Transitioning from direct vision to totally endoscopic minimally invasive cardiac surgery

Introduction

Background

Minimally invasive cardiac surgery (MICS) has evolved significantly over the past two decades, shifting from conventional median sternotomy toward sternal-sparing approaches that offer reduced surgical trauma, lower complication rates, and faster patient recovery (1,2). As incision size has progressively decreased—from mini-thoracotomy to micro-thoracotomy and ultimately to sub-3 cm working ports—the field has advanced toward totally endoscopic cardiac surgery (TECS), in which the entire intracardiac procedure is performed exclusively under thoracoscopic visualization (3). Despite growing clinical adoption and favorable early outcomes (4,5), the transition from direct-vision MICS to TECS remains technically demanding, requiring a structured approach to surgeon training, team preparation, instrumentation, and patient selection.

Rationale and knowledge gap

While individual components of MICS—including cannulation strategies, instrumentation, and outcomes—have been described in the literature (6-8), a comprehensive framework guiding the stepwise transition from direct-vision MICS to fully endoscopic cardiac surgery is lacking. The heterogeneity of self-reported “minimally invasive” definitions (3,9), the absence of standardized training pathways, and the variability in institutional experience create barriers to widespread adoption and outcome comparison. Furthermore, cost-effectiveness and feasibility considerations across different healthcare settings remain underexplored.

Objective

Drawing on our institutional experience at Brigham and Women’s Hospital, Harvard Medical School, and a review of the current literature, we provide a comprehensive overview of the key elements required to successfully build and sustain a TECS program. These include a working definition of totally endoscopic surgery, a proposed four-phase surgeon training pathway, simulation-based learning strategies, robotic credentialing, team-based training, technical instrumentation, scope management, patient selection criteria, procedural challenges, postoperative outcomes, and cost-effectiveness considerations. Both non-robotic and robotic-assisted endoscopic platforms are discussed.

Definition of TECS

A variety of definitions have been proposed to identify a totally video-guided surgical approach, with most focusing on the size of the incision. The Loulmet-Carpentier scale of invasiveness (1) and its modification by Chitwood and Rodriguez (2) correlate the size of the incision with the level of visualization during surgery: direct vision versus video-assisted, video-directed, robotic-assisted, and fully endoscopic port incisions. Within these shades of definition—including video-guided, assisted, and directed—it becomes difficult to distill the true essence of what constitutes “endoscopic” surgery. Katsiroubas et al. conducted a comprehensive search of PubMed, Cochrane Library, and Embase, focusing on meta-analysis outcomes for totally endoscopic mitral valve surgery. The common denominator in their findings was incision size and the avoidance of rib spreading. Based on these factors, the authors defined a totally endoscopic procedure as one performed through a working port smaller than 3 cm without the use of a rib retractor (3). General surgery has faced a similar issue, with a proliferation of techniques for accessing the abdominal cavity leading to a loss of precision in defining laparoscopy. Eyvazzadeh and Kavic reviewed a year’s worth of articles from the Journal of the Society of Laparoscopic and Robotic Surgeons to analyze the technical details of laparoscopic procedures. They found that the common denominator for laparoscopic procedures was the use of four ports, three of which were >10 mm in size. However, the authors concluded that the definition of laparoscopy remains elusive (9).

When this concept from general surgery is applied to cardiac surgery, the distinction between a sternotomy and sternal-sparing access is as clear as the difference between a laparotomy and a laparoscopic procedure. The heterogeneity of self-reported “minimally invasive” approaches complicates the definition of a specific technique that requires unique setups and specialized skills. This variety also limits the ability to effectively analyze outcomes.

When the concept of laparoscopy from general surgery—where the use of a scope is mandatory to perform the procedure and avoid a laparotomy—is translated into cardiac surgery, a coherent definition of endoscopic cardiac surgery should emphasize the essential role of the scope. In a fully endoscopic cardiac procedure, the intracardiac portion of the operation cannot be performed without a thoracoscope. Therefore, a more precise definition should shift the focus from just incision size to the role of the scope, as the incision is used both for visualization and the placement of instruments and devices. As visualization relies entirely on the camera, the miniaturization of the working port becomes a natural consequence.

Surgeon training and experience

Since formal endoscopic training is typically not part of residency or fellowship programs, surgeons who wish to adopt totally endoscopic techniques are most often already in independent practice. In these cases, the acquisition of surgical technique and operative setup is usually developed under the direct mentorship of experienced endoscopic surgeons, either through observational visits, proctored cases, or structured wet-lab training. As TECS has gained traction within the scientific community, more high-volume centers are adopting these techniques as the standard of care for mitral and tricuspid surgeries in unselected patients, increasing the number of training opportunities available to aspiring endoscopic surgeons.

Due to the numerous technical challenges involved, it is unlikely that an entirely endoscopic program can be built from scratch by an inexperienced surgeon. Proper technical skills must be mastered before transitioning from direct vision to totally video-guided surgery. In our experience at Brigham and Women’s Hospital, the most effective training pathway follows a progressive, stepwise model. This transition begins with a direct-vision, minimally invasive sternal-sparing approach—typically a right mini-thoracotomy for mitral or tricuspid valve surgery—which establishes familiarity with peripheral cannulation, intrathoracic anatomy from a lateral perspective, and the use of long-shafted instruments. This foundational phase can provide excellent clinical outcomes from the outset (6) while laying the groundwork for the more demanding endoscopic transition.

We propose a structured training pathway comprising four sequential phases. In Phase 1 (Foundation), the surgeon should be fully proficient in open cardiac surgery, including mitral valve repair, before attempting any minimally invasive approach. A thorough understanding of intracardiac anatomy and repair principles is non-negotiable. In Phase 2 (Direct-Vision MICS), the surgeon transitions to a right mini-thoracotomy with direct visualization, performing a minimum of 20–30 cases before introducing video assistance. This phase builds dexterity with port-based access, peripheral cannulation, and one-lung ventilation management. In Phase 3 (Video-Assisted MICS), thoracoscopic visualization is introduced progressively, initially as a complement to direct vision and then as the primary imaging modality. The surgeon learns scope manipulation, develops hand-eye coordination for indirect visualization, and begins to work with the operative team to optimize camera positioning and lighting. In Phase 4 (Totally Endoscopic Surgery), the working port is reduced to less than 3 cm with no rib retractor, and the procedure is performed exclusively under thoracoscopic guidance. We recommend that this final transition occur only after the surgeon has achieved consistent results in Phase 3 and has undergone at least one dedicated proctored TECS program at a high-volume center.

A comprehensive flowchart summarizing the complete training pathway from open cardiac surgery proficiency to fully independent TECS practice is presented in Figure 1. This flowchart integrates the four sequential training phases with key decision points, including instrument preparation, patient selection criteria, and simulation milestones. At each stage, patient selection and procedural complexity should be calibrated to the team’s cumulative experience: straightforward isolated valve cases in anatomically favorable patients serve as the starting point, with incremental expansion as proficiency is documented. The flowchart is intended to provide clinicians with an intuitive, at-a-glance reference for the operational pathway toward TECS adoption.

Figure 1 Proposed training pathway flowchart for transitioning from open cardiac surgery to TECS. The flowchart illustrates the four sequential training phases, key decision points, instrument preparation requirements, patient selection criteria at each stage, and simulation milestones. ASD, atrial septal defect; AV, aortic valve; HD, high-definition; HRQL, health-related quality of life; MICS, minimally invasive cardiac surgery; MV, mitral valve; OR, operating room; TECS, totally endoscopic cardiac surgery; VSD, ventricular septal defect.

Simulation-based training plays an increasingly important role in accelerating the learning curve at each phase. Various societies and organizations—including the Society of Thoracic Surgeons (STS), the European Association for Cardio-Thoracic Surgery (EACTS), and the Mitral Foundation—now incorporate dedicated workshops, wet-lab sessions, box-trainer exercises, and endoscopic simulation courses into their annual meetings and educational programs. Virtual reality simulators and standardized endoscopic task trainers have been shown to improve hand-eye coordination, instrument handling, and scope navigation in novice endoscopic surgeons before their first clinical case (10,11). In our program, trainees are encouraged to supplement clinical exposure with regular simulation practice, including three-dimensional (3D) video gaming platforms, which have been shown to shorten procedural times and improve precision in early-career endoscopic operators.

For centers pursuing a robotic TECS program, additional formal certification is required. The da Vinci^® platform (Intuitive Surgical, Sunnyvale, CA, USA) mandates a structured credentialing process that includes didactic training, simulation on the robotic console, and a minimum number of proctored cases before independent practice is permitted. In our experience, surgeons who have already completed the non-robotic endoscopic training phases adapt more rapidly to the robotic console, as they have already internalized the visual and spatial demands of indirect visualization. The robotic training pathway should therefore be regarded as complementary to, rather than a substitute for, the foundational endoscopic skill set.

Surgeons who are already proficient in MICS possess a solid foundation in working with small incisions, which aids the transition to performing surgery by looking at a screen and using endoscopic instruments through ports. However, it is important to emphasize that individual surgical dexterity, however refined, is not sufficient for a successful TECS program. The entire operative team must be trained in parallel. In our center, we have found that dedicated endoscopic scrub nurses and perfusionists—who understand the nuances of scope-guided surgery, peripheral perfusion circuits, and the time-sensitive nature of endoscopic cardioplegia delivery—are as critical to outcomes as the operating surgeon’s own skill level. Anesthesiologists must be proficient in managing one-lung ventilation, transesophageal echocardiography (TEE) guidance for port positioning and venous cannula placement, and the hemodynamic monitoring demands of peripheral cardiopulmonary bypass. We strongly advocate for a dedicated “TECS team” model, in which a consistent group of professionals trains together, progressively accumulates shared experience, and continuously refines the operative workflow as a unit rather than as a collection of interchangeable individuals.

Defining objective milestones for progression between training phases is essential to ensure patient safety during the adoption period. In our program, progression is gated by a combination of case volume, operative time benchmarks, repair quality metrics (assessed by intraoperative TEE), and independent peer review of recorded operative videos. We recommend that newly adopting programs establish a formal case review process, with video recording of all TECS procedures from the outset, enabling systematic identification of technical errors and targeted remediation. Furthermore, during the early adoption phase, patient selection should be deliberately conservative: straightforward, isolated mitral valve pathology in patients with favorable anatomy and no prior thoracic surgery represents the ideal starting point. As the team’s experience grows, the complexity of cases can be incrementally expanded. Transparency about outcomes during the learning curve—including honest reporting of conversion rates and procedural times—is not only ethically important but also provides the quantitative feedback necessary to drive continuous improvement.

Technical considerations

A variety of specialized tools, such as endoscopic instruments, 3D endoscopes, and 4K cameras, are essential for TECS.

Instruments

Surgeons must also become familiar with long-shafted instruments, which are used through a fulcrum represented by the chest wall. These instruments, applied through a fulcrum represented by the chest wall, lose at least one degree of freedom compared to standard instruments and two compared to robotic EndoWrist (Figure 2). The limited maneuverability through a 2 cm working port restricts triangulation, which is common in thoracic surgery, and can lead to hand-hand conflicts (Figure 3). Articulated, robot-like instruments can also be used in such procedures. These instruments have articulated tips that provide 7 degrees of freedom, similar to robotic platforms, but their different ergonomics require specific training, skills, and a tailored surgical setup for docking (Figure 4). While their use in cardiac surgery remains limited, adoption in thoracic surgery is increasing (12,13).

Figure 2 Degrees of freedom in minimally invasive and robotic cardiac surgical instruments. (A) MICS instruments provide 5 degrees of freedom. (B) Robotic EndoWrist allows at least 7 degrees of freedom. MICS, minimally invasive cardiac surgery; WP, working port.

Figure 3 Hand-hand conflict during totally endoscopic aortic valve surgery.

Figure 4 Articulated robot-like instruments for endoscopic cardiac surgery. (A) FlexDex wristed instrument. (B) ArtiSential robot-like suturing instrument.

As interest in less invasive cardiac procedures grows, industries have started developing specialized tools to facilitate MICS. Devices for automated annular and vascular suturing, as well as automated knot-tightening systems, are now widely adopted in endoscopic and minimally invasive valve surgery (Figure 5). These instruments address the gap in maneuverability posed by small working ports, significantly improving operative outcomes by reducing procedural time and minimizing complications related to valve implantation (14-16).

Figure 5 Automated annular stitching and knot-fastener devices. (A) RAM. (B) Sew-Easy. (C) COR-KNOT.

Robotic platforms

For the transition from direct-vision surgery to totally endoscopic procedures, the use of a robotic platform—such as the da Vinci^® surgical system—requires specific training and certification. The robotic platform impacts not only the operating room setup but also other aspects of the surgical process. Given the high cost and regular maintenance requirements of this technology, it is crucial for the program to have strong administrative support. Additionally, because the operating surgeon sits at the console, a table assistant is needed to dock the robotic arms and provide assistance during surgery. This staff must also be properly trained for their specific role.

Compared to standard MICS and laparoscopic instruments, robotic arms and tools offer significant advantages, including ambidexterity, natural 3D vision, and the elimination of fine tremors. However, the robotic system lacks tactile feedback, which is a key consideration for surgeons accustomed to open surgery. To compensate for this, robotic endoscopic surgeons must develop a “haptic tactile feedback” mechanism, which relies on visual cues such as the deformation of tissue to assess the state of the surgery (17). Nonetheless, the 4th arm can help in the retraction and the exposure of the valves when needed, also in an adjustable way.

Real-time imaging and scope view

Total reliance on video-assisted imaging requires an excellent video supply. HD, 4K, and 3D cameras and monitors are readily available in the market. Depending on the surgeon’s preference and setup, scopes with diameters of 10 mm, 12 mm, or even 5 mm can be adopted. However, smaller scopes are associated with reduced brightness, which can be a challenge in low-light environments.

Since the surgeon loses direct vision during totally endoscopic procedures, new hand-eye coordination skills must be developed. This is especially important due to the difference between the view angle and the angle of approach (Figure 6). A well-developed totally endoscopic skill results in multiple technical and procedural improvements, including shorter procedural times, greater precision, and fewer unnecessary movements. Studies have shown that surgeons specifically trained to develop endoscopic hand-eye coordination—using methods such as gaming consoles—demonstrate shorter procedural times, increased surgical precision, and reduced unnecessary instrument manipulation, even in inexperienced trainees (10,11).

Figure 6 Delta angle between the camera and working port trajectories. WP, working port.

Scope manipulation

Manipulating the scope is crucial in TECS, as almost the entire intrathoracic procedure depends on it. Poor scope positioning or an inability to achieve a clear and wide view of the intrathoracic structures can severely affect the surgical procedure and may even lead to its abandonment.

Typically, a 30-degree thoracoscope provides enough freedom to explore the entire mediastinum by simply rotating the scope while keeping the camera still (Video 1). Clockwise rotation allows for visualization of cranial structures such as the ascending aorta, superior vena cava (SVC), and transverse sinus. Counterclockwise rotation provides a view of the right atrium, Sondergaard’s groove, right ventricle (RV), inferior vena cava (IVC), and diaphragm. For reference during rotation, the light source connection can be used as a guide. A clear view of the anterior chest wall, including the right internal mammary artery (RIMA), can be obtained by rotating the scope clockwise or counterclockwise until the light source faces downward (Video 2).

However, 3D cameras and scopes typically do not allow the same level of manipulation, as the camera head and the scope are integrated into one piece. While digital rotation can be performed, it is usually at a fixed angle of 90 or 180 degrees, limiting the flexibility of movement compared to traditional scopes.

Patient selection

Generally speaking, this technique is particularly beneficial for certain patient populations, including those with high surgical risk, those requiring less extensive procedures, and those with comorbidities such as obesity or advanced age. Appropriate candidates for MICS typically include individuals with isolated coronary artery disease, mitral valve disease, or atrial fibrillation, where the disease is localized and does not involve extensive damage to the heart or other organs (18). Additionally, patients who have failed or are not candidates for traditional open-heart surgery due to factors such as obesity, prior chest radiation, or advanced age are often considered for these approaches (19). However, careful patient selection is critical, as individuals with complex multivessel coronary artery disease, extensive left ventricular dysfunction, or large aneurysms may not be ideal candidates due to the technical limitations of the minimally invasive approach (20).

The learning curve and the experience of the surgeon and center play a major role. A specific clinical or anatomical condition that might represent a contraindication for an endoscopic approach in a less experienced center might not represent a barrier for an experienced endoscopic surgeon or high-volume center. Certainly, patients with specific anatomical variations such us pectus, previous thoracotomy/lung or heart surgery, high-risk comorbidities, or advanced cardiac disease are challenging and should not be treated endoscopically in early experience (Figure 7).

Figure 7 Totally endoscopic redo mitral valve re-repair in severe pectus excavatum (Haller index 4). (A) Preprocedure external view. (B) Preoperative CTA. (C) Postprocedure result. CTA, computed tomography angiography.

Ultimately, a multidisciplinary team of surgeons, cardiologists, and anesthesiologists must evaluate each case to ensure that minimally invasive procedures are both safe and effective for the patient’s unique clinical condition.

Procedural challenges

Due to the limited size of the working port, TECS is performed entirely by viewing the operative field on a screen, rather than through direct visualization. This inherently restricts the field of view and reduces the ability to perceive spatial relationships between critical intrathoracic structures. As a result, meticulous precision is essential during intrathoracic manipulation, particularly to avoid injury to adjacent anatomical landmarks. In the non-robotic endoscopic setting, the absence of wristed instruments results in a partial loss of degrees of freedom. Surgeons must develop new hand-eye coordination, refine their instrument handling techniques, and adapt to altered depth perception. The use of long, slender instruments through small access ports adds further technical complexity, making familiar surgical maneuvers more challenging and less intuitive. Proficiency in this environment demands extensive practice. In robotic-assisted approaches, the lack of tactile feedback introduces an additional layer of complexity, requiring the surgeon to rely more heavily on visual cues to judge tissue resistance and handling dynamics. Whether robotic or purely endoscopic, the limited working space and indirect visualization mandate the acquisition of a distinct skill set tailored to this approach. Strategic and tactical planning becomes paramount. Each step of the procedure must be deliberately designed in advance, including optimal positioning of the working and camera ports, selection of the perfusion strategy, and planning for cardioplegia route and delivery. Failure to optimize these elements can compromise exposure, increase procedural difficulty, or jeopardize safety. It is also important to recognize that longer operative times are common during the early phase of transitioning. The learning curve for TECS can be steep, and procedures often require additional time until the surgical team gains sufficient experience and confidence. This factor should be carefully considered when selecting patients and procedures during the adoption phase, prioritizing lower-risk cases with favorable anatomy to ensure safety and success.

Postoperative outcomes

MICS, including both mini-thoracotomy and totally endoscopic approaches, has demonstrated comparable—if not superior—outcomes in terms of safety and quality when compared to the conventional median sternotomy. A randomized trial from the UK Mini Mitral Registry investigated the safety and efficacy of thoracoscopically guided mini-thoracotomy for mitral valve repair versus standard sternotomy. The findings concluded that mini-thoracotomy achieves high-quality mitral valve repair with results equivalent to those of sternotomy, establishing it as a safe and effective alternative (4).

Further insights from the Mini-Mitral International Registry, which included 6,541 consecutive patients undergoing mini-thoracotomy mitral valve surgery, revealed an excellent overall mortality rate of just 1.7%. This cohort encompassed patients across the full risk spectrum as defined by the EuroSCORE II (ES II). In all risk categories—low, intermediate, high, and extremely high—the observed mortality was consistently lower than expected, underscoring the reliability and safety of this approach (5).

Totally endoscopic techniques offer an additional refinement by eliminating the need for rib spreading, rib dislodgement, or costal cartilage cutting. This further reduction in invasiveness is associated with decreased tissue trauma, smaller incisions, and consequently, lower rates of postoperative complications such as infection, bleeding, or chronic pain. These features translate into tangible clinical benefits, including faster recovery times, reduced postoperative discomfort, and lower healthcare resource utilization (7).

Historically, MICS and totally endoscopic approaches have been associated with concerns regarding a potentially higher incidence of neurological complications, particularly stroke. Early observational studies reported an increased rate of cerebrovascular events following minimally invasive mitral valve surgery compared to the conventional sternotomy approach (21).

However, more recent evidence has challenged this perception. Meta-analyses now suggest that MICS does not significantly increase the risk of stroke, despite the longer operative and cross-clamp times often associated with these techniques (8).

A contemporary multicenter study by Cresce et al., encompassing a large cohort of 7,343 patients who underwent minimally invasive mitral valve surgery, reported a low stroke rate of 1.3%. The study identified advanced age and mitral valve replacement—as opposed to repair—as independent risk factors for neurological events. Importantly, the presence of peripheral artery disease (PAD) detected on preoperative computed tomography angiography (CTA) was found to influence the surgical strategy, particularly in terms of cannulation and perfusion site selection. However, PAD detection did not translate into improved neurological outcomes, suggesting that anatomical complexity may reflect intrinsic risk rather than a modifiable factor alone (22).

Patients undergoing totally endoscopic procedures also tend to experience shorter hospital stays and quicker returns to normal activities. The minimal-access nature of the procedure enhances cosmetic outcomes, which in turn positively affects patient satisfaction and quality of life. A prospective study by Claessens et al. assessed health-related quality of life (HRQL) following TECS at 14, 30, 90 days, and at 1 year. While a temporary dip in HRQL was noted in the first 2 weeks postoperatively, scores returned to baseline by day 30 and were significantly improved by day 90. Notably, high HRQL levels were sustained at 1-year follow-up, confirming long-term patient benefit (23).

Future perspectives

In the last few years, industries have invested in the development of multiple robotic platforms breaking the monopoly held by the da Vinci system (24). The future of endoscopic cardiac surgery may heavily involve robotic-assisted techniques, which provide greater precision, a more ergonomic interface for the surgeon, and enhanced 3D visualization.

Advanced imaging, artificial intelligence integration, and machine learning will be embedded in the daily practice to assist surgeons in complex decision-making during endoscopic procedures, further enhancing the safety and efficacy of these operations (25).

An important consideration in the future adoption of endoscopic cardiac surgery is cost-effectiveness and scalability across different healthcare settings. While robotic-assisted platforms offer ergonomic and visualization advantages, they are associated with substantial acquisition and maintenance costs, require expert bedside assistance, and are generally limited to addressing isolated pathologies—factors that restrict their scalability, particularly in resource-limited or middle-income healthcare environments. In contrast, non-robotic TECS represents a more scalable and cost-effective alternative: it does not require an expert assistant at the bedside, can be performed with widely available endoscopic instrumentation, and enables the surgeon to address multiple pathologies simultaneously within a single procedure at a reasonable cost. Although robotic platforms will likely play an increasingly prominent role in high-income countries, the broader global expansion of endoscopic cardiac surgery will depend on the continued development and dissemination of non-robotic TECS techniques that can be adopted across diverse economic and institutional contexts.

Conclusions

The evolution from direct-vision MICS to TECS represents a transformative shift in the field of cardiac surgery. This transition reflects a broader movement toward enhanced precision, reduced invasiveness, and improved patient-centered outcomes. Despite the initial concerns regarding procedural complexity and neurological risks, recent large-scale studies and meta-analyses have confirmed that MICS and TECS offer comparable—if not superior—safety and efficacy compared to conventional sternotomy, with the added benefits of reduced trauma, faster recovery, improved cosmesis, and sustained quality-of-life improvements. Successfully implementing a totally endoscopic approach requires not only advanced instrumentation and imaging technologies, but also extensive training and a coordinated, experienced surgical team. The learning curve is steep, yet surmountable with structured mentorship, simulation-based training, and careful case selection during the adoption phase. Emerging innovations, including articulated instruments, robotic platforms, and artificial intelligence-enhanced imaging, are poised to further refine these techniques and expand their applicability across broader patient populations. As technological advances continue and institutional experience grows, totally endoscopic surgery will likely become the new standard for selected cardiac procedures. By redefining access and enhancing surgical dexterity, TECS not only preserves clinical excellence but also elevates the overall patient experience—heralding a new era in cardiac surgery that is both minimally invasive and maximally effective.

Acknowledgments

None.

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 has undergone external peer review.

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2025-1-55/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2025-1-55/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 in Journal of Visualized Surgery from September 2024 to December 2028. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are 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. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this study, accompanying images and the videos.

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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