Robot-assisted cardiac surgery is at a particularly interesting moment. After more than two decades of uneven development, largely concentrated in pioneering centers and driven to a great extent by the enthusiasm of highly specialized teams, the technology appears to have reached a level of maturity that raises a different question. The issue is no longer whether robot-assisted cardiac surgery can be performed safely and effectively, but how it can be expanded without compromising the outcomes that have supported its consolidation. It is precisely in this context that the Society of Thoracic Surgeons (STS) has published its consensus document on training in robot-assisted cardiac surgery.

Rather than providing a technical guide to specific procedures, the document proposes a roadmap for the progressive development of robot-assisted cardiac surgery programs. Its most striking feature is that the focus is not placed on the individual surgeon, but on the program as a whole. The authors understand that this surgical approach cannot be learned solely at a console and does not depend exclusively on technical skill. Its implementation requires a complex, multidisciplinary organization involving surgeons, anesthesiologists, perfusionists, nurses, scrub nurses, administrators, and, of course, carefully selected patients.

The consensus structures program development into four sequential phases. The first corresponds to institutional preparation. Before the first procedure is performed, the center must assess its resources, define objectives, identify clinical leaders, ensure institutional commitment, and establish links with experienced programs. Initial training includes simulation, experimental model training, procedural observation, and familiarization of the entire team with the technology. The message is clear: the success of a program begins long before the patient enters the operating room.

The second phase involves clinical implementation. During this initial period, procedures are carefully selected and performed under the supervision of experienced mentors. The goal is not to rapidly achieve high procedural volumes, but to develop safe and reproducible processes. Team coordination, effective communication, and the ability to manage incidents become even more important than the technical execution of the procedure itself.

The third phase corresponds to consolidation. Once the initial learning curve has been overcome, programs begin to broaden indications and progressively increase case complexity. The authors emphasize the need for continuous outcome monitoring, identification of areas for improvement, and structured mechanisms of evaluation. Experience is no longer measured only by case numbers, but also by objective indicators of quality and clinical outcomes.

Finally, the fourth phase represents program maturity. At this stage, the team not only performs complex procedures safely, but also develops teaching capacity, participates in the training of new professionals, and contributes to knowledge generation. Excellence is no longer defined by individual technical ability, but by the capacity to sustain high-quality outcomes, train other teams, and ensure long-term program continuity.

The proposal is sound, logical, and probably necessary. However, a careful reading of the document leaves an interesting impression: although it appears to address training, it is actually about legitimization. Consensus documents do not usually emerge during the pioneering stages of an innovation. They arise when a community considers that a technology has reached sufficient stability to normalize its use. From this perspective, the real message of the document is not how to train surgeons in robot-assisted cardiac surgery, but rather that this discipline is clearly seeking to move beyond being an exceptional activity and become a standard approach for multiple diseases.

COMMENTARY:

This work, signed by leading international figures in robot-assisted surgery, including Dr Pereda from Hospital Clínic of Barcelona as fourth author, addresses a number of issues that deserve critical analysis. Although the document is extraordinarily interesting, it remains framed within a context that is difficult to see replicated in many other countries, including several European settings, and Spain is no exception.

The first issue concerns the very need for expansion. The need to standardize training gives the impression that the main barrier to the growth of robot-assisted cardiac surgery is the absence of structured programs. However, it is worth asking whether this is truly the problem. In many health care systems, particularly in Europe, the most important barriers remain economic, organizational, and strategic. A perfectly defined training pathway does not, by itself, solve the high cost of the technology, the need to maintain adequate procedural volumes, or the difficulty of justifying major investments in a setting exposed to increasing clinical pressure. In a sense, the document seems to assume that, if teams are properly trained, the expansion of robot-assisted surgery will naturally follow. Reality may be considerably more complex. The question is not only who can perform robot-assisted surgery, but how many centers should do so and under what conditions.

Second, it is striking that the effort devoted to structuring training is, in some respects, greater than the effort directed at resolving certain clinical debates that remain open. The safety and feasibility of robot-assisted cardiac surgery are reasonably well established across multiple procedures. However, questions remain regarding cost-effectiveness, population-level impact, and the true advantages over other well-established minimally invasive strategies. This issue is especially relevant in the treatment of valvular heart disease. Over the past twenty years, many centers have developed minithoracotomy or fully thoracoscopic programs with excellent clinical outcomes, low morbidity and mortality, and a cost-benefit relationship that is difficult to ignore. From this perspective, the question is not whether robot-assisted surgery works. In the right setting and in the right hands, we probably already know that it does. The real question is what additional problem it solves and in which patients it provides a clinically meaningful benefit compared with less complex and widely established alternatives. This may explain why the consensus deliberately avoids comparisons between approaches. The authors rightly understand that they are not producing a guideline on indications, but a training pathway. Nevertheless, the separation between these two issues is more theoretical than real. The pace at which a technology is adopted depends not only on the quality of its training pathway, but also on the clarity of its value proposition.

A third point raises a particularly interesting paradox. Historically, robot-assisted surgery has been presented as the pinnacle of technological innovation. Yet the main lesson of this consensus is almost the opposite: technology matters less than we often think. The four phases described say very little about “robots.” They speak about leadership, patient selection, simulation, teamwork, supervision, outcome analysis, and continuous improvement. In other words, they refer to principles that would equally explain the success of an ECMO program, a mechanical circulatory support program, a TAVI program, or a minimally invasive surgery program. The robot appears as a sophisticated tool, but the true protagonist is, once again, the system built around it. This is probably the most valuable contribution of the document. For years, the conversation around robot-assisted surgery has been dominated by technological issues: three-dimensional vision, instrument articulation, surgical platforms, and engineering advances. This consensus shifts the debate toward a far more relevant area: the construction of sustainable programs, based on the same principles as always, but using a highly sophisticated tool or approach. Put differently, the presence of the robot may lead us to do things differently. However, the key to its consolidation may lie in understanding that the real innovation was never in the robot itself.

Finally, publication of this consensus suggests that robot-assisted cardiac surgery has entered a new phase. It is no longer trying to convince skeptics through technological demonstrations or to impress through exceptional cases. It is seeking something much more difficult: to become a normalized, reproducible, and transferable activity. In the experience of our center, Hospital Clínico Universitario Virgen de la Arrixaca, we are now embarking on this demanding path. Following publication of this consensus, we recognize that we have reached phase II, having fulfilled most of the recommendations proposed in the document. In Spain, Hospital Clínic of Barcelona has accumulated the greatest experience in this field, and it is thanks to its invaluable example and support that we are beginning to incorporate this alternative approach for our patients. Thank you very much.

REFERENCE:

Badhwar V, Arghami A, Černý Š, Pereda D, Ramzy D, Patel N, et al. The Society of Thoracic Surgeons Expert Consensus Pathway for Robotic Cardiac Surgical Training. Ann Thorac Surg. 2026 May;121(5):1038-1048. doi: 10.1016/j.athoracsur.2026.01.003. Epub 2026 Jan 29. PMID: 41619927.