Beyond feasibility: where can robotics truly add value in minimally invasive cardiac surgery?

The report by Murtaza and Badhwar describing single-incision right transaxillary robotic valve surgery combined with left internal thoracic artery (LITA) to left anterior descending coronary artery (LAD) bypass (1) is an impressive technical achievement and an important contribution to the ongoing evolution of minimally invasive cardiac surgery. By completing both valve surgery and coronary revascularization through a right-sided transaxillary approach, the authors challenge the traditional assumption that concomitant coronary artery bypass necessarily requires either median sternotomy or an additional left-sided incision.

The novelty of this report lies not merely in the use of robotic technology, but in the attempt to solve a problem that is genuinely difficult for conventional minimally invasive techniques. Through a right fourth intercostal access with additional robotic ports, the authors successfully treated both valvular disease and LAD stenosis in two highly selected patients. The operation therefore deserves recognition as a proof of concept that expands the technical possibilities of right-sided minimally invasive surgery.

At the same time, the report raises a broader and more important question: where does robotic technology truly provide an advantage in cardiac surgery?

In conventional valve surgery, the superiority of robotic systems remains uncertain. Numerous centers have shown that mitral and even aortic valve procedures can be performed safely (2) and reproducibly through right mini-thoracotomy or totally endoscopic multiport approaches using high-definition three-dimensional endoscopy and long-shafted instruments. In experienced hands, these non-robotic techniques often achieve excellent exposure, low invasiveness, short operative times, and favorable cosmetic results without the expense and complexity of a robotic platform.

Indeed, for routine valve procedures, the technical requirements are often still within the range of normal human dexterity. Standard minimally invasive instruments are generally sufficient to perform annuloplasty, leaflet resection, neochordal implantation, or valve replacement through a small thoracic incision. Under these circumstances, the additional value of robotics is not self-evident.

The true potential of robotic systems may emerge in situations that approach or exceed the physiological limits of human manual performance. Manipulators such as the da Vinci platform were originally developed not simply to reproduce ordinary surgical movements, but to extend them beyond the normal range of human capability. Robotics may therefore be most useful in operations that require either extremely fine manipulation in a confined space or technically demanding movements that are difficult to accomplish with conventional instruments.

The present report is important precisely because it represents such a situation. Harvesting the LITA from the right chest, exposing the LAD, and constructing a coronary anastomosis using long-shafted instruments are close to the limits of human dexterity. The ability of the robotic system to provide articulated instruments, tremor filtration, stable visualization, and enhanced freedom of motion may therefore become particularly advantageous in this setting.

Another innovative aspect of the operation is the method used to expose the LAD. By opening the left pericardium, repositioning it toward the left chest wall, and rotating the heart using suction-based positioning devices, the authors created an operative corridor to the anterior interventricular groove from the right thorax.

In addition, robotic assistance may facilitate LITA harvest through the right chest, where visualization and instrument alignment are otherwise difficult. Therefore, if robotic surgery is to demonstrate superiority within minimally invasive cardiac surgery, concomitant procedures such as those described in this report may represent one of its most appropriate indications.

This distinction is important. Robotic surgery should not necessarily be viewed as the optimal platform for every minimally invasive valve procedure. Rather, its greatest value may lie in enabling operations that are otherwise difficult or impossible with conventional methods. This study, therefore, offers a more convincing rationale for robotics than many previous reports limited to isolated valve surgery.

If I were to point out any shortcomings, total operation time, cardio-pulmonary bypass (CPB) time and aortic clamp time were not presented. If those are described, readers can estimate how the additional coronary procedures are technically demanding and which types of valve surgery this can be combined with.

The terminology of “single-incision” should also be interpreted carefully. Although the cosmetic benefit of a transaxillary approach is attractive, the operation still requires multiple robotic ports. In practical terms, it is therefore a multiport robotic procedure centered on a single utility incision rather than a true single-incision operation.

Despite these reservations, the article by Murtaza and Badhwar (1) deserves recognition because it identifies a clinical situation in which robotics may genuinely provide value. In many areas of cardiac surgery, the debate regarding robotics has focused on whether the robot can reproduce procedures already achievable by conventional minimally invasive techniques. The present report shifts that discussion toward a more relevant question: can robotics enable procedures that conventional techniques cannot perform easily, safely, or reproducibly?

For routine valve surgery, the answer may remain uncertain. However, for highly complex concomitant procedures requiring access, dexterity, and precision beyond the normal limits of human manipulation, robotics may indeed have a unique role.

In conclusion, this report should therefore be regarded not merely as an elegant technical demonstration, but as a potentially important example of where robotic technology may find its most meaningful application in minimally invasive cardiac surgery.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery. The article has undergone external peer review.

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0019/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0019/coif). The author has no conflicts of interest to declare.

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References

1. Murtaza G, Badhwar V. Single incision right transaxillary robotic valve and coronary artery bypass grafting: a future therapy. Ann Cardiothorac Surg 2025;14:235-7. [Crossref] [PubMed]
2. Hosoba S, Ito T, Orii M. Three-Dimensional Endoscopic-Assisted Concomitant Mitral and Aortic Valve Surgery. Ann Thorac Surg 2022;114:e63-6. [Crossref] [PubMed]