - Quantitative Information about Inputs and Valuation Methodologies Used for Fair Value Measurements Classification (Details) $ / shares in Units, $ in Millions	12 Months Ended
	Dec. 31, 2019 USD ($) yr $ / shares	Dec. 31, 2020 USD ($) yr $ / shares
Senhance Surgical Robotic System Acquisition [Member] \| Fair Value, Inputs, Level 3 [Member] \| Minimum [Member] \| Milestone Date, Year [Member]
Contingent consideration, measurement input	2,020	2,024
Senhance Surgical Robotic System Acquisition [Member] \| Fair Value, Inputs, Level 3 [Member] \| Minimum [Member] \| Measurement Input, Discount Rate [Member]
Contingent consideration, measurement input	0.10	0.095
Senhance Surgical Robotic System Acquisition [Member] \| Fair Value, Inputs, Level 3 [Member] \| Maximum [Member] \| Milestone Date, Year [Member]
Contingent consideration, measurement input	2,024	2,029
Senhance Surgical Robotic System Acquisition [Member] \| Fair Value, Inputs, Level 3 [Member] \| Maximum [Member] \| Measurement Input, Discount Rate [Member]
Contingent consideration, measurement input	0.11	0.1575
Series B Warrant [Member]
Fair value (million) \| $	$ 2.4	$ 0.3
Share price (in dollars per share) \| $ / shares	$ 1.47	$ 0.63
Probability of additional financing	100.00%
Series B Warrant [Member] \| Measurement Input, Expected Term [Member]
Warrants, measurement input (Year) \| yr	2.32	1.32
Series B Warrant [Member] \| Measurement Input, Risk Free Interest Rate [Member]
Warrants, measurement input (Year)	0.0159	0.0010
Series B Warrant [Member] \| Measurement Input, Expected Dividend Payment [Member]
Warrants, measurement input (Year)	0	0
Series B Warrant [Member] \| Measurement Input, Price Volatility [Member]
Warrants, measurement input (Year)	1.0980	1.5097

Note 5 - Fair Value - Summary of Change in Fair Value for Warrants and Contingent Consideration (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Warrant [Member]
Balance	$ 2,388	$ 4,636
Change in fair value	336	(2,248)
Settlement	(2,469)
Balance	255	2,388
Current portion	0
Long-term portion	255
Contingent Consideration [Member]
Balance	1,084	10,637
Change in fair value	2,924	(9,553)
Settlement	(74)
Balance	3,936	$ 1,084
Current portion	0
Long-term portion	$ 3,936

Note 6 - Accounts Receivable, Net (Details Textual) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Accounts Receivable, Credit Loss Expense (Reversal)	$ 0	$ 1,634

Note 6 - Accounts Receivable, Net - Summary of Accounts Receivable (Details) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Gross accounts receivable	$ 2,917	$ 2,274
Allowance for uncollectible accounts	(1,802)	(1,654)
Total accounts receivable, net	$ 1,115	$ 620

Note 7 - Inventories (Details Textual) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Other Restructuring Costs	$ 0	$ 7,400
Inventory Write-down	0	8,931
Systems [Member]
Inventory Write-down	$ 0	$ 1,500

Note 7 - Inventories - Components of Inventories (Details) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Finished goods	$ 10,749	$ 9,737
Raw materials	8,098	8,510
Total inventories	18,847	18,247
Current Portion	10,034	10,653
Long-term portion	$ 8,813	$ 7,594

Note 8 - Other Current Assets - Summary of Other Current Assets (Details) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Advances to vendors	$ 1,925	$ 2,534
Prepaid expenses	1,706	1,834
VAT receivable	2,870	2,716
Total	$ 6,501	$ 7,084

Note 9 - Property and Equipment (Details Textual) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Depreciation, Total	$ 2,898	$ 2,166

Note 9 - Property and Equipment - Summary of Property and Equipment (Details) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Property, plant and equipment, gross	$ 24,602	$ 15,674
Accumulated depreciation and amortization	(14,260)	(10,968)
Property and equipment, net	10,342	4,706
Machinery, Manufacturing and Demonstration Equipment [Member]
Property, plant and equipment, gross	10,153	9,711
Operating Lease Assets [Member]
Property, plant and equipment, gross	9,203	710
Computer Equipment [Member]
Property, plant and equipment, gross	2,297	2,321
Furniture and Fixtures [Member]
Property, plant and equipment, gross	640	637
Leasehold Improvements [Member]
Property, plant and equipment, gross	$ 2,309	$ 2,295

Note 10 - Goodwill, In-process Research and Development and Intellectual Property (Details Textual) $ in Thousands			3 Months Ended		12 Months Ended
	Oct. 31, 2018 USD ($)	Sep. 21, 2015 USD ($)	Dec. 31, 2019 USD ($)	Sep. 30, 2019 USD ($)	Dec. 31, 2020 USD ($)	Dec. 31, 2019 USD ($)	Dec. 31, 2018 USD ($)	Sep. 23, 2018 USD ($)	Sep. 03, 2013 USD ($)
Goodwill, Ending Balance			$ 0			$ 0	$ 80,131
Number of Reporting Units					1
Goodwill, Impairment Loss			$ 79,000	$ 79,000	$ 0	78,969
Impairment of Intangible Assets, Finite-lived					0	7,912
Intellectual Property [Member]
Impairment of Intangible Assets, Finite-lived					$ 0	$ 0
Developed Technology Rights [Member] \| Weighted Average [Member]
Finite-Lived Intangible Assets, Remaining Amortization Period (Year)					2 years 2 months 12 days
Technology-Based Intangible Assets [Member] \| Weighted Average [Member]
Finite-Lived Intangible Assets, Remaining Amortization Period (Year)					6 years 3 months 18 days
In Process Research and Development [Member]
Impairment of Intangible Assets, Finite-lived				$ 7,900
Safe Stitch Medical Inc [Member]
Goodwill, Ending Balance									$ 93,800
Senhance Surgical Robotic System Acquisition [Member]
Goodwill, Ending Balance		$ 38,300
Senhance Surgical Robotic System Acquisition [Member] \| Intellectual Property [Member]
Intangible Assets, Net (Excluding Goodwill), Total		$ 17,100
Discount Rate Used in Discounted Cash Flows		45.00%
Medical Surgery Technologies Limited [Member]
Goodwill, Ending Balance								$ 9,600
Medical Surgery Technologies Limited [Member] \| In Process Research and Development [Member]
Intangible Assets, Net (Excluding Goodwill), Total	$ 10,600
Discount Rate Used in Discounted Cash Flows	15.00%

Note 10 - Goodwill, In-process Research and Development and Intellectual Property - Goodwill (Details) - USD ($) $ in Thousands	3 Months Ended		12 Months Ended
	Dec. 31, 2019	Sep. 30, 2019	Dec. 31, 2020	Dec. 31, 2019
Goodwill balance			$ 0	$ 80,131
Foreign currency translation impact				(1,162)
Impairment	$ (79,000)	$ (79,000)	$ 0	(78,969)
Goodwill balance	$ 0			$ 0

Note 10 - Goodwill, In-process Research and Development and Intellectual Property - In-process Research and Development and Intellectual Property (Details) - USD ($) $ in Thousands	3 Months Ended		12 Months Ended
	Dec. 31, 2019	Sep. 30, 2019	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2020	Dec. 31, 2019
Finite-Lived Intangible Assets, Net			$ 28,596
Intangible assets impairment			0	$ 7,912
Finite-Lived Intangible Assets, Net	$ 28,596		22,267	28,596
Finite-Lived Intangible Assets, Gross					$ 69,238	$ 66,813
Finite-Lived Intangible Assets, Accumulated Amortization					(51,902)	(37,030)
Finite-Lived Intangible Assets, Foreign Currency Translation Impact					4,931	(1,187)
Intangible Assets	28,596		28,596	28,596	22,267	28,596
In Process Research and Development [Member]
Finite-Lived Intangible Assets, Net			2,470	10,747
Intangible assets impairment	0	$ 7,900	0	(7,912)
Foreign currency translation impact			(45)	(365)
Transfer of in-process research and development to intellectual property			(2,425)
Finite-Lived Intangible Assets, Net	2,470		0	2,470
Intangible Assets	2,470		2,470	10,747	0	2,470
Developed Technology Rights [Member]
Finite-Lived Intangible Assets, Net			28,287
Finite-Lived Intangible Assets, Net	28,287		21,976	28,287
Finite-Lived Intangible Assets, Gross					68,838	66,413
Finite-Lived Intangible Assets, Accumulated Amortization					(51,734)	(36,918)
Finite-Lived Intangible Assets, Foreign Currency Translation Impact					4,872	(1,208)
Intangible Assets	28,287		28,287	28,287	21,976	28,287
Technology-Based Intangible Assets [Member]
Finite-Lived Intangible Assets, Net			309
Finite-Lived Intangible Assets, Net	309		291	309
Finite-Lived Intangible Assets, Gross					400	400
Finite-Lived Intangible Assets, Accumulated Amortization					(168)	(112)
Finite-Lived Intangible Assets, Foreign Currency Translation Impact					59	21
Intangible Assets	$ 309		$ 309	$ 309	$ 291	$ 309

Note 10 - Goodwill, In-process Research and Development and Intellectual Property - Amortization Expense of Intangible Assets (Details) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Total	$ 22,267	$ 28,596
Intellectual Property [Member]
2021	11,634
2022	8,833
2023	430
2024	430
2025	430
Thereafter	510
Total	$ 22,267	$ 28,596

Note 11 - Income Taxes (Details Textual) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Valuation Allowance, Deferred Tax Asset, Increase (Decrease), Amount	$ 9,800
Unrecognized Tax Benefits, Ending Balance	1,620	$ 1,512	$ 1,363
Unrecognized Tax Benefits, Income Tax Penalties and Interest Accrued, Total	$ 0	$ 0
Effective Income Tax Rate Reconciliation, at Federal Statutory Income Tax Rate, Percent	21.00%	21.00%
Domestic Tax Authority [Member]
Operating Loss Carryforwards, Total	$ 364,300
Operating Loss Carryforwards, Subject to Expiration	254,500
Operating Loss Carryforwards, Not Subject to Expiration	109,800
Domestic Tax Authority [Member] \| Research Tax Credit Carryforward [Member]
Tax Credit Carryforward, Amount	7,200
State and Local Jurisdiction [Member]
Operating Loss Carryforwards, Total	296,200
Operating Loss Carryforwards, Subject to Expiration	289,300
Operating Loss Carryforwards, Not Subject to Expiration	6,800
Foreign Tax Authority [Member] \| Ministry of Economic Affairs and Finance, Italy [Member]
Operating Loss Carryforwards, Total	24,500
Foreign Tax Authority [Member] \| Luxembourg Inland Revenue [Member]
Operating Loss Carryforwards, Subject to Expiration	95,100
Foreign Tax Authority [Member] \| Swiss Federal Tax Administration (FTA) [Member]
Operating Loss Carryforwards, Subject to Expiration	$ 61,900

Note 11 - Income Taxes - Income Tax Expense (Benefit) (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
Federal	$ 0	$ 0
State	0	0
Foreign	169	100
Federal	0	0
State	0	0
Foreign	(1,685)	(3,224)
Total income tax expense (benefit)	$ (1,516)	$ (3,124)

Amount of current income tax expense (benefit) and deferred income tax expense (benefit) pertaining to continuing operations.

+ References + Details

Note 11 - Income Taxes - Domestic and Foreign Components of Loss from Operations (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019
United States	$ (34,398)	$ (91,935)
Foreign	(26,430)	(65,390)
Total loss from operations before taxes	$ (60,828)	$ (157,325)