1. Pike, Nancy A. RN, MN, FNP
  2. Gundry, Steven R. MD, FACS, FACC


Over the past decade, advancements in cardiac surgery occurred secondary to improvements in technology and the desire for a less invasive approach to operations in general. Minimally invasive cardiac surgery has progressed from partial sternotomy incisions to totally endoscopic open-heart procedures with robotic-assistance. There are 2 major companies that produce robotic equipment for use in cardiac surgery. These companies must undergo Food and Drug Association (FDA) mandated clinical trials on each cardiac surgical procedure, before it can be approved for public use. The surgeon must demonstrate clinical proficiency to operate the robotic equipment per FDA approved company testing. The use of computer (robotic) enhancement is well documented for coronary artery bypass grafting and selected cardiac valve procedures. Recent advancements are now being directed at congenital heart disease. The use of robotic-assisted totally endoscopic atrial septal defect closure is a tremendous advancement in congenital cardiac surgery. The future of robotic cardiac surgery will hopefully expand to cover more advanced valve procedures, congenital heart defects, and other procedures once robots are further modified for pediatric use.


Minimally invasive surgery is the performance of operations through limited or smaller than normal incisions. Robotic-assisted surgery is performed with robotic arms controlled by the physician through a small incision or no incision except for the instruments and camera portholes. Minimally invasive techniques/robotic-assisted cardiac surgery has been developed to minimize surgical trauma and improve cosmetic results compared to the traditional full sternotomy incision. Other reported additional benefits to minimally invasive surgery/robotic surgery include a decrease in hospital length of stay, less postoperative pain, faster patient recovery, and faster return to activities of normal daily living. 1,2 The introduction of new surgical instruments, techniques for peripheral cardiopulmonary bypass, catheter-based balloon aortic occlusion/cardioplegia delivery, and 3-dimensional video assistance has given cardiac surgeons the tools needed to perform operations through smaller incisions.


Prior to advances in robotics, a variety of smaller incision, less invasive operations were developed as stepping-stones to endoscopic heart operations. The minimally invasive direct coronary artery bypass (MIDCAB) performed through a small anterior thoracotomy was introduced to reduce the morbidity associated with a sternotomy incision and be performed with or without cardiopulmonary bypass (CPB). Off-pump coronary artery bypass grafting (OPCABG) via a sternotomy incision is receiving renewed interest as a way of reducing the risks associated with CPB in high-risk patients. Minimal access valve surgery was also developed as a minimally invasive approach for valve disease, using either mini sternotomy or thoracotomy incisions.


With technological advances, surgeons have been able to build upon minimally invasive techniques to perform totally endoscopic coronary artery bypass procedures, valve repairs, and recently, atrial septal defect (ASD) closures. 1-7 With smaller surgical incisions, the operation becomes more technically challenging due to limited direct cardiac visualization. Longer operative times are required, depending on the surgeon's experience, and the patient's exposure to general anesthesia increases. There is also the possibility of conversion to a traditional incision in case of unsuccessful repair or an emergency.


Computer (robotic) enhancement was first used to provide visualization via a voice activated endoscopic camera to assess intracardiac structures during operations performed through smaller incisions. The application of a robotic surgical system has allowed for the addition of surgical instruments to be placed through small thoracic incisions and/or ports, thus allowing for totally endoscopic open-heart surgery.


The American Heart Association identified robotic surgery as one of the top 10 research advancements of 2002. 8 Robotic-assisted cardiac surgery represents an advancement in the field of cardiothoracic surgery, which has allowed surgeons to perform selected coronary artery bypass surgery, mitral valve repairs, and most recent totally endoscopic atrial septal defect repairs. The purpose of this article is to review minimally invasive techniques leading to the use of robotic equipment and US application of robotic technology for totally endoscopic open-heart surgery. Training requirements, nursing care, and the future for robotic surgery are also presented.