Minimally Invasive and Robotic Cardiac Surgery: A Guide

Minimally invasive and robotic cardiac surgery repairs or replaces heart valves, bypasses blocked coronary arteries and closes holes in the heart through incisions of 2 to 5 cm between the ribs, in the armpit or through small ports, instead of splitting the breastbone. The operation inside the heart is unchanged; only the route in differs, bringing less blood loss, less pain and faster recovery.

Dr. Udgeath Dhir, Principal Director Cardio Thoracic Vascular Surgery, Fortis Memorial Research Institute, Gurgaon, India, set out this approach for doctors across Africa in September 2025. His unit has passed 550 minimally invasive cardiac and thoracic operations, and he heads a department that covers cardiothoracic, vascular and heart transplant surgery. His central argument was a disciplined one: small incisions are a means, not an end, and the decision to use one is made patient by patient, with safety ahead of cosmetics every time.

What minimally invasive and robotic cardiac surgery involve

Minimally invasive cardiac surgery, often called MICS or keyhole heart surgery, reaches the heart through a small opening instead of a split breastbone; robotic surgery adds console-controlled robotic arms to the same approach.

Conventional heart surgery is performed through a median sternotomy, a vertical incision down the front of the chest with the breastbone (sternum) divided and spread apart. It gives the surgeon wide access to every chamber, valve and vessel, and it remains the standard route for many operations. Minimally invasive cardiac surgery reaches the same structures through a much smaller opening, using long instruments, specialised retractors, and imaging from inside the oesophagus to guide each step.

Dr. Dhir described the shift through an old surgical saying: "big incision, big surgeon". The assumption that only a large exposure was safe held cardiac surgery back. General surgery adopted keyhole techniques first, beginning with laparoscopic removal of the gallbladder and moving on to hernia repair and other operations. Cardiac surgery, in his account, was the last specialty to accept minimally invasive methods, because the heart is complex and, for a long time, the conventional route was simply the safest option available. Minimally invasive chest surgery itself grew out of thoracoscopy, the examination of the chest cavity through a small telescope, which was first used in patients with tuberculosis in the early twentieth century.

The access routes now in use at his unit are:

• Upper hemisternotomy: a 5 cm incision that divides only the upper part of the breastbone.
• Right anterior thoracotomy: an incision between the ribs on the right side of the chest, with no bone cut.
• Inframammary and "bikini" incisions: hidden in the crease under the breast, combined with a small incision in the groin.
• Transaxillary approach: a 5 cm incision in the armpit, through which he replaces two valves at once.
• Periareolar incision: about 2 cm around the edge of the nipple, used for mitral valve repair.
• Robotic ports: small keyhole openings in the chest wall through which robotic arms carry the instruments.

The companion article on minimally invasive valve surgery explains how each of these routes is used for the aortic, mitral and tricuspid valves, and how the robot fits in.

Why small incisions took hold: rheumatic heart disease

The driver at Dr. Dhir's institution was rheumatic heart disease. Valve damage from rheumatic fever is common in the Indian subcontinent, and many of the patients who need valve surgery are young women. A long scar down the middle of the chest carries real social cost for a woman of marriageable age. Hiding the incision under the breast, in the armpit or around the nipple removes that cost. After a transaxillary operation, he noted, nobody can tell the patient has had heart surgery, unless she has a mechanical valve, which makes an audible click.

The same pattern holds across much of Africa, where rheumatic valve disease remains a leading reason for heart surgery in young adults. For referring doctors, the practical point is that his unit treats rheumatic double valve disease through a 5 cm incision in the armpit, subject to the same selection checklist as any other patient.

Which heart operations can be done through a small incision

Valve, coronary and selected congenital heart operations, including redo and hybrid procedures, are done through small incisions at Dr. Dhir's unit; the indications for surgery stay the same. Some cardiac conditions are first treated with medicines, and surgery is considered once medical management is exhausted. What the minimally invasive route changes is how the operation is done. At Dr. Dhir's unit the list includes:

• Aortic valve replacement
• Mitral valve repair and replacement
• Coronary artery bypass grafting (CABG)
• Complex atrial septal defects (holes in the wall between the upper chambers of the heart)
• Selected ventricular septal defects and pulmonary valve replacement
• Redo operations in patients who have had heart surgery before
• Hybrid procedures, which combine open surgical and catheter-based techniques

The case mix of his more than 550 minimally invasive operations is 65% valve surgery, 10% coronary surgery, 10% congenital heart disease and 15% thoracic surgery. Coronary work follows its own logic: valves are approached from the right side of the chest, while coronary arteries are approached from the left, because the left internal mammary artery, the best bypass graft, runs there. The article on minimally invasive coronary bypass and endarterectomy covers that work in detail, including beating-heart grafting and total arterial grafting.

Robotic cardiac surgery: what the robot does and does not do

Robotic cardiac surgery is robot-assisted: the surgeon sits at a console and controls arms that carry the same instruments, clamps and sutures through ports in the chest wall, so the valve is repaired or replaced exactly as in conventional surgery. "It is not the robot which operates," Dr. Dhir told the audience. The gain is control, with four arms instead of two hands and an assistant. How his unit uses the robot for mitral valve and atrial septal defect surgery is described in the valve surgery article.

Who is a candidate for minimally invasive heart surgery

Candidacy is decided by a checklist of body habitus, CT and echocardiography findings, not by preference. Minimally invasive surgery is not the default at Dr. Dhir's unit: about 40% of his operations are minimally invasive and 60% are still done the traditional way, although most patients ask to avoid a sternotomy.

Before surgery his team reviews:

1. Body habitus: severe obesity is one of the reasons he chooses an upper hemisternotomy over an incision between the ribs.
2. CT aortography: a CT scan of the aorta and the arteries of the groin and pelvis shows whether the heart-lung machine can be connected through the groin vessels.
3. Echocardiography: the anatomy of the valve and the function of the heart.
4. High-resolution CT of the chest before minimally invasive bypass, which is protocol in his unit.

The selection rules follow published guidelines from international surgical societies. One case made the point. A man referred specifically for minimally invasive bypass had a routine chest CT that showed the lining of one lung completely calcified and the lung encased, the legacy of old tuberculosis. The minimally invasive route was ruled out; he had total arterial bypass grafting, but through an open sternotomy.

The advantages of the minimally invasive route are particularly relevant in redo cases, where the breastbone has already been opened once or twice, and in other high-risk patients. Across all patients, the gains Dr. Dhir emphasised were limited blood loss and faster recovery.

Is minimally invasive heart surgery safe? Conversion and recovery

Safety comes before the incision. Dr. Dhir's first rule for any doctor is to heal the patient and, failing that, to do no harm. Applied to minimally invasive surgery, it means that converting to a full sternotomy is never a failure: if things go wrong through a small incision, the surgeon opens the chest. Incision size is secondary to the result.

Recovery is managed as a team. Most of his patients have the breathing tube removed on the operating table, and a thoracic epidural (a fine catheter that delivers continuous pain relief near the spinal nerves of the chest) runs for the first 24 hours so they can breathe deeply without pain. After a 2 cm periareolar mitral valve repair, his patient was discharged on day three.

The same team-based readiness extends beyond elective work. Dr. Dhir described a woman who suffered a massive pulmonary embolism, a large clot blocking the arteries of the lungs, while being turned during spinal surgery. With cardiopulmonary resuscitation in progress, she was moved from the neurosurgical theatre to his cardiac theatre, placed on the heart-lung machine, and the clots were removed. She left hospital ten days later and is doing well.

When to refer a patient for cardiac surgery

Breathlessness, waking breathless at night and chest pain are the classic valve symptoms that should prompt referral for assessment. The moderator asked Dr. Dhir about warning signs because most doctors in the session practise in resource-poor settings, and his answer started with those symptoms:

• Breathlessness, particularly on exertion
• Paroxysmal nocturnal dyspnoea: waking at night coughing and breathless, needing to sit up for relief
• Chest pain

"The heart has its own language," he said, and it speaks in only a few ways: a fast or slow heart rate, a rise or fall in blood pressure, breathlessness and pain. Any of these warrants a physician's assessment. On examination, a murmur, swelling, a raised jugular venous pressure (visible distension of the neck veins) and the irregular rhythm of atrial fibrillation (a chaotic rhythm of the upper chambers), with a systolic or diastolic murmur over the mitral area, point to rheumatic heart disease with mitral stenosis and regurgitation, often with high pulmonary artery pressures. An echocardiogram and an electrocardiogram, followed by coronary angiography where needed, establish whether the problem is valvular, coronary or a dilated aorta.

Can cardiac patients fly for surgery? Air transport and ECMO

Dr. Dhir sees no absolute or relative contraindication to flying a cardiac patient for treatment, with one exception: the haemodynamically unstable patient. He gave that answer to a doctor from Ethiopia who asked which cardiac patients cannot be flown. His team has transferred patients with acute aortic dissection and acute coronary syndromes, and regularly moves patients on extracorporeal membrane oxygenation (ECMO), a portable heart-lung support system.

An unstable patient is one on high doses of several inotropes (drugs that support the heart's pumping) or with an unstable rhythm. Those patients should be treated where they are. The decision is made jointly. His team holds a video call with the referring doctors, reviews the vital parameters, the arterial blood gas and the clinical condition, and reaches a consensus. Because "a stable patient may become unstable in the next two hours", the patient is optimised first and the airlift planned around that.

Cost of minimally invasive cardiac surgery

Dr. Dhir put the cost of minimally invasive valve and coronary operations at $6,500 to $18,000, depending on the complexity of the case and the consumables used. Indicative package ranges by procedure are on the treatment-cost pages for aortic valve replacement and coronary artery bypass grafting.

He was equally direct on affordability. In nine years at Fortis, every request he has made for financial help for a patient in need has been granted, and no patient who needed treatment has been turned away on money alone. His principle borrows from the law: as justice delayed is justice denied, treatment delayed is treatment denied.

Cardiac surgeon or vascular surgeon: who does what

Broadly, cardiac surgeons handle coronary and aortic work, while vascular surgeons manage the thoracic and abdominal aorta and peripheral arterial disease, with grey zones in between. Dr. Dhir gave that division in answer to an attendee; he trained in cardiac, thoracic and vascular surgery together. His own practice is coronary, valve and aortic surgery and heart transplantation; a colleague trained the same way concentrates on peripheral vascular work in the leg arteries. He calls these micro-specialisations within one discipline.

The full set of attendee questions and his answers is on the Live Discussion page. For a broader view of valve choices, see Dr. Z S Meharwal's guide to advances in heart valve surgery; for a catheter-based alternative to surgical aortic valve replacement, see Dr. Subhash Chandra's guide to TAVI. For another surgeon's account of robot-assisted valve, bypass and aortic surgery, see Dr. Yugal Kishore Mishra's guide to robotic cardiac surgery, and for a wider view of advances in cardiac diagnosis, surgery and management, Dr. Ajay Kaul's guide to modern cardiac care. More content is collected on the cardiac surgery and cardiology specialty pages.