The publication of the European guideline that restricts the use of robotic assistance in cardiovascular surgery due to safety concerns has significantly slowed the development of this technology within our specialty. Evidence of this stagnation can be seen in the delayed evolution of the Da Vinci® platform (Intuitive Surgical®) across its successive generations (S, Si, X, Xi, and the most recent SP) toward cardiac or vascular applications. This situation contrasts sharply with developments outside Europe, where the growing experience in countries such as the United States, as well as the emergence of new robotic platforms in India (SS Innovations® Mantra®) and China (potentially MedBot® MicroPort® Toumai®, currently applied to major noncardiac procedures), illustrates progress not merely in surgical access but in a fundamentally different conceptual approach to the surgical treatment of heart disease.
Robot-assisted coronary surgery represents the most recent frontier for minimally invasive approaches in cardiac surgery. Although coronary revascularization has become an extremely versatile treatment, allowing procedures to be tailored to individual anatomical characteristics and comorbidity profiles, it remains penalized by being one of the last major cardiac operations still largely dependent on conventional surgical exposure, in contrast to valvular surgery. The incorporation of robotic technology has the potential to profoundly transform both its conceptual framework and clinical outcomes. Beyond graft selection and configuration, robotic technology enables mixed approaches (robot-assisted and surgical), hybrid strategies (surgical and transcatheter), and even fully robotic procedures, performed with or without cardiopulmonary bypass (CPB).
In this context, we review the results reported by a Chinese group following the introduction of the Da Vinci Xi® system for robotic-assisted bilateral internal thoracic artery harvesting (RACAB), followed by multivessel coronary revascularization through a left anterior small thoracotomy (LAST) without cardiopulmonary bypass (OPCAB), using both grafts in situ. The authors describe a cohort of 221 patients treated between 2021 and 2024. During this period, the overall institutional experience included 369 patients; however, the analysis focused specifically on multivessel disease, as 124 patients presented with single-vessel involvement. Outcomes were excellent, exceeding benchmarks typically reported for conventional CPB-supported series, with a low mortality rate of 0.5%, no conversions to median sternotomy, limited transfusion requirements (5.5%), low rates of repeat revascularization or reexploration for bleeding (4.5%), and no need for unplanned rescue procedures.
The surgical technique is described in detail in the manuscript and is thoroughly documented with images. In brief, the robotic system is positioned on the right side of the patient, and a port-based approach is established through the third and seventh left intercostal spaces along the anterior axillary line, with an additional port in the fifth left intercostal space for the endoscope. A left-sided artificial pneumothorax is induced using CO₂ at a pressure of 4–6 mmHg. After opening the right pleural cavity, complete bilateral internal thoracic artery harvesting is performed in a skeletonized fashion under robotic assistance.
Once both internal thoracic arteries are fully harvested, the robotic system is removed, and the incision at the fifth intercostal space is extended anteriorly to create a left anterior small thoracotomy. Through this access, distal coronary anastomoses are performed using the in situ grafts. Cardiac stabilization is achieved by introducing a stabilizer device (Medtronic Octopus®) either through an additional port in the sixth left intercostal space or via the existing seventh intercostal port.
When graft length was insufficient to achieve complete revascularization, a third conduit using the radial artery was employed in 28.5% of patients. In these cases, the radial artery was anastomosed to one of the internal thoracic arteries to form a composite “I” graft (end-to-end configuration), allowing sequential distal anastomoses. In all patients, graft function was systematically assessed using transit-time flow measurement (TTFM). With this strategy, only 4.5% of patients required hybrid revascularization, which was planned from the outset rather than used as a bailout strategy.
Several critical but constructive observations arise from this experience, as also highlighted in the JTCVS publication. First, the cohort represents a highly selected patient population, particularly when compared with the typical profile of patients treated in many European centers. Patients were relatively young, with a mean age of 58 years, lean (mean body mass index 26 kg/m²), and exhibited low operative risk, with a mean STS predicted risk of mortality of 0.69% and a mean EuroSCORE II of 0.99%. Ventricular function was preserved, with small ventricular dimensions. This phenotype mirrors other published experiences from Japanese and Indian centers and contrasts with the higher prevalence of obesity commonly encountered in Western populations.
Furthermore, the low incidence of adverse events (such as conversion to CPB, transfusion of blood products, planned hybrid revascularization, or the need for repeat revascularization) limits the ability to perform meaningful subgroup analyses. As a result, identifying true risk factors or defining clear exclusion thresholds that might compromise procedural safety remains challenging.
The application of this protocol is entirely feasible (and legally permissible) in our clinical environment, as the actual coronary revascularization is still performed manually. Robotic assistance is restricted to bilateral internal thoracic artery harvesting, offering a clear benefit in terms of reducing surgical wound complications. Notably, more than 44% of patients in this series were diabetic, suggesting that the liberal use of bilateral internal thoracic artery grafting may be feasible while substantially mitigating the risk of mediastinitis.
A logical next step would be the performance of coronary anastomoses using robotic assistance. Whether due to limitations in team experience or current technological constraints, this remains an evolving frontier, particularly outside Europe. Although initial experiences have been reported, they are still associated with prolonged CPB times and considerable technical complexity. Robotic instruments (essentially miniature articulated hands introduced into the thoracic cavity) offer clear advantages over conventional minimally invasive surgery, which relies on reproducing surgical gestures at a distance with fewer degrees of freedom. Nevertheless, for now, the combination of surgical expertise and technology has yet to surpass the dexterity of five fingers and a long Castroviejo needle holder when handling 7-0 or 8-0 sutures.
COMMENTARY:
Minimally invasive cardiac surgery has demonstrated clear benefits in terms of reducing surgical trauma by limiting incision size, tissue manipulation, and overall tissue injury, as well as decreasing bleeding and surgical site infection rates. These advantages translate into reduced postoperative pain, lower transfusion requirements, and attenuation of the inflammatory response, thereby facilitating earlier recovery with lower morbidity and mortality. When cardiopulmonary bypass, aortic manipulation, and cardioplegic arrest can be avoided, surgery becomes even more physiologic, further reinforcing these benefits by minimizing hemodilution, systemic inflammatory activation, and complications related to renal, respiratory, or coagulation dysfunction.
It is precisely at the intersection of patient condition (both physical status and comorbidity burden), technical feasibility (which encompasses surgical expertise and technological development), and minimization of invasiveness—both in terms of surgical aggression and deviation from physiologic conditions—where minimally invasive cardiac surgery finds its appropriate role.
Conventional cardiac surgery, with nearly 99% of procedures still performed through median sternotomy, attempts to offer a single solution for a wide spectrum of patient profiles. This approach is acceptable for many patients, given the extensive manual control of cardiac structures and the substantial cumulative experience that support excellent outcomes in terms of procedural efficiency compared with transcatheter therapies and, potentially, minimally invasive surgery. However, simplicity and cost-effectiveness do not necessarily equate to superiority or excellence. Minimally invasive surgery represents a modern surgical paradigm, in which optimal procedure selection tailored to each patient profile aims to maximize outcomes and deliver personalized treatment.
In certain patient subsets, minimally invasive approaches may offer little advantage beyond reduced incision size when compared with conventional surgery. In others, they may significantly reduce morbidity and mortality while providing results equivalent to standard approaches. In yet another group, procedural simplification through the combination of minimized surgical access and transcatheter technologies may enable effective treatment of increasingly frail and comorbid patients. Hybrid approaches, which may be inappropriate for the first group, could become the optimal solution for a growing population with expectations shaped by contemporary society.
Minimally invasive coronary surgery in general, and RACAB in particular, epitomize this conceptual framework. These techniques combine sufficient procedural volume, adaptability to patient-specific characteristics, and the versatility required to deliver individualized treatment, thereby defining a plausible evolutionary path for myocardial revascularization strategies.
However, until the combination of experience and technology achieves a technical standard comparable to median sternotomy, how should patient selection be approached? At present, reliance on the experience of specialized centers remains the only option. Over years and decades, this will gradually generate a meaningful body of scientific evidence. While recommendations as robust as those supporting internal thoracic artery grafting to the left anterior descending artery are unlikely to emerge in the short term, a degree of consensus (beyond clinical intuition, which still governs decision-making in the early experience of many centers) will likely develop.
In this regard, multicenter collaboration, multidisciplinary involvement, team-based practice, and systematic data auditing appear to be essential drivers of progress. Accordingly, and inspired by Isaac Asimov’s Three Laws of Robotics, I propose an analogy grounded in surgical principles to define the clinical judgment that should guide robot-assisted minimally invasive cardiac surgery:
Law 1: Principle of nonmaleficence.
A robot-assisted procedure must be, at minimum, noninferior to the standard surgical approach in terms of safety.
Law 2: Principle of beneficence.
Any reduction, simplification, or automation of the procedure achieved through robotic assistance must result in outcomes that are at least noninferior in efficacy compared with the standard approach.
Law 3: Principle of autonomy.
The least invasive surgical option should be preferred whenever it does not violate the first two laws, in accordance with the patient’s informed consent and clinical condition, as well as the capabilities, experience, and outcomes of the responsible surgeon or surgical team.
In this way, what Asimov envisioned more than 70 years ago (and which has since become reality) may ultimately define the future of cardiac surgery in general, and myocardial revascularization in particular.
REFERENCE:
Fu Y, Hong Y, Ding T, Meng L, Gong Y, Wu S, et al. Early outcomes and follow-up of robotic-assisted multivessel coronary artery bypass with in situ bilateral internal thoracic artery: Report of 221 patients in a single center. J Thorac Cardiovasc Surg. 2025 Dec;170(6):1639-1647. doi: 10.1016/j.jtcvs.2025.06.008.
