Robotic and totally endoscopic cardiac surgery: redefining value, precision, and surgical strategy

Over the past two decades, cardiac surgery has undergone a profound transformation driven by technological innovation, patient-centered care, and the increasing emphasis on value-based healthcare delivery. Minimally invasive strategies—once primarily focused on reducing surgical trauma—have evolved into comprehensive operative platforms capable of enhancing precision, reproducibility, and clinical outcomes. Among these, robotic and totally endoscopic cardiac surgery (TECS) represent the most advanced and rapidly evolving frontier.

At the Mass General Brigham, Brigham and Women’s Hospital Endoscopic Valvular Program, our experience has paralleled—and contributed to shaping—this evolution. The transition from direct-vision minimally invasive approaches to TECS represents more than a technical progression; it reflects a fundamental shift in surgical philosophy. Cardiac surgery is moving from exposure-driven techniques toward imaging-guided, ergonomically optimized, and system-based workflows designed to improve reproducibility and scalability. This transformation is supported by growing evidence demonstrating excellent clinical outcomes, faster recovery, and improved patient experience compared to conventional approaches (1-4). Furthermore, data from high-volume centers highlight how structured programmatic adoption is critical to achieving consistent and reproducible results (5,6).

This special series in the Journal of Visualized Surgery (JOVS) brings together a group of internationally recognized experts to provide a contemporary and comprehensive overview of robotic and TECS. The series combines original research, narrative reviews, and high-quality surgical tutorials, reflecting both the current state of the art and the future direction of the field.

A central component of this series is the contribution from Di Eusanio and colleagues, who present a sub-analysis from the Mini-Mitral International Registry. This work provides a valuable “real-world” perspective on endoscopic mitral valve surgery, reinforcing its safety, reproducibility, and applicability across a wide range of centers and practice environments.

The evolving role of robotics in endoscopic mitral surgery is addressed by Cresce and Geirsson, who offer a comprehensive narrative review comparing robotic and non-robotic endoscopic mitral valve repair. This contribution provides important insights into one of the most debated topics in contemporary cardiac surgery—whether robotic assistance adds incremental value over purely endoscopic approaches.

The technical versatility of endoscopic mitral repair is further explored by Kofidis, who presents an in-depth review of neochordal strategies. This work highlights the adaptability of endoscopic techniques and underscores how modern repair philosophy can be effectively translated into a totally endoscopic environment implementing the “respect than resect” technique providing multiple ways to use neochords in primary mitral regurgitation correction.

Beyond mitral valve surgery, this series expands into advanced coronary and complex reoperative procedures. Balkhy provides a detailed description of robotic multi-vessel off-pump totally endoscopic coronary artery bypass (TECAB), illustrating one of the most sophisticated applications of robotic cardiac surgery. Zacharias contributes a practical guide to totally endoscopic redo valve surgery, addressing one of the most technically demanding scenarios in minimally invasive and endoscopic cardiac surgery.

Bonatti further broadens the scope of the series with a detailed surgical technique for robotically assisted totally endoscopic myocardial bridge unroofing, highlighting the expanding indications of endoscopic cardiac surgery beyond traditional valvular interventions.

Collectively, these contributions reflect a broader and inevitable evolution in cardiac surgery: from minimizing invasiveness to maximizing value. The adoption of robotic and totally endoscopic platforms must be evaluated not only in terms of technical feasibility, but also through the lens of patient outcomes, recovery, resource utilization, and overall healthcare value. Emerging evidence suggests that, when implemented within high-performing programs, these approaches can achieve favorable cost-effectiveness profiles by reducing complications, shortening hospital stay, and accelerating return to normal activity (4,7).

Nevertheless, important challenges remain. These include the learning curve associated with advanced endoscopic and robotic techniques, the need for dedicated institutional investment, and variability in training pathways. Overcoming these barriers will require coordinated efforts across surgical societies, training programs, and healthcare systems. The future of cardiac surgery will not be defined by a single technique, but by the ability to integrate multiple technologies and tailor surgical strategies to individual patient needs within a value-based framework.

As Guest Editor, and as Director of the Endoscopic Valvular Program at Brigham and Women’s Hospital, I strongly believe that TECS represents not only an evolution, but a necessary progression of our specialty. This series is intended to serve as both a practical guide and a strategic roadmap for surgeons and institutions committed to advancing the field.

Tommaso Hinna Danesi

Acknowledgments

The Guest Editor would like to thank all contributing authors for their outstanding work and commitment to advancing minimally invasive and totally endoscopic cardiac surgery worldwide. Special thanks to the editorial team of the Journal of Visualized Surgery for their support in the development of this series.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery for the series “Endoscopic Cardiac Surgery”. The article did not undergo external peer review.

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-2026-0020/coif). The series “Endoscopic Cardiac Surgery” was commissioned by the editorial office without any funding or sponsorship. T.H.D. served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Journal of Visualized Surgery from September 2024to December 2028. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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