Robotic coronary artery bypass grafting: current status and future perspectives

Robotic coronary artery bypass grafting (CABG) has emerged as a minimally invasive alternative to traditional open-heart surgery, offering reduced surgical trauma and faster recovery. Techniques include robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB), where the internal thoracic artery is harvested robotically and anastomosed via mini-thoracotomy, and totally endoscopic CABG (TECAB), which avoids thoracotomy altogether. Hybrid coronary revascularization, combining robotic left internal thoracic artery-left anterior descending (LITA-LAD) grafting with percutaneous coronary intervention, provides a patient-specific strategy for multivessel disease. While off-pump approaches reduce recovery time, on-pump techniques remain valuable in complex cases and are mainly performed at expert centers. Despite promising outcomes, such as low mortality, short hospital stays, and high graft patency, widespread adoption remains limited due to high costs and technical complexity. Mastering the technique and performing more advanced procedures like TECAB require a long learning curve. Proficiency improves with experience, typically after 10-50 cases, while full mastery may require hundreds of procedures. Most centers now favor RA-MIDCAB over TECAB, which remains limited to a few high-volume institutions. Recent advances in robotic platforms, including systems from Intuitive Surgical, Medtronic, CMR Surgical, and others, promise improved ergonomics, precision, and cost-efficiency. Features like haptic feedback, eye-tracking, and remote operation are advancing robotic surgery into a new era, though challenges persist in training and accessibility. As robotic systems continue to evolve and integrate artificial intelligence and telesurgical capabilities, broader adoption may become feasible, particularly when combined with hybrid revascularization strategies in selected patients.