Robotic-Assisted Cardiac Surgery

Robotic-assisted cardiac surgery, often called robotic heart surgery, uses console-controlled robotic arms, passed through small ports between the ribs, to perform parts of a heart operation without splitting the breastbone. In Dr. Yugal Kishore Mishra's practice the robot harvests the mammary arteries for bypass grafting, closes atrial septal defects, removes atrial myxomas and can unroof myocardial bridges, with patients typically back at work in about three weeks.

Dr. Yugal Kishore Mishra, Chairman, Manipal Institute of Cardiac Sciences | Chief of Cardiovascular Surgery | Chief of Clinical Services, Manipal Hospital, Dwarka, New Delhi, India, conducted this Jivo Masterclass for international doctors on 26 January 2025. His unit began its minimally invasive cardiac surgery programme in 1997 and he began robotic cardiac surgery in 2002. The session traced how an operation that once needed a 20 cm incision is now performed through cuts of about 3 cm, and what that shift demands of the surgeon, the patient and the health system that pays for it.

What robotic-assisted cardiac surgery is

Robotic-assisted cardiac surgery is one form of minimally invasive cardiac surgery (MICS), in which the surgeon operates from a console while robotic instruments work inside the chest through small ports.

Dr. Mishra gave a two-part definition of minimally invasive cardiac surgery. A heart operation is minimally invasive when it is performed without a sternotomy, or when it is performed without the heart-lung machine. A sternotomy is the conventional route into the chest: a long vertical incision down the front, with the breastbone (sternum) divided and spread apart. The heart-lung machine, or cardiopulmonary bypass, takes over the work of the heart and lungs so that the heart can be stopped and opened.

The conventional operation, as he described it, involved splitting the sternum through a large incision, exposing the heart, inserting tubes (cannulas) into the aorta and the right side of the heart, connecting the patient to the heart-lung machine and then performing whatever repair was needed. Around 20 to 25 years ago, surgeons worldwide began to ask why the whole sternum had to be divided when the aortic valve, for example, could be reached through a smaller opening. That question produced the three main minimally invasive routes he uses today:

• Upper partial sternotomy: only the top part of the breastbone is divided, used for aortic valve surgery.
• Lower partial sternotomy: only the lower part is divided, an early route for bypass surgery using both mammary arteries.
• Thoracotomy: a short incision between the ribs on the right side (for valves, atrial septal defects and tumours) or the left side (for coronary bypass), with no bone cut at all.

The robot is the most recent step on this path. In his description of the set-up, two robotic arms carry the left and right instruments, a third holds a retractor, and the camera goes in through one of these ports or a separate one. A small additional cut allows the surgeon to introduce a valve or an annuloplasty ring, the supporting ring sewn around a repaired valve.

Which heart operations can be done robotically

In Dr. Mishra's practice the robot is used for a defined set of tasks rather than for every heart operation: harvesting the mammary arteries for coronary bypass, closing atrial septal defects and removing atrial myxomas, and it can also unroof myocardial bridges. He does not replace heart valves robotically.

• Coronary artery bypass surgery: the robot's job is to take down the two internal mammary arteries, the chest-wall arteries used as bypass grafts, with the chest closed. He sits at the surgeon's console and dissects the artery with robotic instruments, then the bypass is completed. His unit has progressed to totally endoscopic coronary artery bypass (TECAB), in which the whole operation is done through robotic ports without a conventional incision.
• Atrial septal defect (ASD) closure: closure of a hole in the wall between the heart's two upper chambers.
• Removal of atrial myxoma: a myxoma is a benign tumour that grows inside the heart, most often in the left atrium.
• Myocardial bridge unroofing: a myocardial bridge is a segment of coronary artery that runs through the heart muscle instead of over it, so that the muscle squeezes the artery with each beat. Asked in the session whether this can be treated by minimally invasive surgery, he said that the robot can unroof the bridge and remove the overlying muscle without opening the chest, provided the exact site of the bridge is located. Most bridges cause no symptoms and need no treatment; surgical unroofing is reserved for patients whose symptoms persist despite beta blockers or non-dihydropyridine calcium channel blockers, and for them the robotic route avoids opening the chest.

He was equally clear about what he does not do robotically. Some surgeons have started replacing heart valves with the robot; he does not, and said he is not comfortable with it. The valve operations he demonstrated were performed through small thoracotomies and partial sternotomies with long-shafted instruments, a technique covered in detail in port-access heart valve surgery: technique and selection. The coronary programme, from robotic mammary harvest to TECAB, is set out in robotic coronary artery bypass surgery.

For congenital heart disease his scope is narrow. He closes ASDs, including sinus venosus and secundum defects, but does not repair tetralogy of Fallot. Surgeons at Manipal Hospital in Bangalore do repair tetralogy of Fallot through a minimal access approach. For context on cost, see tetralogy of Fallot repair costs.

What anaesthesia is used for robotic heart surgery

Robotic and minimally invasive heart surgery is performed under single-lung anaesthesia: one lung is deliberately collapsed so that the surgeon has room to work in that side of the chest.

Dr. Mishra explained the choice of lung: in coronary artery bypass surgery the left lung is deflated, and in valve surgery the right lung is deflated. The side follows the surgical approach, since bypass surgery is performed through the left chest and valve surgery through the right. Single-lung ventilation is achieved with a double-lumen breathing tube or a bronchial blocker, which allows the anaesthetist to ventilate each lung separately. This is one reason his pre-operative work-up includes pulmonary function tests: the patient must tolerate a period of breathing with one lung.

Benefits of robotic heart surgery and recovery time

The main benefits of robotic and minimally invasive heart surgery are less pain, blood loss and infection, a shorter hospital and intensive care stay, and a return to work in about three weeks instead of three months. Dr. Mishra listed the benefits that lead patients to ask for minimally invasive cardiac surgery:

• less infection and less scarring, with a better cosmetic result
• shorter hospital stay, less pain and less blood loss
• shorter stay in intensive care
• recovery measured in days rather than a month
• no post-operative sternal precautions: after a sternotomy, he noted, the patient has to sleep straight on the back for three months, which is very uncomfortable
• an early return to work and sport

The patients who push hardest for these operations, in his experience, fall into recognisable groups. Executives cannot afford three months away from work. Young women do not want a visible scar down the chest. Manual workers cannot risk an unstable sternum. Young patients with diabetes and poorly controlled blood sugar who need both mammary arteries harvested through a sternotomy are at risk of wound problems that sometimes need major reconstructive procedures.

He illustrated the point with a young international cricketer who had a training camp a month away. After a minimally invasive ASD closure, his physiotherapist asked at three weeks whether he could play; the answer was yes, and he was batting at his camp abroad shortly afterwards.

Who should not have robotic heart surgery

Not every patient is a candidate for robotic or minimally invasive heart surgery. Dr. Mishra listed the relative contraindications, the conditions that weigh against the approach without ruling it out: peripheral vascular disease, atheroma (fatty, calcified plaque) of the aorta, aortic aneurysm and conditions that predispose to it such as Marfan syndrome, any condition that rules out transoesophageal echocardiography (an ultrasound probe passed into the oesophagus, which is essential for guiding these operations), obesity and scarring of the pleura, the lining of the lung.

Age matters at the young end. Because these operations usually connect the heart-lung machine through the femoral artery and vein in the groin, he avoids the approach in children under about six years old, whose femoral arteries are too small; the artery must be large enough to take the cannula. The full selection work-up, including CT, Doppler studies and the choice between thoracotomy and partial sternotomy, is covered in the valve surgery article.

Cost of robotic heart surgery compared with conventional surgery

Minimally invasive cardiac surgery costs more than a conventional operation, and robotic surgery costs more again. Dr. Mishra put the typical premium at about one and a half times the cost of regular surgery.

The reasons are structural. Minimally invasive surgery uses specially designed instruments, and robotic surgery adds the cost of the robotic system and its instruments. His argument for paying the premium is economic as much as clinical: the patient can return to work in about three weeks instead of losing three months, with less pain, earlier discharge, less blood loss and a shorter intensive care stay. He noted that he operates on patients from Ethiopia who afford the minimally invasive and robotic operations they ask for. Indicative package costs for the conventional procedures are on the coronary bypass cost page, the aortic valve replacement cost page and the ASD closure cost page.

Robotic systems for cardiac surgery: da Vinci and SSI Mantra

Two robotic platforms featured in the session. The da Vinci system, made by Intuitive Surgical, is the most widely used surgical robot; Dr. Mishra said the company was earlier reluctant to support cardiac surgery training but has now started to do so. The second is the SSI Mantra, an Indian-made robot that he described as specially designed for cardiac surgery, comparatively cheaper than the Intuitive robot and well suited to cardiac work, with its makers also providing training. He put the number of these systems working in India at around 25 to 30.

For a health system weighing a robotic programme, his framing was blunt: there are two separate requirements, technique and technology. A trained surgeon still needs the hardware, and a robotic system is very expensive.

How surgeons train in robotic cardiac surgery

Robotic cardiac surgery is learned through a long period of training: no one becomes a minimally invasive or robotic cardiac surgeon on day one. That was Dr. Mishra's answer to how a surgeon improves robotic skills.

His own path illustrates the scale of that commitment. Before starting, he visited about 15 countries across the world, including in Europe and North America, to train, and was then proctored at his own centre by leading surgeons from abroad. His unit has since become a training centre in its own right:

• 144 senior and junior surgeons from India, Sri Lanka, Nepal and Bangladesh have trained in minimally invasive cardiac surgery with the unit and returned to operate in their own hospitals.
• Cardiac surgeons from France and Germany, and doctors from the USA, Bangladesh, Nepal and Thailand, have come for training.
• At least five to ten people a month, from across India and abroad, come to train in robotic surgery.

For surgeons from Africa, he set out a practical sequence. Refer patients first and come with them to watch the operation, which is how training begins. Then come for a short visit of one to four weeks to stay with the team and train. Where needed, his team can travel to proctor a few cases in the surgeon's own hospital. He also helped form the Society of Minimally Invasive Cardiovascular and Thoracic Surgeons of India, which holds an annual meeting and a midterm meeting, and which planned a short visiting fellowship of about a week with some financial assistance for surgeons interested in the field. The society's 10th annual meeting was scheduled for Delhi in October 2026, held jointly with an international minimally invasive workshop and an Asian cardiothoracic congress.

His closing advice to surgeons in the session was that this kind of surgery rests on dedication, commitment, practice, patience and persistence.

Related reading

Dr. Udgeath Dhir's separate masterclass covers the same field from a different angle in minimally invasive and robotic cardiac surgery. The questions doctors put to Dr. Mishra during the session are on the Live Discussion page. More on the specialty is on the cardiac surgery hub.